A boy of 12 years has been suffering from pain in the right hip joint and limping of the right leg for three years. The pain was intermittent and relieved by pain killer as prescribed by local physician.
The patient is now improving.
A boy of 2 months presented with persistant pallor and growth failure. He is normally delivered and breast fed.
He has no craniofacial deformity, limb anomalies or cardiac malformations. He has no lymphadenopathy or any other organomegaly.
On investigation, his Hb was 4.1 gm/dl, ESR -27 mm in 1st hr, platelet 1,86,000/cmm, Total RBC 3 m/cmm, Total WBC 4600/cmm, Neurophil-38%, Lympho-56%, Mono 04%, Eosini02%, Baso-00%.
Peripheral blood ilm shows anisochromia and anisocytosis with low distribution,WBC -mature and normal count and distribution, platelets are normal.
Bore marrow shows hypercellular marrow with increased M: E ratio. Erythropoesis is grossly depressed. Only occassional megaloid erythroblasts are seen.
Granulopoesis is hyperactive and maturing into segmented forms. Histocytes are increased.
Lymphocytes and plasma cell are within normal limit. Megakaryocytes are normal. The bone marrow is suggestive of Pure Red Cell apasia.
The case may be lebelled as Congenital Hypoplastic Anaemia or Diamond-Blackfan Anaemia.
Badrud Doza
A girl of 8 years presented with fever, pupuric rashes , gastrointestinal bleeding and hematuria of 2 weeks duration.
Fever is moderate in degree and intermittent in nature, palpable rashes are distributed on the external surfaces of the body with occasional overlap on the other areas, GI bleeding was in the form of hematomesis and melena , hematuria was mild in nature.
He had no past history of the same illness, no history of offending drugs or agents taking that may cause blood dyscrasias
On physical examination, the child has mild pallor with normal pulse, BP,temp and respiration. She has no lymphadenopathy or hepatospenomegaly. Other system reveals no abnormality.
The case was suspected as a case of Henoch Schulen Purpura.
Because of fever among the other possibilities we consider Dengue Haemorrhagic fever, Leaukemia, aplastic anaemia were considered.
On investigation, Hb was 13.5 gm/dl, TC, DC, BT, CT, Platelet, PBF, X-ray Chest were normal.
So the provisional diagnosis prevailed as the final diagnosis.
Pt responded well to prednisolone with the subsidence of bleeding tendencies. Patient is still our ward waiting for more recovery.
Badrud Doza
A boy of 12 years presented with vomiting of several times for 7 days. On enquiry he reported to have polyuria and polydepsia for 1 month.
He was dehydrated and had mild acidotic breathing. His pulse was rapid and Bp was 90/50 mmHg. His other system was found normal.
A boy of 2 year 4 months presented with respiratory distress of 1 day, fever of high grade for 7 days and swelling of left shoulder and arm of 8 days
On examination, he was found in dyspnoea, left side of the chest full with restrictricted movement,vocul fremitus absent with shifting of the trachea and apex beat and breath sound and vocal resonance absent.
His left should
er was found swelled, hot and tender which extended down to the arm.
His X-ray of the shows Pneumothorax of the Lt side with collaps of the lungs and shifting of the mediastinum. Xray of the left arm shows no bony pathology.
The case was labeled as Septic arthritis of the left shoulder and Spontaneous with Pheumothorax of both lungs.
Water seal drainage of the chest was given immediately after admission and later when the patient settled the pus was drained out from the left shoulder by giving incision. Inj Ceftriaxone and Inj flucloxacillin were given as antibiotics.
Interestingly the patient developed later pneumothorax of the rt side of the chest which was found on check x-rays.
Temporary relieve of the tension in the Rt chest was also required. Now the Patient is recovering and we hope to discharge the patient within few days.
Our surgical and orthopedic colleagues helped us in the management of the patient.
Bdoza
A boy of 3 months presented with persistent jaundice from 3 days o life, pale color stool , high color urine and occasional vomiting.
On examination he is found nutritionally compromised, moderately jaundiced, has hepatosplenomegaly but no ascites.
