Case-based Reviews in Pediatric Infectious Diseases Vipin M Vashishtha, Ajay Kalra
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
A
Abdomen
ultrasonography of 51, 162
ultrasound of 42
Abdominal distension, mild 122
Abdominal pain 37, 163
ABM See Acute bacterial meningitis
Abscess 144
pneumatocele 69
Absolute lymphocyte count 110
Acellular pertussis vaccine 217
Acetazolamide 32
Acholic stools 97
Acid-fast bacilli 46, 63, 215
Acidic pH 124
Acinetobacter 180
Acquired disease, history of 95
Actinomyces species 62
Activated partial thromboplastin time 57
Acute disseminated encephalomyelitis 10, 16, 26f
Acute fever, causes of 35
Acute kidney injury, staging of 191
Acyclovir 27, 28, 86
ADEM See Acute disseminated encephalomyelitis
Adenovirus 108
Adequate analgesia 71
Adrenaline 205
AES See Acute encephalitis syndrome
Aflatoxins 16
Alagille syndrome 104, 105
Alanine aminotransferase 59
Albendazole 147, 148
Albumin globulin 165
Alkaline phosphatase 41
Amatoxins 16
Amikacin 82
Anasarca 80f
Anemia 53, 118
cause for 90
severe 8, 90
Anorexia, symptoms of 161
Antenatal infections 134
Antibiotic 122, 202
course, duration of 72
dose 184
misuse of 177
prophylaxis 115
resistance 177
therapy 5, 72
Anti-endomysial antibodies 127
Antiepileptic
drug 143
valparin 86
Antimalarial drugs 7, 8
Antimotility agents 122
Antinuclear antibody test 51
Antiparasitic drugs 122
Anti-tetanus antibodies 38
Anti-tissue transglutaminase antibodies 127
Antitubercular drugs 214
Antitubercular therapy 161, 185
Antitubercular treatment 210
Artemether-lumefantrine 184
Arterial blood gas 201, 207
Arteriovenous malformation 141
Arthralgia 42
Arthritis 42, 48, 77
Aspergillus 114
pneumonia 38, 113
Aspiration 152
syndromes 108
Autoimmune hepatitis 165
Autoinflammatory diseases 44
AVM See Arteriovenous malformation
Azithromycin 28
with steroids 27
B
Babinski's sign 172
Bacillus Calmette-Guérin
infection 47
vaccine 47
Bacterial diseases 43
Bacterial endocarditis 7
Bacterial infection 1, 7
self-limiting 122
Bacterial meningitis 11, 32
Bacterial pneumonia 177
Bacterial strain 6
Bacteriostatic drug 182
Behçet's disease 43
BERA See Brainstem evoked response audiometry
Bile duct
plugging of 99
proliferation 99
Biliary atresia 99, 100
Biliary ducts, lymphocytic proliferation of 99
Biliary system, congenital defects in 164
Biliary tract, normal 101
Bladder, ultrasound of 105
Blastomycosis 36
Blood 206
ammonia 136
culture 77
glucose 27, 136
pressure 6, 200
Body ache 58
Body mass index 42
Body temperature, normal 35
Bone marrow 93, 96
biopsy 96
disorder 8
Borrelia recurrentis 43
Bowel movements, normal 127
BP See Blood pressure
Bradycardia 26
Brain
damage 30
herniation 30
histopathology 15f
magnetic resonance imaging 131
parenchyma, inflammation of 15f
Brain herniation syndromes
signs of 31
symptoms of 31
types of 30f
Brainstem
evoked response audiometry 132
neurocysticercosis 145
Breathing
irregular 26
work of 200
Bronchiectasis 112
Bronchoalveolar lavage 157
Brucella 3, 77, 79
antibody 36
Brucellosis 1, 88
diagnosis of 79
treatment for 36
Budd-Chiari syndrome 165
Burkholderia cepacia 114
Burkholderia pseudomallei 43
Burst suppression 132
C
Cachexia 94
Campylobacter 123
Capillary filling time 200
Cardiac abnormality 135
Cardiovascular disease 51
Cardiovascular dysfunction 199
Cardiovascular system 104
Cataract 117
causes of 121
etiology for 117
with rubella 119
Catecholamine refractory 205
Causative organisms 181
Cefepime 71
Cefpodoxime 168
Ceftriaxone 82
injection 84
Celiac disease 126
diagnosis of 127
Central nervous system 200
infections 10, 12
Central venous pressure 203
Cephalosporins 86
Cerebral cortex 131
Cerebral decongestants 173
Cerebral edema 141f, 143
Cerebral hemisphere, right 140
Cerebral ischemia 29, 30
Cerebral malaria 16, 28
Cerebral perfusion pressure 25, 29
Cerebrospinal fluid 5, 84, 139
Cervarix 219
Cervical cancer 218
Cervical lymph node 212, 213f
enlargement of 93
Cervical lymphadenopathy 37, 40, 185
CFT See Capillary filling time
Chandipura 19
Chikungunya 19, 81
Chills 185
Cholangiogram, intraoperative 98
Cholangitis 43, 60
Cholecystitis 60
Choledochal cyst 100, 163
prognosis of 100
Choledocholithiasis 163
Cholestasis 104, 105
cause of neonatal 98, 100, 104
Chromosomal disorder 118, 130, 133
Chromosomal microarray 134
Chylothorax 65
Ciprofloxacin 125
Clarithromycin 28, 71
Clean-catch sample 182
Clindamycin 28
CMV See Cytomegalovirus
CNS See Central nervous system
Coccidioidomycosis 36
Coenzyme A 13
Cold 202
shock 203, 205
Collagen disorders 82
Collagen vascular diseases 51
Coma 25
diabetic 10
fever with 10
Common metabolic syndrome 23b
Community-acquired empyema 71
Complete blood count 36, 38, 77, 89, 90, 92, 110, 111, 118, 201
Conjugate vaccine 221
Conjugated hyperbilirubinemia 97
