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Case Write up 1
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Case Write-up: Influenza A

Pediatric Clerkship

Patient’s Demographics:

Patient’s initials: R. N

Age: 4 months Gender: Female

DOB: 18/06/2022 Nationality: Emirati

Admission Details:

Date of clerking by student: 27/10/2022. Date of admission: 26/10/2022

Admission source: ER

Chief complaint:
Fever, cough, and nasal congestion that started 2 days

History of presenting illness:

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R.N is a 4-month-old infant with a known history of extrahepatic biliary atresia s/p
Kasai procedure, presented to the ER with a 2-day history of fever, cough, and nasal
congestion. R.N came to the ER with her mother at around 9pm on the 26/10/2022.
Before coming to the ER, the fever was intermittent and reached 39C at its highest,
measured tyrannically. The mother gave her Adol syrup 3ml which lowered the
fever temporarily, she gave her Adol approximately every 4 hours for 2 days before
admission. Her fever was not associated with sweating, chills, rigors, or abnormal
movements. R. N’s cough was wet, as it contained sputum. The mother did not
notice any cyanosis, shortness of breath, labored breathing. In addition, on the day
of admission R.N developed diarrhea, the mother said that it was large in quantities,
and it was watery and brown, R.N had up to 30 diaper changes in one day. R.N’s
feeding was reducing during these past 2 days, however, there was no vomiting and
there were no changes in the urine amount or color. The mother noticed that R.N
had reduced energy and was not as energetic as she is usually, and she was not
sleeping well throughout the night. R.N was brought to the ER 1 week ago with
similar symptoms and was admitted for 3 days. When she presented back then, she
had a 38-degree fever, cough, nasal congestion, and diarrhea. R.N was doing well
after this first admission. However, the symptoms started again a few days later and
R.N’s mother noticed that she was not getting better and decide to bring her to the
ER again.
The mother did not notice R.N complaining of any ear tugging and did not notice
any skin rash. Other than the admission a week ago R.N has not suffered any
similar episodes previously. R.N’s mother mentioned that herself and her other
children were also sick with similar symptoms so there is a history of sick contact.
R.N has a known history of extrahepatic biliary atresia diagnosed at 2 months of
age after 2 months of prolonged non-resolving jaundice. She was treated in August
for the biliary atresia in King’s College London where she underwent the Kasai
procedure also known as hepato-portoenterostomy. There were no complications
after the surgery, and it took about 2 months for the jaundice to resolve.
R.N had a high fever, cough with sputum, and nasal congestion, diarrhea in large
quantities, decreased oral intake; she was brought to the ED and given IV fluids,
ibuprofen, Tamiflu (oseltamivir) and tazocin (piperacillin/tazobactam) on the day of
presentation.
Review of system:

General: fever, decrease appetite, reduced oral intake, decreased activity, no chills, rigors or
sweating

Skin: No rash, no skin changes, no jaundice

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Head: No photosensitivity, no eye redness or discharge

Ears, Nose, Throat: Nasal congestion, no ear tugging, no sneezing

Mouth, Neck: no mouth ulcers, no neck swelling.

Cardiovascular: no palpitations, no cyanosis, no syncope

Respiratory: Cough with sputum, no apnea, no shortness of breath

Gastrointestinal: diarrhea, no vomiting, no abdominal pain

Genital/Urinary: normal urine output, no change in urine color, no hematuria

Endocrine: normal growth and development

Neurological: normal mental status, normal neurological development

Past medical and surgical history:

R.N has a history of extrahepatic biliary atresia, diagnosed at 2 months in Tawam hospital after 2
months of non-resolving jaundice. The jaundice first appeared at around 3 days after birth, which
persisted she had scleral icterus and generalized jaundice. Lab investigations done 1 day after
birth showed hyperbilirubinemia, a repeat blood test done on the 27/07/2022 (~ 1 month later)
also showed conjugated hyperbilirubinemia and an elevated in AST and ALT levels. At around a
month and a half, R.N began developing pale clay colored stool and the urine had become a dark
yellow color. She had a HIDA scan on 2/8/2022 and a Liver biopsy both of which confirmed the
diagnosis of extrahepatic biliary atresia. R.N was then transferred to King’s College Hospital in
London, United Kingdom. In London she had a portoenterostomy Kasai procedure, this is a
surgery where the obstructed biliary ducts are removed, and part of the small intestines is
connected to the liver. She remained in the hospital for 2 weeks post-operatively and there were
no complications after the surgery.