On investigation, Serum bilirubin- was 8.8 mg/dl( direct -3.6mg/dl, indirect- 5.2 mg/dl)
SGPT (ALT)-105 U/L, Serum Alkaline phosphatase- 970 U/L, prothrombin time -23 sec against control of 15 sec.
USG shows non visualized gall bladder and common bile duct
HIDA scan shows radiotracer concentration in the liver in early images. No radiotracer concentration is seen in the gall bladder region and in the intestine even after 2 and ½ hours .
The case is diagnosed as Biliary Atresia
Our surgical colleagues were consulted for surgical management of the patient.
Bdoza
A boy of 3 years coming from endemic area of Dengue presented with 5 days fever, vomiting for several times, gum bleeding and bleeding per rectum He has no h/o bleeding in the past.
On exam the found irritable, mildly anemic, not jaundiced or cyanosed. There is no lymphadenopathy, no hepatosplenomegaly, no bony tenderness. His has tachycardia but blood pressure is normal.
He develops no ascites or pleural effusion.
On investigation, he has thrombocytopenia( 60,000) but PCV -normal (36%)
His IgG and IgM for Dengue were positive.
The patient is lebeled as Dengue Haemeorhagic Fever -grade II.
He is kept under mosquito net, given infusion/ORS, antipyretic, normal diet and kept under close monitoring.
Badrud Doza
A boy of 2 years and 3 months presented with deep jaundice, in semiconscious condition and with bleeding per rectum.
When asked mother said that he developed jaundice I month back from which he gradually recovered. Then he was given antihelmenthic 3 days back after which his condition deteriorates
On examination, he was found to be deeply jaundiced with oedema and ascites.
On admission pulse was 126/m, BP 90/60 mmHg, temperature 102.5, respiratory rate 50/m, liver was not palpable.
On investigation, his Hb was 11.5 gm/dl(on admission), TLC-15200/cmm, N-78%, L-12%, bilirubin 28.8 mg/dl, direct 12.7, indirect-16.1, SALT 342 U/L , Alkaline phosphatase 487U/L , HBsAg negative, Prothrombin time 60 sec with control 22 sec, ratio 4.28, Index 23.3%, INR 5.56 Serum Albumin 3.4gm/dl. Random blood sugar 42.8 mg/dl, Serum creatinine .6 mg/dl, serum electrolytes-normal.
Patient was progressively deteriorating, develops convusions and anuria
Patient is labeled as Hepatic Encephalopathy with Hepatic failure and Hepatorenal Syndrome
The patient is kept on parental fluid, oxygen, antibiotics, lactoluse, konakion, pulv streptomycin, Inj Mannitol and blood , domamine etc.
The patient is fighting for his life.
[Note: When the liver in hepatitis patient regresses in size, it indicates grave sign and poor prognosis
Recovery from hepatorenal syndrome is also difficult
When Hepatic Encephalopathy is grade IV, mortality is also high]
Badrud Doza
A boy of 8 years presented in outdoor setting with choreotic movements of the limbs of the right side and slurring of the speech for the last one and half months.
He has no h/o sore throat, no joint pain or chest pain.
On examination, he was found alert but emotionally labile and afebrile.
Muscle tone and power of the limb on the right side decreasedBut reflexes normal and gait were found normal
Milkman’s grip- positive, serpentine tounge- absent, supination pronation test normal.
On Investigation- hw was mildly anaemic, ESR slightly raised , TLC & DLC normal, ASo titre 200 iu/ml, Xray, ECG normal, CT –was also found normal .
Patient was provisionally diagnosed as Rheuamtic Chorea.
The patient was treated with Injection pecilicillin, Tab prednisolone, Tab peridol,Tab parkinil, then Tab clobam
The patient responded to treatment and his symptoms alleviated. Patient was on close follow up.
The posibilities of intracranial tumor was excluded on first examination ansl on follow up and recovery of the patient on anti Reumatic treatment and his wellbeing at one year aftyer diagnosis assures the first clinical conclusion.
