Chief complaints:

● On and off Fever for 6 months

● Pain abdomen for 6 months
● Joint pain ( left ankle and Right wrist) for 10 days

HOPI
Child was apparently normal 6 months back following which she had fever, on and off [max
documented 102-103°F], lasting for 20 days in a month, relieved on medication.
H/o pain abdomen, on and off, upper abdomen,not associated with food intake,aching pain,
No h/o constipation / vomiting / diarrhea.No h/o blood in stool /vomiting.
H/o joint pain on and off with swelling left ankle Joint & Right wrist joint ], associated with
restriction of movement, releived partially with medication

No h/o rashes / bluish discolouration of fingers

No h/o oral ulcers/ alopecia
No h/o weight loss/ night sweats / anorexia
No h/o TB contact / Cough
No h/o breathlessness
No h/o headache I blurring of vision
No h/o reduced urine output /hematuria/frothy urine
No h/o blood transfusion
No h/o jaundice
No h/o recent dental caries, procedures.

Hospital course
On examination child had fever,pallor, grade 2 clubbing with hepatosplenomegaly. On CVS
examination there was pansystolic murmur present in mitral ,trucuspid and pulmonary area.
Echo was done which showed Moderate MR with free mobile mass in mitral valve.
USG abdomen was suggestive of anechoic pulsating lesion in segment 8 of liver,showing
turbulent arterial flow 3.3x 2.6 cm (? Pseudoaneurysm) and 9x2 cm aneurysm seen anterior
to aorta at level of bifurcation of aorta. CT angiography showed Aneurysm 4x3 cm in a
branch from hepatic artery with slow filling in venous and fast filling in arterial phase. Other
aneurysm 3x3 cm seen in SMA branch with some surrounding edema? Bleed . Small filling
defects in b/l kidney at lower pole.
Possibilities kept were Infective endocarditis with mycotic aneurysm, polyarteritis
nodosa ,SLE , tropical infections like malaria, leptospira,scrub. Infective workup was done for
malaria, leishmaniasis which was negative Blood culture were sent before starting IV
antibiotics and patient was shifted to ward. Samples were sent for ANA,ANCA,ENA, Anti
dsDNA. APLA workup was also sent. Workup for atypical organism like Bartonella was also
sent.
On day 5 of admission (13/12/23) in early morning child had sudden onset episode of
unresponsiveness with bladder incontinence and loss of tone with frothing from mouth and
oral movements. No tightening of limbs at that time. This episode lasted around 5 -7mins
and was aborted by inj midazolam. O2 by face mask was started.Hemodynamicaly she was
stable , post ictal drowsiness was present. She recieved loading dose of leviracetam
followed by maintenance dose. After 1 hr there was 1 episode of vomitus with worsening of
sensorium and decerebrate posturing with brisk DTR and clonus. 3 % saline bolus at 5ml /kg
was given and i/v/o worsening sensorium she was intubated under all aseptic condition.
Possibilities kept were IC bleed ? aneurysm rupture or Infarct. NCCT was planned and child
was shifted to HDU