R.N was admitted on 19/10/2022 for a high fever and upper respiratory tract symptoms. R.N had
a persistent fever and a productive cough for 5 days and diarrhea for 1 day. She also had poor
oral intake, decreased energy, and was dehydrated. Her brothers also had similar symptoms of
fever and cough. She was diagnosed with viral upper respiratory infection and enteritis; all
microbiology samples were negative including influenza A. She was admitted for 3 days
managed with IV fluids and paracetamol. She started feeling better and was discharged on
21/10/2022.

Medication & Allergies:

Vitamin K orally 2.5mg
Vitamin D 400 IU daily
Vitamin E 50mg
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Phenobarbitone 15mg once daily: this is given to increase the flow of bile and is given in the
evening
Ursodiol 10mg/kg twice daily: ursodexocycholic acid promotes the flow of bile
No known allergies.

Perinatal History:
Antenatal: Mother is diabetic, it is controlled by diet and medications. The
mother had COVID-19 during the 5th months and had symptoms of fever,
cough, and flu-like symptoms. Otherwise, no other complication was reported
during the pregnancy.

Birth: Born to term (40 weeks), vaginal delivery, birth weight was 3.2 kg. Cried immediately
after birth, no complications.

Post-natal: R.N was normal, no feeding difficulties, no jaundice in the 1st day,
normal APGAR score at 1 and 5 minutes, and did not need any special care or
NICU admission. Newborn screening test was normal. A small nodule in the
lower gums was seen upon inspection of the mouth. Blood test conducted on
day 2 indicated hyperbilirubinemia and on the day 3 she developed jaundice.
Jaundice was said to be normal, and she did not need phototherapy and R.N
was discharged after staying in the hospital for 3 day.

Developmental history:
R.N. has met her developmental milestones.
Gross motor: As a 4-month-old R.N can roll over from tummy to back and can support herself
with her forearm when laying on her stomach.
Fine motor: She can reach out to things and is able to grab toys when presented to her.
Social: During the examination she responded and reacted to us when we played with her.
Language: She is orients to sound and recognize her mother and smiles when played with.

Immunization History:
Received her Hepatitis B and BCG vaccines at birth. However, she has not taken
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any other vaccinations. The mother said this is because of her past medical history
and frequent hospital visits due to her jaundice and diagnosis with extrahepatic
biliary atresia. After the Kasai procedure the mother said that the doctors
recommended to wait before giving R.N her vaccinations.
Nutrition History:
She was started on breast feeding exclusively for the first 1 month approximately.
When she was exclusively breastfed, she fed every 2-3 hours and would wake up
from sleep require feeding. Then the mother introduced formula milk during the
second month of life and was using a combination of both breast feeding and
formula. Then the mother continued R.N on formula milk only using mainly
Aptamil and Nomogen.

Family history:
Father and mother are not related. R.N has two older brothers one is 5 years-old and the other is
6 years-old who are healthy. Both her brothers were born to term through vaginal delivery with
no complications. One of her brothers received phototherapy for neonatal jaundice and he was
diagnosed with thalassemia.

Social history:
R.N lives in Al Ain with her parents, 2 brothers. Mother is not employed, and the
father works in the airport. There are no smokers in the household. They also have a
pet parrot at home. Currently both of R.N’s brothers and mother are sick with the
flu-like symptoms and fever.

