Acute Gastroenteritis

A 4.5-month-old female presented to hospital with a 2-day history of watery diarrhea and
fever developed in the 12 hours before admission. The infant was reported to have had 10
watery stools over the previous 24 hours, during which she became quite unsettled, crying a
lot, whilst drinking half her usual amount of liquids. There was no history of vomiting.

Her medical history revealed delivery at term via emergency cesarean section due to severe
fetal distress, with a birth weight of 2910 g. Her Apgar score was 0-1 at one and five minutes,
respectively, after delivery requiring tracheal intubation and transfer into neonatal intensive
care unit. She was put into induced coma and active hypothermia for 72 hours. The infant
was extubated on the fourth day of life, followed by reestablishment of enteral nutrition by
day 5. She was fed exclusively on formula milk from birth. An MRI performed on day 5
showed signs of severe hypoxic-ischemic encephalopathy. Followup after discharge was very
irregular and the infant did not receive any vaccines up until the current hospitalization
episode. Her weight curve was a reason for concern; indeed, her weight two weeks before the
current admission to hospital was 4390 g.

On the day of presentation, physical examination revealed an alert but irritable and ill-
appearing infant with a temperature of 39.9°C, heart rate between 170 and 190 beats/min,
respiratory rate between 40 and 80 breaths/min, blood pressure of 102/55 mmHg, and oxygen
saturation by pulse oximetry of 100%. The child’s weight at admission into hospital was
3990 g, meaning she lost 10% of the previous reported weight. The skin was pale grey,
tenting skin turgor, dry lips and dry buccal mucosa, normal looking eyes but reduced tears,
soft fontanele, and capillary refill time of 3 seconds. The urine output was also decreased.
Heart and lung examination were normal except for tachycardia; the abdomen was swollen
and slightly painful on palpation, no hepatosplenomegaly. Abdominal and thorax radiographs
were normal. There were no signs of meningeal irritation. Laboratory tests showed
hemoglobin 12.6 g/dL, white blood cells 11 970/mm3 (PMN = 7590), platelets
1 085 000/mm3, and C-reactive protein was less than 0.05 mg/dL (Table 1). Routine stool
specimen tested positive for rotavirus antigen (Vikia Rota-Adeno, Biomerieux), whilst results
for blood and urine culture were negative. Serum electrolytes were significant for a sodium
concentration of 146 mEq/L and a bicarbonate level of 8 mEq/L. Blood urea nitrogen was
61 mg/dL.
Severe measles pneumonia with possible
superimposed bacterial infection.
A 6-year-old boy from northern Thailand developed rhinorrhea and a mild non-productive cough 8
days before admission to the Chiang Mai University Hospital (CMUH). Six days before admission to
CMUH, he developed a tactile fever and was taken to a local clinic. He was prescribed a mucolytic
and an antihistamine. Despite this treatment, his cough worsened and his fever persisted. Three
days before admission to CMUH, he developed a facial rash, which proceeded to spread to his trunk
(figure 1). On the day before admission to CMUH his fever and cough persisted, and he was
transferred to CMUH for severe respiratory distress and potential need for mechanical ventilation.
He was diagnosed with measles pneumonia. The child had no medical or surgical history. He did not
take any medications. His birth history was unremarkable. He had no known drug allergies. His
vaccination history included: BCG vaccine; diphtheria, pertussis and tetanus vaccine; oral polio virus
vaccine (three doses); and hepatitis B vaccine (three doses).

On the patient’s admission to CMUH, he was febrile (39.5°C), tachycardic (110–120 beats/min) and
tachypnoeic (40 respirations/min). The child appeared ill and had bilateral conjunctivitis, a normal
oral pharynx, decreased breath sounds with fine crepitation throughout, mild subcostal retractions
and a generalised erythematous macular-papular rash with confluence on face, trunk and
extremities
Complete blood count was notable for haemoglobin (10 grams/dl), haematocrit (29.4%) and a white
blood cell count of 9900 cells/mm3 (neutrophils (41%), eosinophils (4%), lymphocytes (42%),
monocytes (3%)). Measles IgM was reactive. Chest radiograph showed patchy infiltration in bilateral
perihilar regions, without pleural effusion or cardiomegally (figure 3). Studies were completed 8 days
after symptom onset. Blood cultures had no growth at 7 days.

Childhood pneumonia due to brucellosis

A boy of 23 months had a dry cough and hyperpyrexia for 3 weeks. His father reported that his
complaints suddenly began and gradually worsened. On admission his temperature was 39.5 °C,
respiratory rate was 26 per minute, and pulse was 106 beats per minute. Total leukocyte count was
10,300/mm3, hemoglobin was 8.5 g/dL, and platelet count was 250,000/mm3. Biochemical analysis
revealed alanine aminotransferase (ALT) of 54 U/L, aspartate aminotransferase (AST) of 54 U/L,
hydroxybutyric dehydrogenase (HBDH) of 385 U/L, and lactic dehydrogenase (LDH) of 453 U/L. The
erythrocyte sedimentation rate (ESR) and procaicltonin (PCT) were 25 mm/h and 0.12 ng/mL,
respectively. Chest radiography showed pneumonic infiltrate in both lungs (Fig. 1). He was initially
diagnosed with pneumonia. Conventional antibiotic treatment (ceftriaxone) was ineffectual. On the
fifth day of treatment, the child continued to show feverish and bechic. The initial bacteriologic test
results were negative. Ten days after admission, Brucella melitensis (B melitensis) were isolated from
the second blood culture. The standard tube agglutination test (SAT) for Brucella antigens yielded to
1:320. His father recalled that the boy had a history of consumption of unpasteurized goat milk for 2
months. Then he was started on oral rifampin and trimethopicin-sulfamethoxazole (TMP-SMZ) for 6
weeks. His clinical condition gradually improved and biochemical findings were within normal
ranges. B melitensis was not available from the blood culture after 6 weeks treatment. The child
remained asmptomatic without any signs or symptoms at a follow-up of 1 year. Written informed
consent was obtained from the parents of the patient for the publication of this case report and
accompanying images.
Urinary Tract Infections
Charlotte is a 13-month-old girl with a history of 2 febrile urinary tract infections (UTIs) 4 and 6
months ago. She had normal renal and bladder ultrasonographic findings 6 months ago. She
presents with a fever that began yesterday. She has no other new symptoms. Her 4-year-old brother
had a self-limited febrile illness 1 week ago, which resolved. At examination, she is fussy but
consolable and alert. She is non–toxic appearing. Her physical examination findings show
tachycardia with a heart rate of 130 beats/min, without murmur. Her respiratory rate is 28
breaths/min, without distress or retractions. Her lungs are clear bilaterally. Her tympanic
membranes appear normal. Her abdomen is soft and nontender. Her genital examination findings
appear normal, without erythema or labial adhesions. Her temperature is 102.5°F (39.2°C). A bag is
placed to collect a urine sample. The urinalysis from the bag sample has 5 to 10 white blood cells
(WBCs) per high-power field, a 1+ leukocyte esterase result, and a 1+ ketone result.