Consanguineous marriage 104, 157
Consanguinity, absence of 131
Cotrimoxazole 114
Cough 185
chronic 113, 157
Craniosynostosis 130
Crohn's disease 43
CRS See Congenital rubella syndrome
Cryptosporidium 115
Cushing's triad 26
Cutaneous tuberculosis, treatment for 212
CVP See Central venous pressure
Cystic fibrosis 127, 153
Cysticercosis 140
Cysticercotic encephalitis 146
Cysticercus encephalitis 146
Cysticidal therapy 147
role of 146
Cytomegalovirus 1, 48, 77, 102, 106, 119, 129
D
Decompensated cirrhosis 99
Dehydrogenase deficiency 13
Dengue 19, 85, 211
fever 50, 169
hemorrhagic fever 17
infection, normal in 89
scrub typhus 56
shock syndrome 17
vaccine 225
Dengvaxia 225
Deoxyribonucleic acid 137
Deresuscitation 202
Diagnostic dilemma 10
Diagnostic pleural aspirate 70
Diarrhea 37
acute 122
prolonged 122
worsening of 126
Diarrheal episode 122
Digestive enzymes, deficiencies of 126
DLC See Differential leukocyte count
DNA See Deoxyribonucleic acid
Dopamine, dose of 205
Doxycycline 28, 36, 176
Drainage catheter placement 65
Drug hypersensitivity reaction 211
Drug rash 169
Drug-resistant Streptococcus pneumoniae 179
DSS See Dengue shock syndrome
Dysarthria 146
Dysfunctional bladder 197
Dysmorphic facies 105
Dysphasia 146
E
Ear 111
Ectodermal dysplasia 54
Ehrlich-Ziehl-Neelsen stain 215
ELISA See Enzyme-linked immunosorbent assay
Embryotoxon, posterior 105
Empirical antibiotic therapy 5
Empyema 69, 7173
antibiotic management of 71
development of 67
diagnosing 70
management of 72
thoracis 67
Encephalitis 11, 12, 12t, 26f, 172
syndrome, acute 10, 11, 17, 25
Encephalopathy 11
acute 22
toxin-induced 16
Endocarditis, infective 43, 88
Endocrine disorders 117
Endoscopic retrograde cholangiopancreatography 163
Entamoeba 115
Enteric fever 56, 59
complicated 57, 59
Enteroviruses 19
Enzyme
assays 22
immunoassays 119
Enzyme-linked
immunosorbent assay 13, 144, 159
immunotransfer blot 144
Eosinophils 49
Epilepsy 138
Epileptiform activity 141f
Epithelioid cells 212
Epstein-Barr virus 1, 16, 102, 119
Erythema multiforme 170
Erythematous rash, diffuse 169
Erythrocyte sedimentation rate 46, 183
Erythroderma 169
Erythromycin 71
Escalate antibiotic 179
Escherichia coli 114, 123, 182
Ethambutol 183
Exocrine pancreatic insufficiency 126
Extended-spectrum beta-lactamase 180
Extrahepatic cholestasis 103
Eyes
watering of 170
yellowness of 164
F
Falx cerebri 31f
Fatty acid oxidation 138
Febrile coma, management of 28
Febrile encephalopathy 11
acute 11, 20, 23, 26, 28
management of acute 25, 29
Feeding difficulties, absence of 113
Fever 1, 41, 50, 76, 163, 185
confusing 76
high-grade 79
long duration 76
low-grade 186
of unknown origin 76
prolonged 76
recurrent 35
short duration 76
symptoms of 161
types of 76
Fibrinolytic agents 72
Fibrinolytic therapy 72, 73
FIESTA See Fast-imaging employing steady-state acquisition sequence
Fine-needle aspiration cytology 41, 92
Fingers, gangrene of 80f
FISH See Fluorescence in situ hybridization
Fluid 28
intolerance
causes of 203
management of 203
management, basics of 193
refractory shock 204
Fluorescence in situ hybridization 134
Fluorescent antibody, indirect 171
Foamy cells 15f
Focal deficits 146
Food protein sensitivity 126
Foreign body, chronic 46
Fosphenytoin 143
Fresh frozen plasma transfusion 84
Fungal granulomas 143
Fungal infections 113
Furosemide 32
G
Galactose-1-phosphate uridylyltransferase 101
Galactosemia 101, 102
Gamma-glutamyl transpeptidase 98, 106
Gardasil 219
Gas chromatography mass spectrometry 22
Gastroesophageal reflux disease 46, 109, 152
Gastrointestinal bleeding 91
Gastrointestinal tract 111
upper 165
Gaze palsies 145
GCT See Glutaraldehyde coagulation test
Genetic syndromes 130
Genexpert mycobacterium tuberculosis 64
GERD See Gastroesophageal reflux disease
GGT See Gamma-glutamyl transpeptidase
Ghon's complex 213
Giardia 115
cysts 111
lamblia infestation 126
Glasgow coma scale 172
Glucose 207
Glucuronosyltransferase gene 164
Glutamic oxaloacetic transaminase 118
Glutaraldehyde coagulation test 106
Gluten-induced enteropathy 127
Glycerol 32
Glycosylation defects, congenital 138
Granulomatous disease, chronic 114, 159, 160
Granulomatous hepatitis 43
Gut diseases, chronic 112
H
Haemophilus influenzae 62, 74, 108, 178
Headache 89
Heart
disease, congenital 46, 92, 95, 105
rate 200
Hematological tests 82, 188
Hemiparesis 146
Hemoglobin 119
Hemolytic uremic syndrome 68, 170
Hemophagocytic lymphohistiocytosis 2, 77
Hemophagocytic syndromes 88
Hemorrhage 141
Hepatic duodenostomy 100
Hepatitis 57
A 60, 217, 226
vaccine 222
virus 162
acute 58, 162
B 217
vaccine 222
virus 162
jaundice in 2
Hepatobiliary iminodiacetic acid 98
Hepatocyte disease 35
Hepatojugular reflux 3
Hepatotoxic drugs 161
history of 162
Herpes simplex virus 13, 26, 100, 106, 186