General Physical examination: (27/10/2022)

On general inspection, R.N looked well, comfortably breathing and not in
any distress. She was active and playful. She looked well-nourished and
moving her legs and arms around and appeared to have normal muscle tone
and activity. R.N was not attached to any IV lines, nasal cannula, or face
mask.
Vital signs: according to her age, her vitals were normal:
Tympanic temperature 37 degrees Celsius
Peripheral pulse rate 110 bpm
Respiratory rate 32 br/min
Oxygen Saturation 99% on room air

Growth parameter:
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According to the WHO growth charts R.N is at a normal centile for her age.
Weight: 5.7kg (24th centile).
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Height: 64cm (80th centile)

Head Circumference: 40.5cm (50th centile)

Head to toe exam:

Head: Head was symmetrical and uniformly spherical and normal in size
measuring around 40.5 cm. On palpation the anterior fontanelle was open
and soft, not sunken or bulging. Suture lines did not show signs of
premature closure or widening. No dysmorphic features noted. No nose
deformity. No central cyanosis, normal palate.
Eyes: Normal sized eyes, no protrusion or ptosis. There were no signs of scleral
icterus or conjunctival pallor. Pupils were reactive to light.
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Ears: Examination of the ears is normal, normal tympanic membrane.
Nose: There is clear nasal discharge on examination.

Oropharynx: Pharyngeal erythema, oral mucosa is moist and pink. There are no
spots or ulcerations on inspection. The lips are pink and do not show any signs
of dehydration.
Neck: On palpation there is no masses or enlarged lymph nodes and thyroid
examination was normal.

Extremities: The hands and feet were warm and pink. In the hands there was no
clubbing or peripheral cyanosis. The capillary refill time was less than 2 seconds.
Skin turgor was normal. Full range of movement in both upper and lower limbs.
Barlow and Ortolani tests were both negative.

Dermatological: the skin is warm and pink. There are no signs of jaundice. There
are no rashes, ulcerations, or other skin lesions.

Respiratory examination:
On inspection, the chest moves symmetrically with respiration, no scars, or
deformities. There is no signs of labored breathing and no subcostal, intercostal
and suprasternal retractions.

On palpation, the trachea was centrally located, normal chest expansion.

On auscultation, there are normal breathing sound was heard. No crackles or wheezes are heard.

Abdominal examination:
On inspection, the Kasai procedure scar is seen as a large transverse scar in the
right upper quadrant of the abdomen extending from the lower costal margin
obliquely to the right flank. The abdomen is symmetrical, not distended and there
are no obvious hernias.
On superficial palpation the abdomen was soft, and no tenderness felt over
the abdomen. On deep palpation, there were no palpable masses or
hepatosplenomegaly.
On auscultation, normal bowel sounds were heard.
Cardiovascular examination:

On inspection there are no chest deformities, scars, or asymmetry. There is no

peripheral or central cyanosis and no edema observed.
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On palpation, the apex beat is felt at the 4th intercostal space mid-clavicular line,
with no heave or thrills.

On auscultation, normal first and second heart sounds are present and there are no
murmurs or added sounds.

The brachial and femoral pulses are palpable, the rate and rhythm are regular.

CNS examination:
Mental status: alert

Cranial nerves: cranial nerves II, III, IV, V, VI, VII, VIII were all normal upon
examination.

Muscle: normal tone, no muscle wasting, normal motor function.

Reflexes: Asymmetrical tonic neck reflex was presents and the palmar reflex was
present

Sensory examination: no sensory impairments were detected

Problem List:
1. Fever for 2 days
2. Symptom of upper respiratory tract infection (cough and nasal congestion) for 2 days
3. Diarrhea for 1 day
4. Sick contact (mother and 2 brothers who have the same symptoms)
5. History of extrahepatic biliary atresia s/p Kasai procedure
6. Family history of thalassemia

Differential diagnosis:
1- Viral Infection (influenza A)

R.N presented with fever, cough and nasal congestion which are all symptoms that can be
attributed to an upper respiratory tract viral infection. She also had diarrhea which could be
attributed to the viral infection as well. In addition, R.N has two brothers who also had the same
symptoms. It is also influenza season. This is possibly the most likely diagnosis considering the
positive history of sick contact and the self-limiting nature of the symptoms.
2- Pharyngitis:

The presence of a fever and a cough along with the erythema and pharyngeal
congestion seen on physical examination suggest that R.N may have viral or
bacterial pharyngitis.
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3- Whopping cough:

At the bottom of the differential list is whopping cough caused by pertussis.

