Thursday, February 28, 2008

Psychological problem in children:a case of faecal soiling

His mother is worried –the boy of 7 years from a affluent family soiling his pants with feces 8 to 10 times a day for the last 1 month. His first symptoms developed actually 1 year back but the frequency increased in the last one month. His friends became aware of his problems because of the foul smell he emits and they started to avoid him. Mother also suspicious that similar situation is arising in the school as feacal soiling is present in her child after coming from school.

He is giving a history of constipation in his early years and avoidance of vegetable in his diet. His stool is otherwise formed

He is healthy, built and nutrition is above average. His abdomen is normal and per rectal examination anal grip is alright.

In psychological assessment, he is found under academic stress in his school and at home and get frequent punishment from parents especially mother who looks after the study of the child.

So, this is a case of Encopresis and the family needs to understand the situation, psychological support, change in attitude and behavioral adjustment.

Monday, February 25, 2008

Judging clinically: A case with prolong vomiting, bulging fontanelle and unconsciousness

The boy was laying in the bed unconscious when I first saw the patient. He is a two year old boy with history of vomiting over 2 months and impaired consciousness for 3 days.
The vomiting was mainly in the early morning.
He was seen by his local physician and more than one pediatrician over the weeks.

On admission his GCS score was 8/15, he has braycardia, mild hypertension and bulging anterior fontanelle and mild papilloeema.

His CSF study was normal. MP was negative. US of the brain shows ventricular dilatations. CT scan shows homogeneous opacity in the cerebellum extending into the 4th ventricle and obstructing the CSF pathway causing hydrocephalus and the mass is labelleled as medulloblastoma

So, the case diagnosed as a case Medulloblastom of the Brain and referred to the Neurosurgeon for further management.

There was clue for the brain tumor in this patient- the vomiting persisting over days an dmostly in the morning and afebrile state of the child go in favour of brain tumour. The child should have been evaluated earlier by the CT scan to explore the possibility of brain tumour and the condition could have been diagnosed earlier.


Thursday, February 14, 2008

Judging clinically: A case of bleeding from mouth, ecchymosis, pallor and shock

The boy was brought to the ward with profuse and fresh bleeding from the mouth for a day. His mother told that he had the same episodes of bleeding 5 to 6 times since birth but never so profuse and no history of hemarthrosis. One of his maternal uncles died from uncle bleeding at the age of 25 years.

He was deadly pale and in shock Few ecchymoses were also found on the lower limbs of the body. He had no fever, no lymphadenopathy, no hepatospelomegaly and no bony tenderness.

We thought the case as Hemophilia. The patient recovered after getting two bags of fresh blood.

Patient’s investigations revealed normal BT, CT and Platelet Count. He had leucocytosis and neutrophilia probably due to acute hemorrhage. Blood his blood film reveals Plasmodium Vivax. Our MRCP Colleague preferred to give him a course of Chloroquine at the same time.

With normal BT, CT the patient may be a case of von Willebrand Disease, Type –I, instead Hemophilia.

The patient was also given inj caprolysin locally in the oral cavity. The patient was also given Trianexamic acid orally. Cryprecipitate containing VWF is not available here as well Desmopressin.

Regarding malarial infection, malaria will not cause bleeding unless it produces DIC in extremely critical cases, that is also related with Plasmodium falciparum, not related with vivax. Could there be a concomitant infection of malaria along with bleeding diathesis? There must have been warning sign such as fever, headache, voming etc for malaria to be present as a parallel disorder in this particular patient.

Badrud Doza.

Monday, February 4, 2008

Judging clinically: A case of prolong fever, jaundice, hepatospenomegaly and ascites

Age of the child is about 2 years. I came across the patient on 9th day as the patient is a relative of one of our doctor. He is suffering from fever which is intermittent in nature, occasionally rising to 103 degree F. The patient has mild jaundice. His abdomen is distended, has mild ascites, liver is moderately enlarged and tender. The patient is anorexic and irritable.

His peripheral blood picture was normal, Mp- negative, TO titre of widal test was 1:320, Urine R/E normal, US reveals mild Asites, hepatosplenomegaly. His Hb-12.3 gm/dl, Serum bilirubin -4.5 mg/dl, ALT -936 U/L, AST 312U/L, Alk phosphatase 1028 U/L. IgG and IgM for Dengue were negative, Serum Albumin 3.3 .Prothombin time 22 secs against control of 14 seconds, His HBsAg was negative. IgG and IgM against Dengue were negative.

Because of prolong fever, endemicity of enteric fever and suggestive titre, my senior colleague who is an MRCP in Paediatrics from UK was suspecting the case as an Enteric fever and giving him Ceftriaxone.

He also covered malaria by giving Quinine as the fever is high and as malaria is also prevalent in this area though his Blood for MP and ICT for plasmodium was negative. In Bangladesh one cannot rely hundred percent on the laboratory finding.

He also excluded the possibility of dengue by doing the serological test for dengue as Dengue may present with fever, ascites and jaundice.

We level the case as Acute Viral hepatitis. In Enteric fever, the lever may be involved but more in the second week and it will take time for the liver to be grossly enlarged by 9 days. It is not malaria as jaundice in malaria is rare and occurs only in sever cases and hemolytic and prehepatic in nature. Hepatic enzymes will not be increased in malaria. Liver may be enlarged in malaria due proliferation of reticulo-endothelial cells with malarial parasites entrapped inside and the spleen will be more enlarged. Present Epidimiological reports goes against Dengue at present.

We stopped quinine and other hepatotoxic drugs and patiet was given lactoluse, Inj Konakion, avoid paracetmol and sedatives. Now the patient is gradually recovering.

Badrud Doza