encephalitis 18, 20f
Herpes virus 102
Herpes zoster 16
Hidden abscess 51
Histidine-rich protein 90
Histoplasmosis 36
HIV See Human immunodeficiency virus
Hodgkin's lymphoma 40, 186
Homogeneous opacity, left-sided 69f
Hospital-acquired empyema 71
HPV See Human papillomavirus
HSV See Herpes simplex virus
Human immunodeficiency virus 38, 46, 78, 100, 123, 137, 159
Human papillomavirus 227
diseases 218
vaccine 217, 218
Hydrogen breath test 125
Hyperammonemia 13
Hyperbilirubinemia 97
Hyperintense lesion 20f
Hyperkalemia 196
Hyperlactatemia 90
Hypernatremic dehydration, calculation for 193
Hyperphosphatemia 196
Hyperplasia, reactive 186
Hypertension 26, 194
Hyperthermia 33
Hypertonic saline 32
Hypoglycemia 90, 201
Hyponatremia 196
Hypoxic-ischemic encephalopathy 129, 131
I
Icterus 80f
Idiopathic neonatal hepatitis 100
IEM See Inborn errors of metabolism
Illness, severity of 179, 181
Immune thrombocytopenia 170
Immunization 216
Immunochromographic test 53
Immunodeficiency 39t, 40t
diseases, primary 159
disorder 37, 108, 159, 160
Inborn errors of metabolism, type of 21, 22, 23b, 130, 136
Indian Academy of Pediatrics 98
Infection
chronic 2, 89
congenital 102, 104, 137
reports of 108
severe 151
site of 181
unusual 108
Infectious mononucleosis 48, 175
Inflammatory disease, progressive 1
Inflammatory disorder 95
Influenza 108
vaccine 220
Insecticides 16
Insulin 28
Internuclear ophthalmoplegias 145
Intestinal malabsorption 126
Intracranial pressure 25, 30
management of raised 32
Intrapleural fibrinolytic 72
therapy 65
Intrauterine growth restriction 102, 118
Intrauterine infection 117, 136
Intrauterine rubella infection 121
Intravenous immunoglobulin replacement therapy 112
Intraventricular cysticercosis 146
Invasive ventilation 204
Ionized calcium 207
Isoniazid 183, 184
Itch 163
Itraconazole 114, 115
J
Japanese encephalitis 11, 16, 18, 26f
vaccine 224
Jaundice 56, 102, 163
absence of 35
infant with deep 97
management of recurrent 161
prolonged 97
recurrent 161
relapse of 162
JE See Japanese encephalitis
Joint pain 58
Juvenile chronic myeloid leukemia 40
Juvenile dermatomyositis 43
Juvenile idiopathic arthritis 42
K
Kala-azar 2, 8, 36, 51, 77, 88, 94f
Kasai portoenterostomy 99, 163
Kasai procedure 99
Kawasaki disease 169
Kidney
disease, chronic 194
injury, acute 191, 191t, 195
ultrasound of 105
Killed vaccine 222
Klebsiella 180
Koch's disease, signs of 143
Koplik's spots 170
L
Lactate dehydrogenase 60, 173
Lactose tolerance test 125
Langhans giant cells 215
Left upper lobe 154f
Leishmania donovani 8
Leishmaniasis 8
Leptospirosis 50, 56, 57, 77, 175, 183
Lesion, skin biopsy of 212f
Leukemia 36
lymphoproliferative disorder, acute 91f
Leukocyte
adhesion deficiency 116
count, differential 192, 195
Leukopenia 53
LFT See Liver function test
Lichen scrofulosorum, lesions of 213f
Liquid chromatography, high performance 14, 22
Live vaccine 222
Liver
abscess 38
biopsy 98, 99, 103, 104
disease, chronic 166
enzymes 56, 98
function 41
function test 38, 78, 89, 161
complete 98
histopathology 14f, 15f
transplantation, facility for 99
Lobar emphysema, congenital 154
Lorazepam 27, 33
injection 173
Lower limb, gangrene of 80f
Lung 111
congenital malformations of 46
malformations, congenital 108, 109
Lupus vulgaris
differential diagnosis of 214
plaque 214f
Lymph node 92, 96
biopsy 41
classification of 187t
group of 185
Lymphadenopathy 91f, 185, 186, 188, 188fc
Lymphogranuloma venereum 186
Lymphoma 36, 144
Lymphoreticular malignancy 41
M
Maculopapular rash 80f
Malaria 2, 56, 77, 85, 88, 175
chloroquine-resistant 51
complicated 89
diagnosis of 90
Malarial parasite 42
Malnutrition
acute 123, 125
chronic 154, 155
Mantoux test 113, 214
Matted lymphadenopathy, etiology of 187t
Mean arterial pressure 201
Measles, mumps, and rubella 227
vaccine 223
Mediterranean fever 43
Meningitis 11
signs of 12
Meningococcal conjugate vaccines 219
Meningococcal septicaemia, acute 172
Meningococcal vaccine 219
Meningococcemia 43, 172
Meningoencephalitis 12, 16, 86, 146
Meropenem 82, 163, 180
Metabolic abnormalities 157
Metabolic acidosis 199
Metabolic disorders 102, 117
Metabolic encephalopathy 10
Metabolic syndrome 2123, 23b
Metastasis 144
Methicillin-resistant Staphylococcus aureus 62, 74, 158, 179
Methylprednisolone
injection 174
pulse therapy 27
Metronidazole 71
Microcephaly 129
with seizures, causes of 129b
Microdeletion syndrome 135
Micturating cystourethrogram 182
Midazolam 27, 33
drip 84
Midbrain
neurocysticercosis 145f
tegmentum of 145
Middle lobe, right 154f
Milrinone 205
MMR See Measles, mumps, and rubella
Mouth ulcers 77
Multiorgan dysfunction syndrome 208
Multiple antibiotics 3
Mumps 16, 19
Mycobacteria 47
Mycobacterium tuberculosis 45, 93, 109, 113
Mycoplasma 16, 17, 28, 178
pneumonia 67, 71, 180
Myeloid leukemia, chronic 94