Pertussis is common in babies under the age of 1 year old which matches with
R.N’s age. R.N is not vaccinated against pertussis as she has not received the 2-
month DTap vaccination. The symptoms of cough, nasal discharge overlap with
the non-specific symptoms of the catarrhal stage of Pertussis infection.
Investigations:
R.N’s symptoms are mild and therefore beginning with a more conservative
approach to the necessary investigations, based on the Uptodate
recommendation:

1- CBC with differential (to assess leukocyte)

2- CRP (Inflammatory marker)
3- Serum electrolytes (checking for signs of dehydration)
4- Liver function test: AST, ALT, GGT, Total and direct bilirubin, albumin (to check
the liver function status and whether its deteriorating after the surgery with this acute
illness)
5- Coagulation workup (as part of checking the liver function)
6- Sputum culture
7- Nasopharyngeal swab for culture and PCR for respiratory viral panel

Testing for other pathogens — Testing for other viral and bacterial pathogens includes:

o Blood culture
o Urine culture
o Throat culture
o Stool culture

Ultrasound of the abdomen checking the liver and biliary system, this is
important to check the Kasai procedure viability and rule out acute
cholangitis.
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Lab results:(26/10/2022)
CBC and differential:
WBC 10.5 x10^9/L
RBC 4.43 x10^12/L
Hgb 111 g/L
Hct 0.34 L/L
MCV 75.8 fL LOW
MCH 25.1 pg
MCHC 330 g/L
Platelet 291 x10^9/L
RDW-CV 13.0% LOW
MPV 9.10 fL LOW

Neutro # 3.30 x10^9/L

Lymph # 6.38 x10^9/L
Mono # 0.75 x10^9/L HIGH
Eos # 0.04 x10^9/L
Baso # 0.05 x10^9/L

Coagulation profile and CRP: (27/10/2022)

PT 12.4 sec(s)
INR 1.15
APTT 39.1 sec(s) HIGH
Fibrinogen Lvl 1.79 g/L
D-Dimer Auto 1.07 mg/L HIGH
C Reactive Protein 2.9 mg/L

General chemistry: (26/10/2022)

Sodium Lvl 137 mmol/L

Potassium Lvl 4.8 mmol/L
Chloride Lvl 103 mmol/L
CO2 20 mmol/L (LOW)
Creatinine <15 micromol/L
Urea Lvl 5.0 mmol/L
Albumin Lvl 34 g/L
AST 147 IU/L HIGH
ALT 158 IU/L HIGH
GGT 2002 IU/L HIGH
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Bilirubin Total 16.0 micromol/L

Bilirubin Direct 14.9 micromol/L HIGH
Glucose (POC) 5.3 mmol/L

General chemistry: (29/10/2022)

AST 104 IU/L HIGH
ALT 131 IU/L HIGH
GGT 1807 IU/L HIGH
Bilirubin Total 14.7 micromol/L
Bilirubin Direct 12.1 micromol/L HIGH

The microbiological result for Influenza A antigen was positive. COVID-19 Ag and the
blood culture were negative.

Ultrasound of the hepatobiliary system showed a coarse echotexture of the liver and mild
ascites measuring at 4.5cc. Other than that, there were no dilation of the common bile duct
noted, no focal lesions on the liver.

