hope 2013 rmmch- vigneshwar

7/23/2019 Hope 2013 Rmmch- Vigneshwar

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Pyrexia of unknown origin-An unusual cause

N.S.VIGNESHWAR

RMMH

Anna!alai "ni#ersi$y



• 10 months old male infant 2nd born to

nonconsanguineous parents residing at

Sirkali was brought to casualty by hismother whose reliability was good withpresenting complaints of

Fever x 1 monthCough x 3 wks

Abdominal distension x 1 wk

Breathing diculty x 3wks

efusal of feeds x 1! days



Fever

• Insidious onset• 1 month• low grade Fever , "ntermittent

• No chills or rigor• No H/o rash•

No aggravating factors• Relieved by antipyretics



oug%

• Cough present on # o$ throughoutthe day disturbing the slee%

• wks duration! Insidious onset• &iculty in breathing " wk• #ore during lying down posture• No H/o foreign body/eye

congestion/mass descending perrectum



• H/o refusal of fee&s " 1$ days• H/o weig%$ loss present• A'&o!inal &is$ension x (wk

•

No H/o melena% vomiting% loosestools % &aundice% bleeding 'R• No H/o fore head sweating% suck

rest suck cycle %(yanosis• No H/o sei)ures% loss of

consciousness



A&!ission a$ )!on$%sof age for)* &ays -+R,I

A&!ission a$ !on$%sof agefor (!on$% +R,I wi$%

a'&o!inal&is$ension

A&!i$$e& a$ /!on$%sof agefor 0weeks-+R,Iwi$%a'&o!inal&is$ension

• 1loo& $ransfusion - ane!ia• 2x as 'B # A'' started ( )th mon * no

contact H3o of ,1

AS, HIS,4R5



B"'+ +",'-./(

• *ntenatal +No H/o ,-R(HIN.(,I-N

• No other maternal risk factors•

Natal + ,erm normal delivery! 0wt 2$kg• 'ostnatal + 3neventful

• 3mbilical cord fell on day 4• 'assed #econium on day 1



"2"A'"-2 /(

– 0(5 6Scar present7 – -'8 9%1%2% – :', 1%2% – Hep;0 1%2% – Hib 1%2%

• <et to be Immuni)ed with measles2'"'"-2/(

• 0.;= months then started weaning

Ac$ual Ex6ec$e&

Ga6

(alorie 4$6>cal

7

?996>cal

7

)789c

al:



&4546-742'A6 age appropriate forchronological age

FA"6. +",'-. no H/o similar illness infamily members

,-C"-4C-2-"C ,'A', - 5rade I86*ccording to modiAed >uppusamy scale 7•(attle present

92

4



+4A& '- F--' 48A"2A'"-2/(

• *. open B Cat• Eyes Pallor ;

• No evidence of 8it deAciency• ars %-ral cavity normal•

.undus ; normal• ars no discharge• Neck ; no lymphadenopathy!• Dimbs 63D/DD7; normal• Pan&igi$al clu''ing ;

• A'&o!en &is$en&e&

• "ternal genitalia/Spine B(ranium ; normal



AN,HR4P4ME,R5A,"A+ E<PE,E

2

EI5H, F$ >g @$ >g => ?0r& cen$ilegra&e IV8IAP7

Dength ==cm 42cm @1G

H*:(IR(3#.

RN(

F$cm rd to 19th centile

9ellcome trust :#arasmus

9aterlow (1; stunting

Chronic malnutrition



VI,A+S

• (onscious % alert• ,emp;192 .•

HR;1$2/min! 0';@9/=9 mmhg! (.,secs! RR;42/min ! Sp92;@G• No e"ternal markers of ,0•

No signs of liver cell failure

RESPIRA,4R5 S5S,EM



RESPIRA,4R5 S5S,EM

INSPE,I4N@-• (hest shape B

movement symmetrical

•

*pical impulsevisible medial to theD, nipple

• No scar% sinuses

• SR;IR; Alanasi <aring =

• No bonyabnormalities

PA+PA,I4N@-

• ,rachea midline• *pical impulse; Dt

Fth intercostal

space J inchmedial to #(D

• 5ocal fremitus

( rightaxillary *infraaxillary #

mammary



PER"SSI4N +;• &ullness over t axillary * infra

axillary # mammary region

A"S"+,A,I4N+;•

0reath sounds ; bronchial breathsound K R$ axillary infra axillaryB !a!!ary

•

5ocal resonance increased on Rta"illary % infra a"illary B mammary• *dded sounds ; B>6 coarse