Myocardial dysfunction 205
Myoclonic epilepsy, early 132
N
National Tuberculosis Control Program 45
Neonatal cholestasis 98b, 100102, 106, 106fc
Neonatal hypoglycemia 129, 131
Neurocysticercosis 32, 140
Neurological disease, acute 11
Neurological disorders 133
Neurological symptoms 42
Neuropsychiatric reactions, risk of 28
Neutropenia 39
syndromes, congenital 159
Neutrophilia 196
Neutrophilic leukocytosis 78
Nicotinamide adenine dinucleotide phosphate 114
Night sweats 41
Nipah 19
virus 18
Nitroblue tetrazolium test 160
Nocardia 114
Noncervical human papillomavirus disease 218
Non-Hodgkin lymphoma 94, 186
Noninfective diseases 5
Nonrebreathing mask 200, 201
Nonresolving pneumonia 151, 153
Noradrenaline 205
Nucleic acid amplification test, cartridge-based 46, 93, 189
O
Ocular nerve palsies 145
Ohtahara syndrome 132
Oligohydramnios 194
Ophthalmological examination 105
Oral rehydration solution 122, 124
Oral typhoid vaccine 222
Organic acidemias 21
Organic acids, analysis of 22
Organic acidurias 21
Orientia tsutsugamushi 176
Osmotherapy 32
Otitis media, acute suppurative 37
Otoacoustic emissions 119
P
Packed cell volume 192, 195
Palate, high-arched 136
Pale stools 163
Pancreatic insufficiency 158
Papilledema 140
Parainfluenza viruses 108
Parapneumonic effusion 73
Parasites 88
Parasitic diseases 43
Parasitic tapeworm 140
Parenchymal cysticercosis 140
Parvovirus B19 119
Pathogenic bacterial infections 86
PCR See Polymerase chain reaction
PCV See Packed cell volume
Pediatric septic shock 198
Penicillin 28
Perinatal asphyxia, injury in 132t
Perinatal hypoxic-ischemic injury 131
Perinatal stroke 129, 131
Peripheral blood smear 38
Peripheral pulmonic stenosis 105
Peripheral smear 89
examination 111
Persistent pneumonia 155
Pesticides 16
Petechiae, absence of 92
Pharyngitis, absence of 92
Phenytoin 143
injection 173
PID See Primary immunodeficiency diseases
Piperacillin 71
Piperacillin tazobactam 82
plus 180
Plasmodium falciparum 90
Plasmodium vivax 90
infection 91
Pleural biopsy 66
Pleural effusion 65, 67, 72
Pleural fluid 70
Pleural infection, management of 68fc
Pleurodesis 66
Pneumococcal polysaccharide vaccine 221
Pneumococcal vaccines 220
Pneumococcus 108
Pneumocystis 110
carinii 110
jirovecii pneumonia 39
Pneumonia 73, 108, 110, 155, 158, 179f
Pneumothorax 65
Polymerase chain reaction 19, 103, 184
Polysaccharide vaccines 219, 221
Pontine herniation syndromes, upper 30
Poor appetite 113
Portal fibrosis, lymphocytic proliferation of 99
Postexposure prophylaxis 224
Potassium hydroxide 110
Precancerous dysplasia 218
Prednisone 147
Preoxygenate 204
Prominent glabella 133
Proteinuria 194
Pseudomonas 180
aeruginosa 67, 71
bacteria 178
Pulmonary hypertension 205
Pulmonary plethora 156f
Pulmonary tuberculosis, sign of 214
Pulmonic stenosis 104
Pulse pressure 207
low 205
PUO See Pyrexia of unknown origin
Purified protein derivative 47, 210
Purpura 92
fulminans 172, 173
Pus discharge 85f
Putative toxin 14
Pyelonephritis 178
Pyrazinamide 183
Pyrexia 62
of unknown origin 1
Pyuria 182
R
Rabies 19
Rash 89
fever with 211
Rat-bite fever 43
Rational antibiotic usage 177
Refractory shock 208
Renal dysfunction and cataracts 102
Renal failure, acute 191
Renal function tests 41
Respiratory distress syndrome, acute 172, 198
Respiratory failure, acute 174
Respiratory symptoms 153
Respiratory syncytial virus 108
Respiratory system 67
examination 172
Respiratory tract infections 151, 157
Retrognathia 136
Reye syndrome 13, 14, 15f, 23
diagnosis of 13
Rheumatic diseases 1
Rheumatic heart disease 92
Rheumatoid arthritis 51
Rickettsia 169, 172, 176, 183
conorii 168
Rickettsial diseases 77, 81, 83, 85, 87, 89, 168
antibody titers for 86
test for 79, 82, 84
Rickettsial fever 170
Rickettsial infection 50, 168
Rifampicin 64, 183, 184
Right lower lobe, collapse of 64f
Ring-enhancing lesions 142
Ringer's lactate 201
Rocky mountain, diagnosis of 82
Routine vaccination 219
Roux-en-Y hepaticojejunostomy 100
Roxithromycin 71
Rubella 16, 19, 129
cytomegalovirus 100
infection 120fc
serology 119
maternal 119
syndrome, congenital 119
Rubeola 16
S
Salmonella 58, 123
infection 58
stage of 58
liver abscess 60
typhi 56
SAM See Severe acute malnutrition
Sanger's sequencing 138
Scarlet fever 169
Scrofuloderma 211
diagnosis of 213
lesions of 213f
Scrub typhus 94, 175
Seizures 146
control 27
recurrent 129
Sensorium, fever with altered 11b
Sepsis
risk factors for 199
screen 98
Septic shock 199, 200, 202, 206
management of 198
vasoactive drugs in 203b
Serological tests 57, 90
Serratia marcescens 114
Serum
aminotransferase levels 60
amylase and lipase 163
bilirubin 99
creatinine 191
glutamic
oxaloacetic trans aminase 192, 195
pyruvic transaminase 52, 118, 192, 195
immunoglobulins 38
sodium 194
