Case 6.

05 - Tak cukup darah

Monday, 7 November 2022 11:26 AM

Trigger 1
Atun, a 22-month-old Orang Asli boy, presents with fever, headache, vomiting, abdominal pain and drowsiness. He was ill for the
past 3 days and his father brought him to the Kuala Kangsar Hospital emergency department. His condition has now worsened with
high fever and lethargy.

Cues
1. Atun, 22 month old, male, orang asli
2. Fever, headache, vomiting, abdominal pain, drowsiness
3. Ill for past 3 days
4. Worsen with high fever & lethargy
5. Brought to ED Kuala Kangsar Hospital

Hypothesis Generation
1. What are the common causes of fever in childhood?
i. Infection - Hemophilus influenza, dengue, parasites (malaria)
ii. Chicken pox
iii. Inflammatory condition
iv. Pyrexia of unknown origin
v. Heat exhaustion

2. How does the fever relates to other symptoms?

i. Nausea - parasites in the gut took up iron, causes bleeding, loss of fluid & abdominal pain
ii. Fever - causes GI tract inflamed
iii. Headache - liquid builds up in sinus in nose
iv. Abdominal pain - food poisoning

Hypothesis Organization
1. Malaria
2. Dengue
3. Influenza
4. Food poisoning
5. Gastroenteritis
6. Cholera
7. Meningitis
8. Encephalitis

Enquiry plan
Enquiries? Clinical Issues & Findings
HOPI 1) How long has been the fever (fever pattern) History of the presenting condition
2) Any medication? (Panadol) - Intermittent high fever associated with shivering, headache and sweating for 3 days.
3) Any insects bites? Mother does not have a thermometer but Atun felt very warm to touch. Irritable during
each episode of fever
4) Associated symptoms
- Decreased oral intake over the last 3 days, breastfeeding poorly. Refusing solids
- Started vomiting 3 days ago, shortly after developing fever. Usually prior to vomiting,
he would cry, bear down and press on
his abdomen. Vomiting on average 3-4 times daily
- Sleepy and tired after each fever episode but today, increasingly drowsy and lethargic

Past Medical History 1) Immunisation status Past Medical History

2) Breastfeeding - Born full term via spontaneous vaginal delivery
3) Delivery history - Newborn screen for Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency was
normal
4) Any allergy?
- Vaccinations up to date (supported by Orang Asli Vaccination Program)
5) Experience same condition before?

Personal History 1) Have you been to the river Personal History

2) Living condition - Able to get clean water - Atun is the youngest of 5 siblings. His parents are both Orang Asli from the Jahai ethno-
source? linguistic group. They reside in a shed built by his father in Kampung Aman Damai,
located within the Belum Forest Reserve in Gerik, Perak

Family History 1) Any siblings having same condition 5 siblings - 2nd sister passed away @ 3yo due to lack of blood
2) Parents economic status
Family history
- Both his parents are well
- Atun’s second sister passed away at 3 years of age from “tak cukup darah” (lack of
blood). Atun’s father is worried that Atun
may have the same problem
Physical Examination 1) Vital signs Palpable liver & spleen
2) General inspection - pallor, jaundice Frontal bossing
3) Abdominal examination - palpation Maxillary hyperplasia
4) Facies - maxillary hyperplasia Dry mucous membrane
5) CVS & Respi examination Sunken eyes
Scleral icterus
Physical examination
- Febrile (40oC), pulse rate: 150 bpm, respiratory rate: 40 per minute, blood pressure
76/53 mmHg - Drowsy
- Responds when called by name
- Pale
- Dry mucous membranes, sunken eyes, scleral icterus
- Examination of the face showed frontal bossing, maxillary hyperplasia
- Examination of abdomen: palpable liver 6 cm below right costal margin, palpable
spleen 5 cm below left costal margin
Generalized tenderness over the abdomen on palpation
Investigations 1) CXR Microcytes, anisocytosis, target cell
2) FBC FBC and blood biochemistry [See Results 1]
3) Blood smear
4) Blood culture
5) Hb analysis
6) Biochemistry
7) Serology test - PCR (Dengue)
8) Cerebrospinal fluid culture (encephalitis)

- Blood culture – no growth

- CSF culture – no growth
- Urine culture – no growth
- Thick and thin PBF – Plasmodium vivax parasites, 0.3% parasitaemia [See Results 2]

Blood film also demonstrated microcytes, target cells and anisocytosis

- Dengue serology negative [See Results 3]

Learning objectives
Trigger 2 = Result 4: 1. Risk factors of malaria and thalassemia
2. Pathophysiology of:
i. Fever and other associated symptoms
ii. Beta Thalassemia Major
iii. Malaria
3. Investigations
4. Complications of malaria and thalassemia
5. Treatment and management of:
i. Fever
ii. Malaria
iii. Beta Thalassemia Major

Iron studies - Rule out IDA

Diagnosis: Malarial infection caused by Plasmodium vivax secondary to Beta Thalassemia major