Diagnosis of Reumatic Chorea is more clinical.
[Footnote: Rheumatic Chorea does not follow the Jones criteria for dianosis.
Rheumatic Chorea as a single manisfestation may indicate Rheumatic fever.
ESR may be low as the inflammatory changes in the brain is minimal.
The clinical manifestation may occur months or years after the initil sterptococcal infection]
A boy of 8 years presented with facial paralysis of 5 day duration in the outdoor setup. He had a history of febrile episode 5 days back. Initially he had mild pain, no history of trauma, no features of CNS involvment.
An 11 year boy admitted in our hospital with fever for one and half months, severe pain and swelling of multiple joints. He has no recent history of sore throat, no family history of RA, no features of Psoriasis, no h/o contact with tuberculous patient, no h/o hear disease.
On examination, subcutaneous nodules over bony prominences, multiple, discrete, non tender, lymph nodes at different sites were found. There were no hepatosplenomagaly, no murmer, no bony tenderness and no bleeding manifestations .
He has anaemia, leucocytosis with neutropenia, high ESR. Urine analysis, Platelet, PBF, X ray of the chest and ECG were normal. Xray of the right knee joint shows soft tissue swelling, blood culture negative. ASO titre was 400 IU ( may be a coincidental finding of past streptococcal infection). RA factor abd ANF were absent.
Possibility of tuberculosis, leaukaemia, bacterial endocarditis were excluded.
The patient was level as Systemic onset JRA.
The patient was given tab Ibuprofen and 2 days later as the patient was not improving oral prednisolone was added.
One week after the admission the patient is now settled.
Bdoza
Ultrasonography of the Abdomen reveals a cystic structure behind the urinary bladder.A boy of 4 years admitted in our ward with gradual weakness of lower limbs started 5 days back with inability to stand and walk. The weakness gradually involves the upper limbs and the patient become unable to move or hold anything by his hands.
He had a history of short viral episode 7 days back
Patient is conscious but irritable, had tachycardia (pulse 130/m) and Hypertension (BP 130/85 mmHg) but the patient had no bladder or bowel involvement.
Muscle Tone and Muscle Power of the limbs were decreased. The reflexes of the limbs were absent or diminished. Sensory minimally affected.
The patient was level as Gullaine-Barre Syndrome with Ascending Paralysis and hypertension.
CBC is normal, CSF study on the 8th day showed Lymhocytes 30/cmm, Protein 145 mg/dl.
The patient was given Inj Methyl Prednisolone for 5 days. The IVIg was not available in the local market. For hypertension no specific drug was given, it came to normal on 3rd came down to normal on 3rd hospital day.
The patient now is slowly improving, his power of the upper limbs is much regained but the lower limbs is still weak and he is not able to stand or walk.
The patient is still in our ward and under our care.
Bdoza
Links : GBS-information page of National Institute of Neurological Disorders & Stroke
GBS Foundation International
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A boy of 8 years, a child of immigrant parents to USA, who recently came to visit Bangladesh presented with fever, abdominal pain and vomiting.
He had no definite tenderness in the abdomen and no other abnormal finding. Other members of the family had viral fever in the recent past.
Initially the child was thought to be a case of viral fever. But as the fever was not subsiding as that of others, investigations were done. Widal test showed strongly positive (TO 1:320), in ICT for Salmonella IgM was positive but not the IgG, MP in blood film and in ICT was negative.
The Patient was treated with Injection Ceftriaxone and supplemented by oral Azithromycin Response was slow. Initially vomiting stppped, then the abdominal pain, fever took 6 days to come to the base line after introduction of Ceftraixone. He had fever for total 11 days
We continue Ceftriaxone for 4 afebrile days and Azithromycin for 5 afebrile days.
Bdoza
A boy of 14 days admitted in the Neonatal ward of our hospital with fever, respiratory distress, rash and abdominal distention.
On close examinatin, the rashes were found to be purpura and ecchymosis; the lung has bilateral crepitations, the abdomen is distended for hepatospenomegaly.