SGOT See Serum glutamic oxaloacetic transaminase
SGPT See Serum glutamic pyruvic transaminase
Shigella 123
Shock
early recognition of 200t
intubation in 204
management 207
Single-enhancing lesions, causes of 142
Sinopulmonary infections 40
Sinus tenderness 37
Skin
manifestations, unusual 210
rash 48, 77
tuberculosis 210
Skull, ultrasound of 103
Sore throat 185
Spina bifida occulta 104
Spine, X-ray 104
Spirillum minus 43
Spleen 88, 96
Splenic biopsy 96
Splenic enlargement 88
Splenomegaly
fever with 88
massive 94
Spongiosis, mild 15f
Spotted fever
disease 174
group 168
Staphylococcus 108
aureus 62, 74, 114, 178
Step-ladder fever 175
Steroids 32, 147
Stevens-Johnson syndrome 170
Streptococcus
pneumoniae 62, 74, 178
species, group A 62
Subacute bacterial endocarditis 1, 6
Succinylcholine 204
SVR See Systemic vascular resistance
Swine flu 220
Systemic blood pressure 201
Systemic illness 65
Systemic inflammatory
disease 2
disorder 42, 48
Systemic lupus erythematosus 43, 88
Systemic vascular resistance 203
Systemic vasculitis 88
T
Tachycardia, disproportionate 4
Taenia solium 140
Tandem mass spectrometry 22, 136
Tazobactam 71
TBM See Tuberculous meningitis
T-cell defects 109
Td See Tetanus-diphtheria vaccine
Tdap See Tetanus, diphtheria, and acellular pertussis
Temperature 207
Temporal lobe, right 20f
Tentorium cerebelli 31f
Tetanus, diphtheria, and acellular pertussis 227
vaccine 217
Tetanus-diphtheria vaccine 217
Tetracycline 176
Tetralogy of Fallot 105
Thalamic abnormalities 18
Therapeutic end goals 202
Therapeutic plasma exchange 208
Third-nerve palsy, acute 145
Thoracocentesis 65
Thoracoscopic surgery, video-assisted 63, 66
Throat swab 213
Thrombocytopenia 82, 118, 212
renal impairment 90
Thrombotic thrombocytopenic purpura 172, 173
Thyroid function tests 98
Thyroid-stimulating hormone 100, 119
TMS See Tandem mass spectrometry
Todd's palsy 140
Toddler's diarrhea 126
Tolosa-Hunt syndrome 145
TORCH 100, 134
Total leukocyte count 89
Toxic epidermal necrolysis 211
Toxic injury, acute 14
Toxic shock 208
Toxoid-containing vaccine 218
Toxoplasma 143, 144
Toxoplasmosis 88, 100, 129
Tracheoesophageal fistula 152
Treponema pallidum 43
Triad of fever 89
TSH See Thyroid-stimulating hormone
TST See Tuberculin skin test
Tuberculin skin test 45
Tuberculin test 51
Tuberculomas 144
Tuberculosis 1, 35, 43, 77, 85, 88, 113, 183, 210
diagnosis of 49
Tuberculous meningitis 10, 32
Typhoid 11, 175, 221, 226
fever 56, 58, 59, 169, 170, 175
hepatitis 58, 59
vaccines 221
Typhus group 168
U
Uncal herniation 30
Upper respiratory tract infection 10, 112, 212
symptoms of 37
Ureter, ultrasound of 105
Urethral valve, posterior 196
Urinary tract infection 77
coexisting 124
diagnosis of 78
Urine
for glucose 136
for ketones 136
microscopy 51
output 191
V
Vaginal delivery, vacuum-assisted 130
Vancomycin 71, 82
Varicella 16, 18, 85
vaccine 223
Vasopressor-inotrope infusions 205
Ventricular septal defect 155
Vertebra 104, 105
Vertebral anomalies 105
Viral agents 18b
Viral diseases 43, 85
Viral encephalitis 11
acute 13, 18b, 19, 28
cause of 18
etiology of 18
types of acute 18t
Viral hepatitis 56, 59, 60, 89
A, acute 162
acute 60
Viral infections 1, 119
Viral meningitis 11, 12t
Viridans streptococci species 62
Viscera 14
Visceral abnormality 135
Visceral leishmaniasis 92
Visual acuity 144
Vital signs, normal pediatric 200t
Vitamin
A 103, 105
D 103, 105
E 103, 105
fat-soluble 105
K 103, 105
Vomiting, symptoms of 161
Voriconazole 114, 115
W
Warm shock 199, 203
WBC See White blood cell
West-Nile virus 18, 19
Whipple's disease 43
White blood cell 192, 195
Widal titer 42
Wilson's disease 166
Wiskott-Aldrich syndrome 159
X
X-linked agammaglobulinemia 109, 112
treatment of 112
Z
Zika
fever 81
virus 129
×
Chapter Notes

Save Clear


A Child with Fever for Three MonthsCHAPTER 1

YK Amdekar
 
INTRODUCTION
In the year 1961, Petersdorf and Beeson defined pyrexia of unknown origin (PUO) as persistent fever for more than 3 weeks or in spite of investigations in the hospital for more than 1 week. PUO is now defined as persistent fever at the end of three outpatient visits or 3 days in the hospital without finding a cause or in spite of 1 week of relevant investigations. The common causes of PUO include bacterial infections [tuberculosis (TB), subacute bacterial endocarditis, and brucellosis], viral infections [EB virus (Epstein–Barr virus) and CMV (cytomegalovirus)], fungal and parasitic infections (kala-azar), noninfective illnesses (rheumatic diseases and malignancy), and rarely central fever due to hypothalamic disturbances, hyperthyroidism, heat fever, and drug fever. Analysis of detailed history and focused physical examination are the prerequisites of a rational approach to diagnosis which is then confirmed by relevant tests.
