Today i've managed to present one case of a 4 year old child with fever for 4 weeks with no other clinical symptom except loss of appetite, lost of wt of 1 kg and a bit lethargic and less active. There was no RTI, GIT, CNS symptom. Fever was reduce by antibiotics. No night sweat. Then later was referred from a GP due to fever and palpable cervical lymphnodes. Got a history contact to TB patient(grandmother). Vaccination was complete.
Physical examination reveals fever, palor, with hepatomegally (1cm) and generalised lymphadenopathy. No bcg scar noted
So differentials would be
1) Tuberculosis
Points favour - History contact with TB, loss of wt and appetite. PE reveals fever, palor, hepatospleenomegally and also generalised lymphadenopathy and no BCG scar.
points agains - No cough, haemoptysis, and night sweat.
2) Leukaemia
Points favour - Lethargy, fever, palor, hepatomegally, lymphadenopathy
Points against - No bleeding tendency, no family history of blood malignancy, no spleenomegaly
3) Lymphoma
Points favour - B symptom? (must really need to clarify is there any night sweat because patient was in an aircond when sleeping) and also lymphadenopathy
Points agains - i couldn't think of... maybe u can give me a comment
4) HIV - fever
points against - No hx of blood transfusion,
5) Thyphoid/thyphus
Points favour - PUO, lymphadenopathy, hepatomegally
Points against - no spleenomegally, no
6) autoimmune? connective tissue disease?
Investigation that was done and some I think should be done base on the differentials given are:
1)FBC
Investigation fbc reveals hb low, white cell low, but platelet and wcc differentials are normal.
2)PBF shows normocytic and normochromic anaemia. No blast cell seen
3)Mantoux test
negative
4)Chest xray
No mediastinal lmphadenopathy noted.
5)Bone marrow film
No abnormal/malignant cell noted. Comment said that we should look for viral causes.
6)Lymphnode biopsy
Not done yet
7) HIV screening (permission should be taken 1st when doing HIV screen), Hepatitis screening
-ve
8) Toxoplasmosis?
No plan yet for this toxoplasma screen
9) Infectious Mononucleosis??
10) Blood culture
-ve for all bacteria, virus,
11) Thyphoid/Thyphus
-ve
12)
Diagnosis
PUO and currently on investigation.
Comment
Currently, patient on IV antibiotics, fever are up and down, and relief with PCM. Antibiotics given shown to have positive result, but they are trying to off it to let see if the fever spike up again.
Platelet count was normal despite HB and WBC low. wbc was low until 2 and this is what we call febrile neutropaenia. Prof Amir has said that if a patient come with febrile neutropaenia, we should do a septic screen (blood culture, urine culture, oral swab etc..). However all the test was negative.
Mantoux test was negative however it doesn't mean that the diagnosis should be exclude. there was no BCG scar showing that
Bone marrow was also negative of malignant cell, however, if the bone marrow is negative we can do a lymph node biopsy. Correct me if I'm wrong.
I will follow-up the patient progress and post it on here later. Anything in mind can contact me. Thanks in advance.
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