Updated problem list:

1. Fever for 2 days
2. Upper respiratory tract symptoms (cough and nasal congestion) for 2 days
3. Sick contact (mother and 2 brothers who have the same symptoms)
4. History of extrahepatic biliary atresia s/p Kasai procedure
5. Family history of thalassemia
6. Elevated liver enzymes (AST, ALT) and bilirubin

Discussion/interpretation of lab data:

R.N presented with a fever, cough and nasal congestion and a positive sick contact
this is all suggestive of a viral upper respiratory tract infection. Microbiology testing
of a nasopharyngeal swab was positive for the influenza A antigen. During her
illness 1 week ago influenza A was negative, so it seems that she has developed a
secondary influenza A infection on top of her previous viral illness. She has no
signs of respiratory distress, no drop in the oxygen saturation and no labored
breathing. In additions there were no complications or signs suggesting the
possibility that the infection has spread to the lower respiratory tract. The laboratory
findings showed normal white blood cells except for a slight elevation in the
monocyte count. I think that this is normal since a large percentage of patients who
have influenza have normal WBC count.
The liver function test results showed an increase in the AST, ALT, GGT and direct
bilirubin value. R.N has had elevated liver enzymes and bilirubin since the first few
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weeks of life because of the biliary atresia. R.N had the surgery about 2 months ago
and these values do not go down till about 6 months after the surgery when the
success of the surgery can be evaluated. Since the ultrasound showed no focal liver
lesions, dilations of the common bile ducts and any signs of portal hypertension
then the likelihood of this being an acute exacerbation is low. In addition,
comparing the US results done on the 27/10 with those done on 20/10 there were no
additional positive findings. A repeat of the liver function test on the 29/10 showed
a gradual reduction in the AST, ALT, GGT and direct bilirubin levels.
Considering her history of a recent Kasai procedure surgery for extrahepatic biliary
atresia we need to consider acute cholangitis since it is a common complication that
occurs following the surgery. Important to keep this in mind to detect deterioration
This diagnosis is less likely though because of the absence of abdominal pain and
jaundice. This is an important diagnosis to consider and rule out in patients who
have had the Kasai procedure as it can cause further damage to the liver. We will
need an abdominal US and liver function test monitoring to rule it out.
Based on the laboratory, microbiology indicates that R.N just had a simple upper
respiratory tract viral infection. The rise in the AST, ALT, GGT and direct bilirubin
levels from the previous time they were measured could indicate deterioration of the
liver post-Kasai procedure however no new lesions on US and no new symptoms
like jaundice or abdominal distention were detected.

Hospital course:

The patient was started on IV fluids (5% dextrose, 0.45% NaCl and 20mmol KCl
continuous for 23mL/hr), oral Ibuprofen (50mg, 2.5ml) when needed, Tamiflu
(17.1mg, 2.85ml) orally twice a day for influenza A, IV Tazocin (570
mg,22.8mL/hr, q8hr) which was given since R.N was suspected to have acute
cholangitis because of her past medical history and her high fever and worsening
liver function tests. She was also given saline nasal drops to be given 4 times daily
for the nasal congestion.

She continued her usual home medication which consists of:

- Oral phenobarbital

- PediVit multivitamin oral drops with iron (15mg, 0.5 tab)

- Vitamin E oral liquid (50 units, 0.5ml)

- Vitamin K1 oral (2mg)

- Vitamin D3 oral solution (400units, 1mL)

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Ultrasound of the hepatobiliary system was ordered along with, liver function test, albumin, and
coagulation factor levels and glucose level.

R.N was stable and respiratory and neurological statues were being monitored. Glucose levels
and oxygen levels were also being monitored.

The fever resolved the next day, and R.N was improving, no new symptoms
developing. However, the liver function tests were not improving despite no
significant findings on ultrasound or clinically.