 
CASE 1
A 6-year-old child presented with fever for the last 3 months. The child was well prior to the onset of present illness when he started with high fever. After few days of symptomatic therapy, he was treated with multiple antibiotics such as amoxicillin, gentamycin, and ceftriaxone but fever persisted to varying degree. He had poor appetite and lost 4 kg weight. There were no other symptoms. There was no history of recent travel or contact with animals. There was no significant family history. The physical exami-nation showed chronically sick child, with weight 17 kg, height 109 cm, moderate pallor, enlarged liver with 10-cm span, firm in consistency, not tender, spleen 4 cm, no jaundice, ascites, significant pallor, lymphadenopathy, skin rash, and joint involvement. Other systems were normal.
Q1. What is differential diagnosis?
Ans. This child has progressive inflammatory disease as suggested by prolonged fever with loss of weight over 3 months. Hepatosplenomegaly is the only positive finding in this child. Absence of jaundice rules out 2hepatocyte disease and absence of ascites rules out portal hypertension. So, hepatosplenomegaly in this child is likely due to reticuloepithelial cell involvement secondary to infection or noninfective disorder such as systemic inflammatory disease or malignancy. Systemic inflammatory disorder would have manifested with skin rash, arthritis, mouth ulcers, or other organ involvement over few weeks and so is unlikely. Absence of severe anemia, purpura, or lymphadenopathy rules out hematological malignancy though histiocytosis including hemophagocytic lymphohistiocytosis (HLH) is a possibility as anemia and thrombocytopenia may be subclinical. Slowly progressive chronic infections include tuberculosis, brucellosis, CMV, malaria, and kala-azar besides fungal infection. Malaria and kala-azar would have severe pallor and large splenomegaly while CMV would have localized in some organs causing dysfunction such as jaundice in hepatitis. Fungal infection presents in an immunocompromised host and so unlikely in this child. Primary streptococcal infection may present with prolonged fever due to toxins produced by bacteria but fever may not last so long for 3 months and hence unlikely in this child. So, differential diagnosis in this child would include infections such as tuberculosis and brucellosis, though histiocytosis including HLH secondary to infection is not obvious.
Q2. What investigations would you consider?
Ans. Complete blood count (CBC), peripheral smear, and erythrocyte sedimentation rate (ESR)—neutrophilic leukocytosis may favor brucellosis, anemia, and thrombocytopenia may suggest HLH. High ESR is expected in all three conditions:
  1. Abdominal ultrasonography (USG)—may reveal liver and spleen echostructure that may offer clue to diagnosis
  2. Chest X-ray—to look for tuberculosis focus
  3. Results of these tests should decide further tests.
Laboratory Test Results
  • CBC: Showed moderate neutrophilic leukocytosis with thrombocytosis and moderate anemia—normocytic normochromic with ESR 108 mm
  • Chest X-ray: Normal
  • Abdominal USG: Showed multiple small abscesses in liver and spleen.
Q3. What further tests would you order?
Ans. Multiple small abscesses may suggest brucellosis or abscesses may be mistaken for granulomas. So one must order serological tests for brucellosis; it is a noninvasive test and if the antibody test is positive, diagnosis can be reasonably confirmed. Computed tomography (CT) scan of abdomen is done to confirm abscesses in liver and spleen as granulomas may be mistaken for abscesses on USG.
Blood culture and pus culture from USG-guided drainage are performed to rule out common bacterial infections. As common bacterial infection is 3not likely and it is not easy to culture Brucella organism, this test may not help. PCR may be the most specific test for diagnosis of infections but often it is not available.
Laboratory Test Result
Brucella antibody test was positive though this antibody is known to cross-react with many other bacteria and so is not confirmative.
Final Diagnosis
Diagnosis of brucellosis was made on circumstantial evidence of prolonged fever resistant to commonly used antibiotics and presenting with multiple abscesses in liver and spleen. Child was treated with oral tetracycline and improved.
Q4. Why did this child not respond to multiple antibiotics?
Ans. Antibiotics of choice for brucellosis are tetracycline, rifampicin, and aminoglycosides. As Brucella bacteria multiply inside the cells, antibiotic needs to be continued for 4–6 weeks. Empirical antibiotic use is usually restricted to few days and in case of no response, antibiotic is changed. This explains why gentamycin did not work in this child.
Take Home Message
Prolonged fever may be due to infection or noninfective disorder. If it is due to infection, it may be chronic infection, partially treated infection, or infection-induced immunological or toxin-mediated disorder. Partially treated infection often localizes to kidneys, lungs, or brain and usually provides some clues. Partially treated typhoid fever may present without localization, but fever does not last for 3 months. Toxin produced by bacterial infection such as streptococci may prolong fever but not for 3 months. Noninfective cause must be ruled out in a child with fever for 3 months and include evolving systemic inflammatory disorder or malignancy, often hematological.
 
CASE 2
A 10-year-old child presented with fever for last 3 months. He was well prior to onset of present illness. It started with low-grade fever that has varied in intensity over time in spite of various drugs used including antibiotics. He has poor appetite and has lost some weight. Over the last one month, he seems to get tired with accustomed exertion and is reluctant to go out to play. There are no other symptoms. Physical examination showed mild fever in a child who looked chronically sick. His pulse rate was 120/min and respiratory rate 25/min. He had moderate hepatomegaly firm in consistency with span of 10 cm, mildly tender, spleen not palpable, engorged neck veins and absent hepatojugular reflux (HJR), no murmur or cardiomegaly, chest was clear, and other systems normal.4
Q1. What is differential diagnosis?
