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.

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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.

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

Legg-Perthes disease with limping

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.

He has no fever and he is otherwise healthy.

As pain was not improving, he had his Xray done which shows subchondral erosion on the right side prominently and on the left side mildly. The changes are suggestive of Leg Perth’s disease.,

Osteotomy of the Rt femur was done below the neck and internal rotation and fixation done by our Orthopedic Specialist Prof Imamuddin(dr_imamuddin@yahoo.com). To improve the blodd supply and the change the aaxis of the load of through the leg.

The patient is now improving.

Badrud Doza

Congenital Hypoplastic Anaemia (Diamond-Blackfan Anaemia)

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

Henoch -Schonlein Purpura with gastrointesinal bleeding and hematuria

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

Badrud-Doza

Emaciation and vomiting ends in the diagnosis of Diabetic Ketoacidosis

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.

His father is a NIDDDM.

On physical examination, he was found apprehended, lethargic and emaciated. His ht is alright but the weight is less.

He was dehydrated and had mild acidotic breathing. His pulse was rapid and Bp was 90/50 mmHg. His other system was found normal.

On investigation his urine shows 4+ glucose. His random blood sugar was found 298mg/dl. Fasting blood sugar was 228 mg/dl.. In blood gas analysis PH was 7.18 and HCO3 was 19, pCO2, pO2, SaO2 were und normal, in serum electrolytes Na was 133 mmol/L and K 3.6 mmol/L, others optimum. Serum creatinn was found normal . His urine for ketone bodies was positive.

The case was diagnosed as a case of Diabetic Ketoacidosis.

The patient was given fluid, Insulin, potassium, antibiotic and diabetic diet.

Patient after becoming stable , transfer under care of a diabetologist.

Badrud Doza