2. Dr. Rida Zahid PGT Paediatrics HFH
CASE PRESENTATION
Dr. Rida Zahid
PGT Paediatrics HFH

3. Demographic Details
Name: Maria Father’s name: Syed Masood Gillani Age: 14 months Sex: Female Address: Azad Kashmir DOA: 22/8/2015

4. PRESENTING COMPLAINTS
Fever and progressive pallor -- 3 months

5. History of Present Illness
Fever was sudden in onset, high grade, intermittent, temporarily relieved by antipyretics and not associated with rigors and chills. Progressive pallor associated with lethargy, weight loss and abdominal distension. No h/o bleeding from any site, ear discharge, cough, loose stools, vomiting, burning micturition, rash, joint swelling, fits, headache, jaundice, blood transfusions.

6. PAST MEDICAL HISTORY
Unremarkable

7. Birth History
LSCS with immediate cry after birth. Postnatal history is unremarkable.

8. Developmental History
Gross motor Fine motor Hearing and Speech achieved at appropriate ages Vision

9. Feeding History
Exclusively breastfed for 7 months. Weaning started at 7 months and was not adequate. Her daily caloric intake is 200 kCal/day

10. Vaccination History
Vaccination is up-to-date according to EPI

11. Family History
Product of consanguineous marriage. One sister of 7 months of age. Alive and healthy.

12. Socioeconomic history
Low socioeconomic status Father is driver by profession. Monthly income Rs.10,000. Own house with two rooms.

13. Examination
Grossly malnourished child with marked pallor with vitals of: H/R: 92/min, R/R: 30/min Temp: 100F Height 65cm Weight 7kg (below 5th percentile) Head circumference 42cm No clubbing,cyanosis,edema,bruises,petechiae jaundice, lymphadenopathy.

14. GIT EXAMINATION
Abdomen is distended with umbilicus central in position, soft and non tender. LIVER: Upper border in 4th intercostal space. Lower border is palpable 5 cm below costal margin. Total span of liver is 12 cm. Firm in consistency, smooth surface regular margin and non-tender. Spleen 7 cm BCM. No shifting dullness or fluid thrill BS + Rest of the systemic examination is unremarkable

15. SPLEEN: Firm in consistency Lower border is palpable 9 cm below costal margin. No fluid thrill or shifting dullness present. Bowel sounds are audible.

16. SYSTEMiC EXAMINATIoN
Respiratory System Cardiovascular System Unremarkable Central Nervous system Musculoskeletal System

17. Differential Diagnosis
Malaria
Visceral Leishmaniasis
Malignancy(Leukemia)

18. Investigations COMPLETE BLOOD COUNT: RBC: 376,0000/uL Hb: 7.2g/dL
WBC: /uL
DLC:
Lymphocytes %
Neutrophils %
Monocytes %
Eosinophils %
Platelets: ,000/uL

19. MCV: 64 fL MCH: 19. 5 pg MCHC: 30. 6 g/dL Reticulocytes: 0
MCV: 64 fL MCH: 19.5 pg MCHC: 30.6 g/dL Reticulocytes: 0.6 % Malarial parasite: Not seen

20. Peripheral Film
Anisocytosis ++ Poikilocytosis + Hypochromia ++ Microcytosis +++ No abnormal/ blast cells seen.

21. Iron Studies
S/Iron: 48 ug/dL ( mcg/dL) TIBC: 500 mcg/dL ( mcg/dL)

22. Serum Chemistry LFTS RFTS Bilirubin: 0.6mg/dL ALT: 23 U/L ALP: 232 U/L
Urea: mg/dL
Creatinine: mg/dL

23. SERUM ELECTROLYTES: Sodium: 135 mEq/L Potassium: 3.6 mEq/L
Chloride: mEq/L
Calcium: mg/dL

24. Bone marrow biopsy
Bone marrrow biopsy of the patient showed numerous LD bodies suggestive of Visceral Leishmaniasis.

25. Final diagnosis
Visceral Leishmaniasis

26. Treatment SUPPORTIVE CARE Antipyretics RCC transfusions
Nutritional rehabilitation

27. DEFINITIVE TREATMENT
Injection Sodium Stibogluconate in a dose of 20 mg/kg/day I/M for 28 days.
Patient became afebrile after 10 days of treatment.
Blood counts started improving.
Hepatosplenomegaly regressed to some extent.
The patient was discharged after completion of treatment.

29. Follow up
Patient remained well for 1 month after discharge and then developed similar complaints of fever and progressive pallor but reported to hospital after 4 months of illness on 22/3/2016.

30. O/E, Grossly malnourished, febrile child with marked pallor and hepatosplenomegaly. Her CBC revealed pancytopenia. Bone marrow biopsy was repeated which revealed numerous LD bodies(both extracellular and intracellular).

33. Diagnosis
Relapse of Visceral Leishmaniasis

34. Patient has been started with 2nd line treatment
Patient has been started with 2nd line treatment. Lyophilized Injection Amphotericin B in a dose of 1mg/kg/day for total 14 doses.