On clinical imprestion it was first thought to be a case of Neonatal Sepsis. The next possibility is Torch Infection.
But the blood count reveals Hb-5.3 gm/dl, TC of WBC -1,600,000 /cmm, 90 of them are blast cells, peripheral blood film study reveals them as lymphoblasts.
So the diagnosis was lebelled as Congenital Acute Lymphobalstic Leukaemia.
Bdoza
A girl of 7 and half years presented in gasping with obesity, uncounciousness with a history of gastroenteritis. She was on Sodium Valproic Acid for the last 5 years for siezure disorder. Her CT Scan at 2 and half year showed cerebral atropy due to hypoxic ischaemic encephalopathy.
She was extremely obese and short statured, had developmental delay and mental retardation. But her facial dysmorphismis not marked and she had no polydyctaly.
Labratoty finding shows sodium-187 meq/L, potassium-2.3 meq/L, cl, HCO,glucose and Ca normal.
The patient was lebelled as Prader-Willi Syndrome with epilepsy and acute metabolic derangement.
The patient was intubated, fluid was appropriated, dopamine and dolbutamine was given, antibiotic and anticonvulsive were added
Bdoza
Congenital Teratoma
A boy of 3 days, home delivered presented with massive abdominal distension. Otherwise the patient had no sign of sepsis, hemorrhage or toxicity. Bowel and bladder moved normally.
CBC, CRP, urine for R/E, Liver and Renal functions were found normal. US shows solid tumor suspecting teratoma.
The patient was shifted from Neonatal ward to the Paediatric Surgery.
Laparatomy was done, a solid tumor adherent with the posterior wall of the stomach was found.
The tumor was resected, stomach repaired and anastomosis done.
The excised tissue was sent for histological and was reported as Teratoma containing elements of connective tissue and neural tissue.
Bdoza
ITP with pupura and subconjunctival Haemorrahge
A girl of 6 years presented with 5 days fever, subconjuctival haemoorage and skin rashes.
The patient was also giving the history of passage of stool mixed with altered or fresh blood and also passage of reddish urine.
On examination, the patient was alert and conscious, non toxic, the rashes were identified as purpura present all over the body. There was mild hepatomegaly. but no splenomegaly no lymophadenopathy and no bony tenderness.
Clinically we suspect the case as ITP or Dengue fever, or Laukaemia
Though at present, there is no epidemiological evidence for Dengue, we wanted to exclude the Dengue as the rainy season begins in our country. But though platelet count was 50000/cmm, But the PCV was 38% and antibodies against the Dengue were absent.
The other features of peripheral blood pictures are normal. We were preparing for bone marrow aspiration.
In the meantime , pt was start improving, her bleeding stops, there was no further crops of purpura, no epistaxis, no malean and no hematuria.
The fever may be a coinfection on ITP.
Bdoza
A girl of 8 years presented with fever, abdominal pain and vomiting of one day. I have seen the patient in outdoor setting. The fever was high grade, pain was central, vomiting occurs once containing food particles which suggesting the case as food poisoning.
On examination, the patient was looking sick, abdomen was tender centrally with muscle guard. Macburney’s point was not definitely tender.
To exclude the appendicitis, we suggested investigation for blood R/E, Urine R/E and Ultrasonography.
Ultrasonography reveals Acute Appendicitis and Ascites.
The patient was admitted and operated.
A 7 year old child from Sandvip, an Island west of Chittagong came to our hospital with fever for 22 days, jaundice and abdominal pain.
On examination, his jaundice was moderate, abdomen was tender on the epigastric, right lumber and Rt hypochondriac region. His liver was 5 cm enlarged, tender.
Ausculatation of the heart reveals a murmur which is systolic in nature at the left upper sternal border.
We thought it could be a) a case of Infective Endocarditis out of a noncyanotic congenital heart disease
b) Enteric fever with hepatitis
c) Hepatic abcess
We started treating the patient with Injection Ceftrixone and Inj penecillin.