Ans. This child has presented with subacute onset of slowly progressive disease with exertional tiredness, disproportionate tachycardia (heart rate faster than that expected with fever), and mildly tender hepatomegaly without jaundice. It suggests cardiac and liver involvement of long duration. Mild hepatic tenderness indicates either mild inflammation or congestion. Bacterial or amoebic liver abscess is unlikely as there would have been severe tenderness with fast progression. Chronic hepatitis should have presented with jaundice. However, mild jaundice may not be visible clinically and may be picked up by blood test. If not inflammation, then it may be congested liver and engorged neck veins and disproportionate tachycardia support such a possibility. However, it is not cardiac failure as there is no cardiomegaly and HJR is absent. Engorged neck veins without HJR suggest obstruction to superior vena cava and congested liver is due to obstructed inferior vena cava. So diagnosis is constrictive pericarditis. Fever of long duration is in favor of chronic infection, most likely to be tuberculosis. Restrictive cardiomegaly would be another possibility as it also presents with gradually progressive cardiac disease without cardiomegaly. So, differential diagnosis in this child stands to be constrictive pericarditis due to tuberculosis and restrictive cardiomyopathy must be ruled out.
Q2. What investigations would you consider?
Ans.
  • CBC: May not be directly helpful except to pick up comorbid deficiency anemia
  • ESR: Significantly high ESR may favor infection
  • Chest X-ray: Expected to show normal size heart without signs of cardiac failure, to look for focus of tuberculosis
  • 2D echocardiogram: Expected to reveal diminished filling of cardiac chambers and may show thickened pericardium
  • CT chest: May not add any more information
  • Mantoux test: Positive test does not help to diagnose tuberculosis while negative test at the age of 10 years may be taken against diagnosis of tuberculosis
  • Gastric aspirate for AFB (acid-fast bacilli): It may be worth it though in absence of obvious lung lesion, test may be negative
  • Biopsy: It is too invasive test and better avoided.
Laboratory Test Results
  • CBC was within normal limits
  • ESR was 85 mm/end of 1 hour
  • 2D echocardiogram showed thickened pericardium
  • Gastric aspirate did not show AFB.
Final Diagnosis
  • Constrictive pericarditis due to TB
  • Diagnosis is based on circumstantial evidence of prolonged fever due to subacute onset of chronic infection resulting in constrictive pericarditis 5and tuberculosis being the most common cause of such presentation in local epidemiology.
  • Child was treated with anti-TB treatment and improved.
Take Home Message
Diagnosis in a child presenting with prolonged fever evolves over time as physical signs appear as disease progresses. Periodic physical examination often offers a clue to diagnosis more than randomly ordered laboratory tests. Physical finding of enlarged liver demands observation for engorged neck veins, if any that may suggest not a primary liver disease but evidence of venous congestion or obstruction. Empirical antibiotic therapy should be avoided and minimum relevant laboratory tests must be ordered prior to antibiotic therapy. Partially treated bacterial infections pose a challenge to diagnosis and usually end up with increased morbidity. Noninfective diseases should always be kept in mind.
 
CASE 3
A 5-year-old child presented with fever off and on for last 3 months. He was well prior to present illness. It started as mild-to-moderate fever that increased over next few days to higher degree. Fever would spike 3–4 times a day at the interval of 6–8 hours and reduce in severity after antipyretic drugs. Fever pattern hardly changed over last 3 months though there were periods of low-grade fever interspersed with high fever. There were no other significant accompanying symptoms. Few antibiotics were tried in succession for a period varying from 4–7 days without any sustained improvement. Several tests were done that included CBC (repeated several times), blood and urine cultures (often done after antibiotic therapy), cerebrospinal fluid (CSF) examination and culture, serology for various infections, imaging studies, rheumatological tests, and bone marrow examination. Except persistent neutrophilic leukocytosis with thrombocytosis, there were no significant abnormalities in other test results. Considering systemic inflammatory disease, steroids were tried but stopped after few days as the child seemed to deteriorate. This child was referred for further evaluation. Physical examination at the end of 3 months revealed the following:
  • Weight 14 kg (had lost 5 kg)
  • Height 104 cm
  • Temperature 100°F
  • Pulse 140/min
  • Respiration 25/min
  • Blood pressure 90/55 mm
  • Mild pallor
  • No other significant findings on general examination
  • Systemic examination was normal.6
Q1. What is differential diagnosis?
Ans. This child is progressively deteriorating as evident by loss of 5 kg over last 3 months in a previously healthy child. Mild-to-moderate fever gradually increasing in severity over next few days may suggest initial bacteremia that settled in some organ resulting in higher degree of fever. However, organ in which it may have settled has not manifested with specific symptoms. This is what happens typically in a typhoid fever. However, it would have usually responded to several antibiotics, unless this bacterial strain was partially resistant. Thus, nonlocalizing partially treated bacterial infection is probable in this child. Other infections including tuberculosis, chronic viral, fungal, or parasitic infections are unlikely as they would have been localized by now. Fever of long duration may also be systemic onset of inflammatory disorder but would have by now developed joint involvement, skin rash, or organ affection. Common malignant disorders in children are hematological and by now would have manifested with symptoms such as pallor, or bleeding. Thus, this child is probably suffering from bacterial infection that is not properly treated. The only significant physical finding in this child is disproportionate tachycardia for age, degree of fever, and anemia while respiratory rate and blood pressure are within normal limits. This suggests cardiac involvement without any evidence of structural defect or it is an acquired disease and fever denotes inflammation, mostly infective as there are no other signs of systemic inflammatory disorder. As this is a chronic progressive infection, it favors diagnosis of subacute bacterial endocarditis.
Q2. What investigations would you consider?
Ans. Specific investigation would be echocardiogram for evidence of endocarditis and any structural defect.
  • Chest X-ray for cardiomegaly and status of pulmonary circulation
  • Electrocardiogram (ECG) for any rhythm disturbance
  • Blood culture is done for etiological diagnosis. Multiple blood samples would enhance bacterial yield
  • CBC is done for evidence of acute bacterial infection
  • Abdominal USG is done to assess spread of infection in other organs such as liver, spleen, or kidneys even in absence of clinical findings.