cre%titations present in all areasR,LD,



E<AMINA,I4N

INSPE,I4N@-• :istended• 3mbilicus everted/

displaced down• *ll Muadrants moves

eMually with respiration



PER"SSI4N@-

• +i#er s6an-(*.7c! 6normal=7

•

No ShiftingdullnessA"S"+,A,I4N@-

•

0S;4/min• No bruit

PA+PA,I4N @-

•No rigidity•+i#er 6al6a'le - c! 'elowRM

–

rounded edges –Surface ; smooth

–.irm in (onsistency

–No 'ulsations

•S6leen 6al6a'le - 0c! +M•No Cuid thrill



4,HER S5S,EMSVS @-•

S 1 % S 2 heard• No murmurs• No added sounds

NS@-• Higher mental functions intact• (ranial nerves intact on Rt B Dt•

No sensory disturbances• #otor system ; intact• No meningeal signs



S5MP,4MS BCIN2INGS

- A S"MMAR5

PA++4R

PAN 2IGI,A++"11ING

5MP,4MS@-CEVER4"GH1REA,H+ESSNESS

A124MINA+ &is$ension

,4SP+EN4MEGA+5

RS• VCVR• 1R4NHIA+

1S• 1D+ 4ARSE

REPI,A,I4NS



• 'yre"ia of unknown origin• Rt side consolidation%

hepatosplenomegaly % with grade I8'# most probably due totuberculosis 6disseminated ,07

PR4VIS4NA+ 2IAGN4SIS



232

• 0ronchiectasis• ,ropical diseases 6dengue% malaria%

enteric fever% 3,I7

• Haemolytic anemia• HDH• ImmunodeAciency



Investigations

• (0(;*nemia with mildthrombocytopenia

• H0;=.7 g3&l E0( 1$99!';4=G!D;1?G!;=G

• SR + 1/2hr;=9mm % 1hr ;119 hr8E+EVA,E2:

• 'latelet;(.07Dakhs/mm• 'eripheral smear microcytic

hypochromic anemia with mildthrombocytopenia no abnormal cells



•

,I0(; F4$ mcg/dl! #(8;D-E! '(8;$• Sr .erritin; normal! #(H( ;normal• Hb electrophoresis;normal! Reticount

;2G• :(,;Negative

• R0S/R.,/D(,R-D<,S;N-R#*D



• ,?-'(1@,?7'(10/ ,0ilirubin;

N-R#*D• ,rDA6B(ED! 5/:D!5D-;$• *D' ;1$

• (oagulation proAle normal• *05;respiratory alkalosis• Srammonia normal• (S. analysis ; normal



• Man$oux

s$rongly6osi$i#e-))!!



• 3rine R/;normal

•

0lood urine c/s;sterile• Stool (/S;No enteric growth

• 2engue Ig# lisa negative

•

+e6$o Ig#;negative• ,4RH proAle negative

• #';negative

•

Gas$ric Fuice AC1 6times7 ; negative



, ,%orax-R$ !i&&le lo'e consoli&a$ion an& 13+no&ular o6aci$ies ;



• ,reated with ampicillin K clo"acillin Kgentamicin

• No response % fever persisted• Suspected HDH



• Sr.ibrinogen ;normal• ,riglyceride normal• 0one marrow aspirate normal• Diver biopsy to r/o I#; normal

• *ntibiotics changed to #eropenamand vancomycin

Fever %ersisted



• .ungal Dung aspirate (/S Candida?rowth

• Started on Am%hotericin B ;1F days



• (*, II *,, started

•

In$ensi#e 6%ase - )S0H0R00E0 ;(H0R00E0

• on$inua$ion 6%ase - 7H0R0E0

• Steroids added• Reasons for starting *,,

– .ever on B o since 2 months of life – 'ersistent pneumonia – .ailure to thrive

– #antou" strongly positive



'RSIS,N, 'N3#-NI*

( < S , I (

. I 0 R - S I S OOOOOOOO

•(ystic Abrosis work up normal•Retroviral screening 6parents/child7 -#e•Immunoglobin proAle normal



M.tuberculosis- catalase %ositive

organism - disorder of %hagocytosis

2B'



HR4NIGRAN"+4MA,4"S

2ISEASE

:ue to Anancial constraint .low(ytometry not done



2IS"SSI4N G2HR4NI GRAN"+4MA,4"S2ISEASE8G2:

In%eri$e& disorder of phagocyticactivity common in boyssusceptibility to recurren$ infec$ion

since 'ir$%#utations in NA2PH oxi&ase

subunits



+INIA+MANICES,A,I4NS

Onset ; infancy to young adulthood• Recurrent pneumonia•

Hepatic or any other abcess• *nemia of chronic disease• 'oor growth• Hepatosplenomegaly• GRAN"+4MA formation

,I-D-5<;catalase

K8organisms ;

#tuberculosis!Serratia%

0urkholderia

%



4NCIRMA,I4N• .low cytometry

6:HR7• N0, dye test

,REA,MEN,• HS(,• 'rophylactic

antibiotic Bantifungal

• (orticosteroids

• Interferon P

hope 2013 rmmch- vigneshwar

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