In the meantime , the investigation reveals normal widal test, normal blood culture and X-ray shows mild cardiomegaly and Echocardiography suggests ASD.
The fever started to subside and sense of wellbeing improved on the 4th day and by 9th day, the patient become afebrile.
After review, we settled our final diagnosis as Enetric Fever with hepatitis and ASD.
Ridwan, aged 8 years, is a case of Nehrotic Syndrome. He is suffering from NS since the age of 3 years. He has repeated attacks over the years. This is his 8th relapse. He is a case of Minmum Change Nephrotic Syndrome.
Each time he responded to oral prednisolone. But this time he develops persistant vomiting . Vomiting is so severe that he develops anuaria which is partly contributed by low albumin in his blood.
We admitted the patient in the hospital and investigate. His serum electrolytes reflected hyponatrimia, hypochloramia and hypokalamia.
We exclude any infection and peritonitis. We conclude that the vomiting is prednisolone induced.
We stop the drug and switch over to I/V Methyl Prednisolone. He has kept on Methyl Prednisolone for 10 days.
We also have to give him I/V albumin for 3 days as the diuretics are not enough to induce urination.
When vomting stops and the patied sattled and urine become albumin free, we switch over to oral prednisolone and discharge the patient from the hospital.
Bdoza
She has developed jaundice for the last 7 days. She is 4 and 7 months of age. No other complaints. No fever, no nausea or vomiting. even no abdominal pain, only anorexia.
But she was taking Sodium Valproate (Sup Valex) for the last 4 years. She was given this drug after convulsions at the age of 6 months. Since then she had no further convulsion and continued to take the medicine till date. She was vaccinated in infancy against Hepatitis B.
On examination, the patient was found moderately icteric.Liver was enlarged 8 cm, mildly tender. Other systems were normal.
Serum bilirubin was found 5.3 mg/dl, SGPT 535 IU/dl, Alkaline phosphatase 1388 IU/dl. Her HBsAg was found negative, prothrombin time normal.
Ultrasonography was consistent with Acute inflammation of the liver.
We conclude this could be a case of Acute Hepatitis induced by prolonged use of Sodium Valproate.
We withdrew the drug.,admit the patient in the hospital for better observation.
Patient was gradually improving. After 7 days, we repeat the Liver Function test. The Serum bilirubin come down to 1.3 mg/dl, SGOT 57 IU/dl, Alkaline Phosphatase 103 IU/dl.
Patient was discharged with advice to come after 7 days for follow up.
Bdoza
The girl admitted for severe pallor. She was a 7 year old girl with poor socioeconomic background. She had clinical features suggestive of Down Syndrome with facial dysmorphism, hypotonia, developmental delay and low IQ.
On examination, she was found to be severely anaemic. No clue could be identified for such a degree of anaemia. Possibility of malaria, leukemia, thalassemia were excluded clinically and by blood examinations.
There was cardiomegaly but no murmer. On Xray , lung field was translucent and there was no sign of pulmonary oedema.
Echocardiographist identified ‘truncus solitarius’ and pericardial effusion.
For pericardial effusion, we are searching for cause, tuberculosis is a possibility.
Bdoza
A boy of 3 years presented with limping and weakness of the lower limbs of acute onset.
After admission, his paralysis was deepened in the lower limbs and the upper limbs developed paresis.
When the patient shifted to our ward, he was already in respiratory distress.
His was conscious but his Bayniski’s sign was negative and reflexes in the limbs were absent. His pulse was rapid and blood pressure norrmal.
His bladder and bowel were not affected.
The case was diagnosed as GBS (Gullain-Barre Syndrome) with ascending paralysis with respiratory failure
We have taken all supportive measure and at one stage the patient was intubated but the patient deteriorates rapidly and expires.
Bdoza
A child of 6 years presented with 14 days fever and rt upper abdominal tenderness. He was lebelled as 'Enteric Fever' and admitted in hospital for parenteral medication(30/5/07). Among lab test, widal test was found positive. On the second day of hospital, he developed hypothermia and shock. Pt was transfered to critical care unit and managed. Pt recovered from hypothermia and shock after 48 hours of intensive manuevre with blood, fluid, dopamine, dulbutamine, nasogastric suction and oxygen. Ceftrixone was contuied but oral Azithromycin has to replaced with IV ciprofloxacin.