Laboratory Test Results
  • 2D echocardiogram showed vegetation on mitral valve. There was no structural defect in the heart
  • Chest X-ray revealed mild cardiomegaly
  • ECG was within normal limits
  • Blood culture grew Streptococcus viridans sensitive to penicillin
  • WBC 18,000/mm3, P 72, L 26, M 2, E 0, Hb 10 g%, Pl 3.2 lakhs
  • Abdominal USG normal.
Final Diagnosis
Subacute bacterial endocarditis without any valvular defect is diagnosed. Diagnosis is based on vegetation seen on echocardiogram and blood culture 7showing growth of S. viridans. This type of infection is commonly seen in damaged valve while infection in normal valve presents more acutely. This child presented with subacute illness due to partial treatment with antibiotics. As antibiotics in such a case need to be continued for at least 4 weeks, early discontinuation or change of antibiotics must have caused acute illness behave like subacute disease.
The child was treated initially with intravenous penicillin and gentamycin but after blood culture report suggested sensitivity to penicillin, gentamy-cin was omitted. Therapy has to be continued for 4–6 weeks till vegetation disappear and so also reversal of all other laboratory and clinical parameters. Supportive treatment includes symptom relief and nutritional rehabilitation.
Take Home Message
Bacterial endocarditis is often subacute or chronic infection because heart valves have no dedicated blood supply and so when bacteria get attached to the valve to form vegetation, antibiotics do not reach the site of disease. It is also the reason why antibiotics need to be administered intravenously for 4–6 weeks to ensure control of infection. Thus this is one of the bacterial infections that may continue to manifest for many weeks, and hence referred to as subacute bacterial endocarditis. Thus, this is one example of chronic active bacterial infection.
 
CASE 4
An 8-year-old child presented with fever for last 3 months. He was apparently well prior to onset of present illness that started with an erratic fever pattern. At times, he would get severe rigors with high fever ending with sweating and normal temperature while at other times, fever would be continuous, low grade for several hours. He had no other significant accompanying symptoms. However over the last 3 months, he had poor appetite and had lost considerable amount of weight and became severely cachectic. Several tests were done without any clue to diagnosis though tests revealed severe anemia for which he received packed red blood cell transfusion and so also few courses of antibiotics and antimalarial drugs were tried without benefit.
On physical examination, the child looked wasted and chronically sick with severe pallor.
Weight 16 kg, height 120 cm, pulse rate 134/min, RR 36/min, no lymphadenopathy, bone and joints normal, no edema.
Abdomen distended, more in upper part, liver 5 cm below costal margin, firm, not tender, liver span 12 cm, spleen 8 cm firm, no ascites, soft systolic murmur over precordium and other systems were normal.
Q1. What is differential diagnosis?
Ans. This child has severe progressive disease as suggested by development of cachexia and had also resulted in severe anemia requiring transfusion.8 It indicates a probable hematological disorder. Long-duration fever may favor diagnosis of malaria; however, it would have been easy to prove by simple tests and moreover this child did not respond to trial with antimalarial drugs. Severe anemia requiring transfusion at this age is not likely to be deficiency anemia. There has been no history of blood loss or evidence of hemolysis in the form of jaundice. Hence, anemia in this child must have resulted from bone marrow disorder. Bone marrow aplasia is ruled out as hepatosplenomegaly is not a feature and it would have presented with bleeding manifestations in the form of purpura or ecchymosis. Acute lymphatic leukemia is less likely as disease often manifests over short time and cachexia is not a feature. Chronic myeloid leukemia mostly presents without significant anemia. Bone marrow infiltration is often a slow progression and those with prolonged fever may be due to myelofibrosis or HLH; both are commonly secondary to infection that may go unnoticed. Another possibility is a chronic infection itself such as kala-azar (leishmaniasis). In fact cachexia due to disease, as often seen in malignant disorders in adults, is rare in children but untreated kala-azar does present in similar way.
Q2. What investigations would you consider?
Ans.
  • CBC, peripheral smear, and ESR
  • Reticulocyte count
  • Bone marrow examination
  • Depending upon bone marrow examination result, further tests need to be planned to rule out either HLH or kala-azar.
Laboratory Test Results
  • Hb 4 g% microcytic hypochromic anemia
  • WBC 16500, P 63, L 30, M 4, E 3, Platelet 0.35 lakh, ESR 120 mm
  • Corrected reticulocyte count 3%
  • Bone marrow examination showed Leishmania donovani (LD) bodies
  • No further tests were carried out as diagnosis is confirmed. Serological tests are not dependable.
Final Diagnosis
Bone marrow showing LD bodies is the gold standard of diagnosis of kala-azar. He was treated with amphotericin B. Liposomal preparation is most preferred but costly. Antimony compounds are also used in the treatment of kala-azar such as sodium stibogluconate. Child recovered completely.
Take Home Message
Severe anemia as a significant feature often suggests hematological disease, either primary or secondary. Anemia with hepatosplenomegaly is a feature of either hemolytic anemia or bone marrow infiltration. A chronically sick and febrile child almost favors bone marrow infiltrative disorders. Diagnosis is 9confirmed only on bone marrow examination and at times marrow aspiration fails and marrow biopsy may be necessary. Similarly in case of strong clinical suspicion of bone marrow involvement, single bone marrow examination may not pick up the diagnosis and repeat examination may be necessary. This is because many diseases evolve over time to offer classical laboratory results.
SUGGESTED READING
  1. Bennett JE, Dolin R, Blaser MJ. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Elsevier Inc.,  2014. 3697 p.
  1. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J (Eds). Harrison's Principles of Internal Medicine, 18th edn. New York, NY: McGraw-Hill;  2012.
  1. Parthasarthy A. IAP Textbook of Pediatrics, 7th edn. India: Jaypee Brothers Medical Publishers;  2019.