ATYPICAL MANIFESTATIONS OF A

TYPICAL INFECTION
CASE DETAILS
• 10 year old female child – well thriving, developmentally normal, no
significant illness in past

• Immunisation history – Not received typhoid vaccine

• History of eating outside food

• High grade fever, vomiting, abdominal pain and loose stools – 1 day

• Sick looking, hemodynamically stable

• Abdomen – tumid

• Rest systemic examination - Normal

Investigations
• CRP – 124

• WBC – 7040 ( 80% Neutrophils)

• Platelet count - 1.87 lac

• Blood culture sent

• High grade fever and abdominal pain persisting

• Mild Guarding present

• Hemodynamically stable

• Urine output monitored

• Cefotaxime + Metronidazole started

USG ABDOMEN
• Mild Splenomegaly

• Oedematous Gall Bladder wall

• Mild free fluid in pelvis

• High grade fever persisting – Day 5 of fever

• Loose motions decreased

• Abdominal pain intermittent

• Blood culture – salmonella Typhi

• Ceftriaxone started. Cefotaxime and Metronidazole stopped

Day 6 of illness
• Fever persisting

• Tachypnea and tachycardia

• Abdominal distension and Guarding increasing

• Third spacing and compensated shock

• Mild metabolic acidosis

• Shifted to PICU

• Fluid Resuscitation + Dopamine infusion

• X ray and USG abdomen – Perforation ruled out. Ascites and Right pleural
effusion present

• Decreasing TLC and Platelet count. Elevated CRP, Liver Enzymes and INR

• Ceftriaxone Continued
• Do we change antibiotics?

• Is it HLH?
• Fever spaced out

• Tachypnea increasing – Right pleural effusion increasing

• Fluids gradually tapered off

• Hypoalbuminemia – Albumin Infusion with diuretics started

• TLC count improving, platelet count stabilized

 15/11 18/11 19/11 20/11 22/11 25/11 29/11

Hb/HCT 11.5/36 10.4/35 10.2/32 9.8/29.6 10.4/32.6 8.5 9.9/32

TLC 7040 2790 5570 6072 12390 8820 6031

N/L/E/M/B 80/18/0/2 81/17/0/2 81/17/0/2 81/17/0/2 71/26/0/2 N 63,L 31 N 50 L 40

PLATELETS 1.87 lakhs 1.17 75000 75000 78000 1.57lakhs 3.79lakhs

CRP 124.4 160 136 21 6.6

SGOT/AGPT 231/88 209/79 183/98 68/77

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ALBUMIN 1.8
ALK 291
PHOSPHATA
SE
NA/K 130/3.6 133/2.7 144/3 135/4.1
Cl 100 101 109 105
Bun/creat 12/0.6 9/0.4
HCO3 15 13

Dengue ns 1
IgM,igG Negatiive

Urine R/M 4-6 puss

cells.
 22/11 25/11 29/11
Sr ferritin 1970 604 307 ng/ml
Sr triglyceride 569 388 212
22
• Tachypnea and Tachycardia decreased

• Oral intake improved

• Shifted out of PICU

• Intermittent diuretics given