When the patient become stable and we were feeling a little relaxed, the patient developed respiratory distress and little puffiness of the face. We vealuate the renal funtions- his output was normal, serum creatinine and electrolytes was found normal.
On auscultation, pt had bilateral crepitaions and tender hepatomegaly. Pulse was 142/m, BP 105/70, Ultrasonograpgy of the abdomen was found normal. Xray shows mild pulmonary edema. Myocarditis with heart was suspected and pt improved after giving Inj Lasix and lasix prescribed for twice a day.
Pt's fever was persisting and oral Azithromyecin was added. But the patient develops hypothermia again in late hours of the day(5/5/07). To raise the temparature, blanket was used and pt was given steroid in Inj form. His pulse, BP,bowel was normal. So, is the hypothermia is a beacuse of toximia?Pt was also irritable and restless then.
By morning the patient become a bit settled, distress decreased and temparature normalised.
We are still fighting for the patient.(6/6/07). Not yet sure about the outcome.
Bdoza
A girl of 6 yrs presented with hemiperesis of 1 month standing. On clinical evaluation She also had facial palsy of upper motor neurone type.
She had no fever, no cardiac problems, no hematologial abnormality.
Provisionally we diagnosed the case as Acute stroke syndrome.
Her routine examinations reveal no abnormality. But CT scan shows Astrocytoma of the the brain stem.
Bdoza
A boy of 7 years presented with dyspnoea, precordial bulging, hepatomegaly and leg oedema. Clinically he had pansystolic murmer over the left lower sternal border with loud second sound. Provisionally it was thought to be a case of VSD with heart failure.Xay showed cardiomegaly with pulmonary oedema. In ECG, there was right ventricular hypertrophy and right atrial hypertropy. In hospital, the patient had ungone a critical phase developing shock. When the shock was overcome, in Echo, the cardiologist commented ASD(secundum) with mild mitral incompetence and pulmonary hypertension.
But if we clinically corralate the case, it is better conform with ASD(primum) with Mitral incompetence with heart failure.
Bdoza
A boy of 10 years presented with fever and abdominal pain for 15 days. Then he developed vomiting which was persistent in nature. On evaluating the patient, ultrasonography showed uniformly echogenic swollen pancreas suggestive of Panacreatitis. The patient serum amylase was found normal but urine amylase was highly elevated. The patient also had neutrophilic leucocytosis. At one stage, pt developed muscle spasm of the hands and neck. Serum calcium was found decreased.
The patient was a case of Acute Pancreatitis with persistent vomiting with hypocalcimia.
The patient was treated conservatively with nothing by mouth, infusion, parenteral antibiotic and calcium. The patient was improved and discharged .
A boy of 6 years otherwise healthy developed sudden unconsciousness. He had a distant history of convulsive disorder at his earlier years for which he had taken anticonvulsant for one and half years. Than he discontinued the medicine for 3 years. Malaria, meningitis, metabolic derangement and intoxication were excluded.
The patient was levelled as 'Non convulsive Status Epilepticus'.
Bdoza
A boy of one and half years presented with fever of 5 days becoming pale rapidly and passing red colored urine coming from an endemic area.
The patient was found to be a case of Severe Malaria where anaemia developed due to rapid haemolysis of RBC and the urine become red due to presence of excess haemoglobin.
The patient was treated with Inj Quinine and responded well within days and then discharged.
Bdoza
At this momont, we have two patients of thalassemia with jaundice. Both are male, age 7 yrs, both are from poor socioeconomic class and both are thalassemia intermedia.
The first case has taken blood transfusion 1 year back, the second case was on hydroxyurea.
Both are HBsAg negative.
The first one develops jaundice due to acute hepatitis-nonB virus.In second the jaundice is induced by the hepatoxicity of the hydroxyurea.
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