A case of Child with Fever, lymphadenopathy and Hepatosplenomegaly

Patient Details
Master Lama
Age-6 years
Address- Kathmandu
Total stay-18 days

History given by Parents and child himself. ( Reliable)

Chief Complains-
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.
Sleep -normal.

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.

Cardinal Signs-
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)

Systemic Examination-
Skin texture and hair are normal.
ENT examination-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 –

•Splenomegaly, Hepatomegaly
•Fever with headache
•Relative Bradycardia
•CBC- low count with relative leucocytosis
•Lymphadenopathy can occur with enteric fever.
Points Against-
•Not responding to Cefixime
•Not responding to Ofloxacin
•No GI symptoms
Differential Diagnosis-
Infectious Mononucleosis
Disseminated Tuberculosis
Occult Abscess
Hodgkin Lymphoma
Rikettsial Fever

Inpatient Course-

Day 1
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.

Day 2-
Blood C/S & Urine C/S traced -no growth , Mantoux Performed.
LP done(Irrelevant talk) –Normal

Day 2-Day5-
Response was guarded, fever persisted, vomiting 1-2 episodes, after feeding, appetite significantly decreased.
CSF= no growth, Mantoux = 0 mm

Day 5
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

Day 7
Inj Ceftriaxone was stopped as fever did not respond to it.
Inj Chloramphenicol was added
Inj Cloxacillin was continued.

Day 8
Bone Marrow Cytology and Biopsy –No abnormality, no LD bodies. Bone marrow C/S-No growth
ANA= Negative, Brucella IgM= Negative VCA IgM = negative

Day 9
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.

Day 10-
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 .

Final Impression-
Undiagnosed Fever (Resloved) most probably Enteric Fever.
Inj Chloramphenicol was given for total 10 days.
Child was Discharged and Followed up.


ANY Suggestion on which disease it should have been diagnosed as , please leave comments.

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