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566 SELF ASSESSMENT QUESTIONS Postgrad Med J: first published as 10.1136/pmj.78.923.568 on 1 September 2002. Downloaded from Fever, , and ...... Unusual cause of fever, jaundice, and hepatomegaly in a middle aged man S Kumar, S Uthamalingam, A R Vasudevan, A Lim, Figure 1 Peripheral blood smear A Feliz, J M Brensilver, R Yarrish (Wright-Giemsa stain)...... 16 cm. It was tender, firm, and smooth Answers on p 569. surfaced. The spleen was not palpable, and there was no . 48 year old man presented with the northeastern United States for the Neurological examination was normal. gradual onset of fever, anorexia, past four years. He was a gardener by Laboratory values on admission are Aepisodic and , a 40 occupation. There was no history of shown in table 1. Viral profile pound weight loss, and deepening jaun- travel abroad during this time. was negative for , B, and C dice over a six week period. Fever was On examination, the temperature was viruses. Monospot test (infectious mono- intermittent and associated with chills 39°C, pulse rate 92 beats/min, blood nucleosis) and ELISA test for HIV were and rigors. There was no history of pain pressure 120/60 mm Hg, and respiratory negative. Urinalysis revealed large bi- in the right hypochondrium, pruritus, or rate 18 breaths/min. There was no lirubin and >8 EU/dl (nor- clay coloured stools. The patient had a 30 significant lymphadenopathy. He was mal <1 EU/dl). Chest radiography was pack year smoking history and con- markedly icteric, but there was no normal. A computed tomogram of the sumed alcohol in moderation. He took no or stigmata of chronic disease. Car- showed diffuse hepatomegaly . Five years previously, he diorespiratory examination was within without biliary dilatation or ; had an emergent laparotomy after a normal limits. the spleen was not visualised. Electrocar- motor vehicle accident, details of which revealed a midline scar. The liver was diogram showed sinus tachycardia. he was unable to supply. He was a native palpable 8 cm beneath the right costal Over the next 48 hours, the patient of El Salvador, but had been residing in margin and percussed to a liver span of complained of increasing lassitude and dyspnoea. He had intermittent fever with chills, but Table 1 Laboratory values on presentation was otherwise unchanged. Laboratory Test Value Normal range findings over days 2–4 are summarised in table 2. Serum on day 3 Haemoglobin (g/l) 86 140–180 was less than 0.06 g/l (normal 0.5–2.2 Packed cell volume 0.26 0.42–0.52 Leucocyte count (× 109/l) 12 4–11 g/l). Multiple blood cultures and a Platelet count (× 109/l) 169 130–400 culture were done, all of which showed http://pmj.bmj.com/ Mean corpuscular volume (fl) 100 86–98 no growth as of day 4. A peripheral blood Red cell distribution width 0.24 0.13–0.15 smear was taken (see fig 1). Reticulocyte count (%) 12 0.2–2 Lactate dehydrogenase (U/l) 1200 100–190 QUESTIONS Sodium (mmol/l) 136 136–145 Potassium (mmol/l) 4.4 3.5–5.0 (1) In this patient’s clinical context, how Blood urea nitrogen (mmol/l) 8.2 3.6–7.1 do you interpret the laboratory tests on Creatinine (µmol/l) 150.2 50–130 admission (table 1) and those done

Glucose (mmol/l) 7.54 3.5–7.8 between days 2–4 (table 2)? on October 2, 2021 by guest. Protected copyright. Amylase (U/l) 55 60–180 Total (µmol/l) 265 5.1–17 (2) What does the blood smear show (fig Direct bilirubin (µmol/l) 140 1.7–5.1 1)? What is the ? Aspartate aminotransferase (U/l) 96 15–45 Alanine aminotransferase (U/l) 49 15–45 (3) How would you treat this patient? (U/l) 217 30–120 What are the common complications of Total protein (g/l) 56 55–80 this condition? (g/l) 23 35–55 International normalised ratio 1.1 0.7–1.1 Postgrad Med J 2002;78:566 Activated partial thromboplastin time (sec) 29.3 Up to 32.3 ...... Authors’ affiliations S Kumar, S Uthamalingam, A R Vasudevan, A Lim, J M Brensilver, Sound Shore Medical Center of Westchester (SSMCW), New York Table 2 Laboratory findings over days 2–4 Medical College, 16 Guion Place, New Rochelle, NY 10802, USA: Department of Haemoglobin Reticulocyte Total/direct Medicine (g/l) MCV (fl) count (%) bilirubin (µmol/l) LDH (U/l) A Feliz, R Yarrish, Department of Pathology

Day 2 70 104 12 280 / 170 – Correspondence to: Dr Yarrish; Day 3 68 108 – – 1320 [email protected] Day 4 63 115 21 275 / 158 – Submitted 25 February 2002 MCV, mean corpuscular volume; LDH, lactate dehydrogenase. Accepted 25 March 2002

www.postgradmedj.com SELF ASSESSMENT QUESTIONS 567 Postgrad Med J: first published as 10.1136/pmj.78.923.568 on 1 September 2002. Downloaded from Failure to thrive QUESTIONS ...... (1) What are the radiological findings and findings on peripheral smear and Failure to thrive in a 3 month old boy bone marrow? (2) What is the diagnosis? What are the D Basu, S Ferns, M Arun Prasad, P Nalini possible differential diagnoses? (3) What is the prognosis and treatment ...... of this condition? Answers on p 569. Postgrad Med J 2002;78:567

