Total stay-18 days
History given by Parents and child himself. ( Reliable)
Fever X 11 days
Swelling in Neck X 11 days
History of Present Illness
The child was apparently well 11days back, when he developed fever, continuous, highgrade, upto104F, maximum during nights,coming down on medication(Ibuprofen+Paracetamol) and was a/w profuse sweating how ever there was no h/o chills or rigors.
Fever was followed by swelling in the neck region below jaw on both side, more prominent over rightside, which was progressively increasing. There was no h/o any redness over swelling, pain or discharge from the swelling.
No h/o sore throat, oral ulcers or difficulty in swallowing.
No h/o ear discharge or ear ache, running nose or nasal blockade.
No h/o cough, chest pain or shortness of breath.
No h/o progressive pallor, or prominent wt loss or bony tenderness, or bleeding from any sites.
No h/o joint pain, joint swelling or blurring of vision
No h/o rashes over the body, or photosensitivity
No h/o vomiting, altered or loss of consciousness or abnormal body movements.
No h/o abdominal pain or swelling.
No h/o travel to malaria and kalaazar endemic region , or forest regions.
No h/o exposure to TB or prolonged intake of any drugs.
The child has cattle in his house –cows. And gives h/o drinking unboiled cow milk. No exposure to cats or dogs
Bowel/Bladder habit was Normal.( No h/o loose stool, blood or mucus in stool, no h/o burning micturation or frequency)
Appetite decreases since illness.
For this Problem he was taken to Local health post where he was given Paracetamol. After the fever was not relieved he was brough to ER after 5 days of fever.
CBC TC= 4500 N=66, L=30, M=04, Hematocrit=32, Plateletes= 142,000
Urine RME= WNL CXR-Normal Blood C/S, Urine C/S sent
Discharged on syp Ofloxacin 15 mg/kg/day (took for 3 days)
Then he was taken to clinic after s/s did not improve ,where Cefixime 14mg/kg/day was given for 3 days.
Past History-No significant illness in the past.
Birth, Neonatal and developmental h/o were non-contributory
Family Hx-His grandmother was treated for PTB 35 yrs back. Dose completed. His brother has similar illness 3 years back with neck swelling and fever , he was treated at PH as well and recovered fully. ( Documents could not be retrieved)
Immunization Hx-Complete as per EPI schedule, BCG scar +
Socio-economic Hx-Child lives in nuclear family in village, in cement house, Cattle-shed attached to house.
Allergic Hx-no known allergy to any substance
General condition-ill-looking, lethargic
Temperature= 102 F
PR= 110/min, regular, good volume, bounding, all peripheral pulses palpable, no radio-radial or radiofemoral delay.
RR= 25/min, regular BP= 100/60 mmHg Lt hand supine.
B/L Submandibular LNswere palpable,multiple, Discrete, mobile, non-tender, firm, no discharging sinuses and redness, size-Right side measuring upto 2 cm, and 1.5 cm on left side.
Axillary LNwere palpalble B/L, multiple, 1 LN =1.5 cm size with similar characteristic.
Inguinal LNS were palpable B/L but were insignificant size.
Pallor , Icterus, Edema, Clubbing, Cyanosis were absent, JVP-not raised.
Wt-17kg (25-50thcentile) , Ht-108cm (5-10thcentile)
Skin texture and hair are normal.
Thyroid examination –Normal
Bone and joints -Normal
Chest –B/L Moving equally with respiration ,B/L equal expansion, Normal resonance on percussion. B/L VBS, no added sounds. VF= B/L equal.
CVS-S1,S2 Normal, No Murmur.
Per Abdomen Examination-
Soft, non-tender, Liver –palpable 6 cmbelow Rt.SCM in MCL, span = 12 cm, firm, Non-tender, sharp margin, smooth surface, Rt. Lobe was enlarged as well.
Spleen palpable 3cmbelow Lt CM, soft, smooth, non-tender and notch felt.
Fluid thrill –, Resonant note on percussion and Shifting dullness –
Bowel sound heard.
HMF-Normal, CN-were intact
Motor and Sensory system were normal.
Meningeal sign –, Cerebellar signs –
Assessment- Fever with Generalized Lymphadenopathy with Hepatosplenomegaly
Provisional diagnosis – Enteric Fever
Points in favour –
Rx-Injection Ceftriaxone 100mg/kg/day Started.
Repeat CBC TC=8800 , N=48, L=48, ESR= 78 mm/hr
Peripheral Blood Smear-Hypochromic normocytic RBCs, Malarial parasites not seen, no atypical cells.
Chest X-Ray PA view-Normal findings
Repeat Blood C/S sent.
Blood C/S & Urine C/S traced -no growth , Mantoux Performed.
LP done(Irrelevant talk) –Normal
Response was guarded, fever persisted, vomiting 1-2 episodes, after feeding, appetite significantly decreased.
CSF= no growth, Mantoux = 0 mm
c/o-Fever not relieved, spikes 103.5 F, 102 F,102 F
Headache +, Swelling over neck not subsided.
Child was irritable and lethargic.
Examination within Normal limit, Meningeal signs were absent.
Bone Marrow Aspiration and Biopsy performed and Sent.
ANA, Brucella IgM, VCA IgM were sent
Inj Cloxacillin 100mg/kg/day added
Inj Ceftriaxone was stopped as fever did not respond to it.
Inj Chloramphenicol was added
Inj Cloxacillin was continued.
Bone Marrow Cytology and Biopsy –No abnormality, no LD bodies. Bone marrow C/S-No growth
ANA= Negative, Brucella IgM= Negative VCA IgM = negative
Fever spikes Persisting, LN-not regressed.
Ultrasonography –Hepatomegaly 13.3 cm , Splenomegaly=12.2 cm, minimal ascites, rest normal.
LN Biopsy was planned for Next day.
Inj Cloxacillin stopped.
Child afebrile for 18 hours, no new spikes of fever, LNs subsiding.
Child’s General condition improved.
Plan for LN Biopsy was cancelled.
Over Day 11-18 :
No new episode of fever, LN-regressed completely, Liver -2cm, spleen-0
Appetite Improved and child better .
Undiagnosed Fever (Resloved) most probably Enteric Fever.
Inj Chloramphenicol was given for total 10 days.
Child was Discharged and Followed up.
THE INVESTIGATIONS NOT SENT WERE NOT AVAILABLE IN OUR SCENARIO.
ANY Suggestion on which disease it should have been diagnosed as , please leave comments.