Management plan:

1. In patient management (admit the patient):

According to Uptodate, the decision to hospitalize a child with influenza is

individualized. Potential indications for hospitalization include:

- Significant dyspnea at rest

- Change in mental status

- Progressive illness or clinical deterioration, especially if associated with

hypoxemia

- Dehydration or inability to maintain hydration orally

- Worsening of chronic medical conditions

- Development of serious complications

R.N meets two of these criteria. The first is dehydration because when she
first presented to the ED she had dry mucous membranes, delayed capillary
refill and generally ill-looking. She also had reduced oral intake, therefore, she
needed IV fluids to rehydrate as oral rehydration could not be done. The
second is worsening of her chronic medical condition (extrahepatic biliary
atresia), because when the blood test was done is should elevation in the AST,
ALT, GGT and bilirubin levels compared with the values measured a week
ago.
2. Re-hydration:
R.N presented with symptoms of dehydration which could not be corrected orally because of
poor oral intake. The amount of fluid she should receive is:
Since she has moderate dehydration, we can estimate the amount of water lost is about 7% of
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her body weight.
She weighs 5.7kg
Amount of fluid needed: 399ml ~ 400ml
Bolus given as 10ml/kg = 57ml ~ 60ml given as a bolus (0.9% NaCl)
Remaining 340ml are given as an infusion over 24hrs as a rate of 14.1mL/hr. of 5% dextrose,
0.9% NaCl and 10mmol/L of KCl

3. Administer an Antipyretic:

An antipyretic needs to be administered to lower R.N’s temperature which can

either be ibuprofen or acetaminophen.

4. Symptomatic treatment of the nasal congestion:

Nasal saline drops to help in loosening and hydrating the mucus to relieve the
congestion.

5. Antiviral (Tamiflu – oseltamivir):

Antiviral medications are not indicated an all cases of influenza A, there are
certain individuals that are at a higher risk of developing complications from an
influenza A infection. According to Uptodate

R.N meets two of these criteria: first being under 2 years of age and the second is
having extrahepatic biliary atresia (liver disorder)
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6. Empiric antibiotics:

No antibiotics are needed for the respiratory symptoms.

Considering that R.N has undergone a Kasai procedure and it now presenting with a high fever it
is very important to rule out cholangitis because it may lead to deterioration. According to
UpToDate, there should be a high level of suspicion for cholangitis in children (s/p kasai
procedure) presenting with fever without a clear source of infection, especially if the fever is
accompanied by acholic stools, irritability, and laboratory abnormalities. While the imaging
and cultures are being done starting R.N on an antibiotic is important for prophylaxis in case
she does have acute cholangitis, especially considering the worsening liver function tests.

My comment: I agree with the Tawam management plan, however I think that the solution
used for rehydration should have been 5% dextrose, 0.9% saline and 10mmol/L KCl
instead of the solution that contains 0.45% NaCl because of risk of developing
hyponatremia.

Progress during hospitalization:

The patient was admitted with fever and cough, the fever persisted for 2 days after admission and
the cough was gradually resolving. She stayed in the hospital for 4 days. R.N was afebrile by day
3, breathing comfortably and tolerating oral feeding. R.N is vitally stable and fit for discharge by
the 4th day.
FOLLOW-UP

By the time of discharge the liver function tests and bilirubin levels were beginning to decrease,
however, follow up with the pediatric gastroenterologist should be done in a few days to repeat
the liver function test labs. This is to ensure that R.N doesn’t suffer complications after the Kasai
procedure.
Discharge plan: (29/10/2022)
- Continue the current at home medication
- Appointment with pediatric gastroenterologist
- In case of Emergency, get in touch with ED or Urgent Care.

Follow up: (SOAP format) 29/10/2022

Subjective: 4-month-old girl who has a fever, cough, and nasal congestion.
Known case of extrahepatic biliary atresia s/p Kasai procedure. She is vitally
stable, improving and is doing well.
Objective: Microbiological studies showed that R.N was positive for influenza
A, the cause of her upper respiratory tract infection. Labs showed elevated AST,
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ALT, GGT, and direct bilirubin which have begun improving by now.
Assessment: Most likely an upper respiratory tract infection caused by
influenza A. The worsening liver function test raised suspension that it
could be acute cholangitis, because of her history of extrahepatic biliary
atresia, however the ultrasound findings and the symptomology did not
support this diagnosis.
Plan: Continue the current at home medication, stop the Tamiflu. Follow up
appointment in 3 days with gastroenterology to monitor the liver function by
doing a repeat liver function test.