3 month old boy weighing 3.5 kg showing prominent vacuolation in the ...... was admitted because of excessive cytoplasm (fig 1). His blood was lipaemic Authors’ affiliations Ableeding from an intramuscular when drawn, though investigations re- D Basu, M A Prasad, Jawaharlal Institute of injection site for the past 12 hours. The vealed a normal cholesterol and triglyc- Post Graduate Medical Education and mother had observed that his abdomen eride fraction. Hepatic enzymes were as Research, Pondicherry, India: Department of had been progressively distending since follows: 600 IU/l, Pathology S Ferns, P Nalini, Department of Pediatrics the first week of life and that he had had 789 IU/l, and alka- low grade fever for the past month. line phosphatase 1200 KA units/l. Radio- Correspondence to: Dr Debdatta Basu, Recently, on receiving an intramuscular graphy of the skull and long bones and Department of Pathology, JIPMER, Pondicherry injection in the gluteal region for this an echocardiogram were unremarkable. 605006, India; ddbasu@ satyam.net.in fever he began to bleed uncontrollably An abdominal radiograph (fig 2), an Submitted 24 January 2002 from the site. There was no history ultrasound of abdomen (fig 3), and a Accepted 25 March 2002 of birth asphyxia or contact with bone marrow aspiration (fig 4) were tuberculosis. requested. A physical examination revealed se- vere pallor and massive hepatospleno- megaly and ecchymotic spots in the glu- teal regions. His medical history revealed failure to thrive, repeated episodes of diarrhoea, and upper respiratory tract infections for the past month. Examina- tion of his cardiovascular, respiratory, and neurological systems was unre- markable. A complete blood count re- vealed severe anaemia with a haemo- concentration of 60 g/l, platelet Figure 3 Ultrasound of the abdomen showing × 9 count of 25 10 /l, total leucocyte count calcification in the region of the adrenals. of 13 × 109/l, and many lymphocytes http://pmj.bmj.com/ on October 2, 2021 by guest. Protected copyright.

Figure 2 Radiograph of the chest and Figure 4 Bone marrow aspiration showing Figure 1 Peripheral smear showing abdomen showing bilaterally symmetrical a large population of macrophages with vacuolated lymphocytes (Leishman’s stain × and enlarged adrenals with stippled vacuolated cytoplasm (Leishman’s stain × 1000). calcification. 1000).

www.postgradmedj.com 568 SELF ASSESSMENT QUESTIONS Postgrad Med J: first published as 10.1136/pmj.78.923.568 on 1 September 2002. Downloaded from Paediatrics ...... Refusal to walk in an afebrile well toddler S Lim, W Sinnathamby, H Noordeen ...... Answers on p 570.

19 month old well boy presented take a few steps across the room when with a week’s history of refusal to supported. He crawled well with no Awalk unsupported and favouring obvious asymmetry of movements. In- crawling. He had been increasingly un- vestigations revealed raised C reactive steady during the preceding three weeks protein of 45 mg/l, erythrocyte sedimen- and appeared to be in pain during nappy tation rate of 73 mm/hour, and a white changes when both legs were held flexed cell count of 8.5 × 109/l (neutrophil count and abducted at the hips. There was no 2.98 × 109/l). Ultrasound of the hips and recent feverish illness or trauma. Bowel abdomen and a bone scan were normal. and bladder function was normal. His Rheumatoid and viral serological screens development had been age appropriate were negative as were all blood cultures. to date. He walked unsupported at 1 year Plain radiography of the thoracolum- of age and had been an active member in bosacral region showed loss of the disc a child care group. Examination revealed height at the L5–S1 level and loss of clar- symmetrically decreased deep tendon ity of the adjacent end plates (fig 1). He reflexes of the lower limbs with flexor had magnetic resonance imaging of the Figure 3 Follow up magnetic resonance plantar response. Lower limb muscula- spine (fig 2). He was given a three week image of the spine one year later. ture and spine looked normal. Anal tone course of antibiotics (parenteral ceftriax- and hip examination was normal. He one and oral sodium fusidate for the first elicited, and he was standing unsup- pulled easily to stand and would only 10 days followed by oral flucloxacillin ported for longer periods. By the end of and sodium fusidate for the rest of the the course of antibiotics, the inflamma- course). Before starting antibiotics, C tory markers had normalised and he was reactive protein had fallen to 2.9 mg/l, able to walk unsupported. More recent x lower limb reflexes were more easily rays did show that there was no signifi- cant disruption of the disc space. Repeat magnetic resonance imaging of the spine a year later is shown in fig 3. http://pmj.bmj.com/

QUESTIONS (1) What is the likely diagnosis and what do the magnetic resonance imaging studies (figs 2 and 3) show? (2) What are the alternative differential diagnoses of refusal to walk in a well afebrile toddler? on October 2, 2021 by guest. Protected copyright. Postgrad Med J 2002;78:568

...... Authors’ affiliations S Lim, W Sinnathamby Paediatric Department, St John’s Hospital, Wood Street, Chelmsford CM2 9BG, UK H Noordeen, Department of Orthopaedics, Great Ormond Street Hospital, London

Correspondence to Dr Lim; [email protected]

Submitted 25 February 2002 Figure 1 Radiograph of spine on Figure 2 Magnetic resonance image of the admission (lateral view). spine on admission. Accepted 25 March 2002

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