CLINICAL MEETING

DR ISMAT JAHAN SHIMI

DCH STUDENT
DMCH
PARTICULARS OF THE PATIENT
Name : Abdur Rahim
Age : 12 years
Sex : male
Address : Pabna
Date of Admission :18/09/10
Date of examination : 18/09/10
CHIEF COMPLAINTS

1. Fever for one month

2.Mass in the abdomen for same duration.
3. Yellow discoloration of eyes and urine for 25
days.
 HISTORY OF PRESENT ILLNESS
According to the informant mother’s statement her child was reasonably
well 1 month back. Then he developed fever which was initially low
grade gradually became high grade intermittent in nature not associated
with chill and rigor but associated with generalized weakness and gradual
wt loss. Mother noticed a mass in the abdomen for same duration which
was gradually increasing in size and causes marked abdominal distension.
After 5 days of initiation of fever mother noticed yellow discoloration of
eyes and urine of patient. On query mother told that pt experienced single
episode of bleeding per nose and well preservation of appetite during the
course of illness.
He has no H/O contact with TB pt, previous history of
jaundice, taking any offending drugs or exposure to
radiation, blood or blood product transfusion, travelling
to malaria endemic zone. For these complaints pt was
first admitted in Pabna Sadar Hospital and some
investigations were done. Patient then referred to DMCH
for further evaluation and subsequent management.
HISTORY OF PAST ILLNESS: No significant past illness.
BIRTH HISTORY: He was delivered by NVD at term without
any complications.
FEEDING HISTORY: Pt is now on family diet.
DEVELOPMENTAL HISTORY: Age appropriate
IMMUNIZATION HISTORY:
As per EPI schedule except Hep B.BCG vaccine was
given.
TREATMENT HISTORY: Inj Ceftriaxone, tab Paracetamol.
FAMILY HISTORY: He is 2nd Issue, 2 sibs, all of them and parents
are healthy. No consanguinity.
SOCIOECONOMIC CONDITION: Patient belongs to a low
socioeconomic family. They live in kacha (mud built) house,
sometimes sleep on the floor, drinks tube-well water and use
sanitary latrine. Father is a farmer.
 PHYSICAL EXAMINATION
General examination:
Appearance : ill-looking
Anaemia: moderate pallor
Jaundice: mild
Cyanosis:
Clubbing:
Koilonychia: Absent
Leuconychia:
Oedema:
Dehydration:
Neck vein: not engorged
Lymph node: not palpable
Skin survey: BCG mark present
Ear, nose, throat : normal
Vital signs:
Pulse: 90/min
BP: 100/70 mm of Hg
Temp: 1010 F
R/R: 24/min
Bony tenderness: absent
Signs of meningeal irritation : absent
Bed side urine for albumin: nil
Anthropometry:
Weight 20 kg
Height 120 cm
Wt for age Z score -3.5 SD(severe undernutrition)
Ht for age Z score -4.2 SD(severely stunted)
Wt for stature Z score -1.2 SD
 SYSTEMIC EXAMINATION
ALIMENTARY SYSTEM:
Mouth and fauces: normal
Tongue: moist, clear
Abdomen:
Inspection: distended with centrally placed flat umbilicus.
Palpation: no localized area of tenderness.
Liver: palpable 8 cm from Rt costal margin along MCL, firm,
nontender, smooth surface, sharp border and upper border of liver
dullness in Rt 5th ICS. No hepatic bruit.
Spleen: palpable 12 cm along its long axis, firm, nontender,
smooth surface with palpable splenic notch. Splenic bruit absent.
No other organomegaly.
Percussion: shifting dullness absent.
Auscultation: bowel sound present.
NERVOUS SYSTEM EXAMINATION
Mental function- Conscious
Appearance -
Behavior - Normal
Communication
Emotional state
Orientation in time and place
Speech -normal
Memory - Intact
Intelligence -
Sleep pattern - Normal
Cranial nerves - Intact
Motor function- Normal
Co-ordination- Normal
Sensory function-Intact
No involuntary movement
Gait- Normal
Fundoscopy- Normal
OTHER SYSTEMIC EXAMINATION:
No abnormality
SALIENT FEATURES
Abdur Rahim, 12 years old immunized male child of
nonconsanguineous parents hailing from a poor socioeconomic
family of Pabna a highly endemic zone for Kala-azar with the
complaints of high grade intermittent fever associated with wt
loss inspite of having good appetite for 1 month, abdominal mass
for same duration and jaundice for 25 days. Pt had a H/O
epistaxis. He had no previous H/O jaundice, travelling to malaria
endemic zone, contact with TB pt, exposure to radiation or
taking any offending drugs or blood transfusion.
 On examination, Rahim is ill looking, severely
undernourished and stunted, toxic, moderately pale,
mildly icteric, BCG mark present. There was huge
hepatosplenomegaly. Patient has no
lymphadenopathy or bony tenderness. Fundoscopy
normal and other systemic examination revealed
nothing abnormality.
PROVISIONAL DIAGNOSIS

KALA-AZAR
DIFFERENTIAL DIAGNOSIS
• DISSEMINATED TUBERCULOSIS
• CHRONIC LIVER DISEASE
• ACUTE LEUKAEMIA
• CHRONIC MALARIA
INVESTIGATIONS
Complete blood count:
Hb 7.9gm/dl
TC 3520/cu mm of blood
DC N 25%, L 60%, M 12%, E 3%
Platelet- 1,25000/cu mm of blood
ESR 110 mm in first hour
PBF- normocytic normochromic anaemia
WBC-mature with above distribution
Platelet- low
Blood for Malarial parasite: absent
Blood group: B+ve
ICT for Kala-azar: +ve
ICT for Malaria: -ve
MT: 6 mm after 72 hours.
Chest X ray: normal
Liver Function test:
S. Bilirubin 2.02mg/dl
Prothrombin time control 12 sec
Patient 15 sec
ALT 378 U/L
HBsAg (ELISA) -ve
 S.Albumin 26 gm/L
S. Globulin 6gm/L
ECG normal
Serum Creatinine 0.8mg/dl
USG of whole abdomen hepatosplenomegaly without
ascites.
Splenic puncture: Leishman stain of splenic aspirate reveal
presence of L. D body.
MANAGEMENT
Supportive management:
Nutritional support- high protein diet
Parenteral Antibiotic Inj ceftriaxone, Inj Gentamycin.
Syrup Paracetamol
Specific management:
Inj Sodium Stibogluconate
20 mg/kg(400mg/4ml) deep IM for 30 days
Follow up plan
Clinical improvement
Fever
weight
Spleen size
pallor
well being
Haematological and Biochemical status
Hb %
Total WBC count
Platelet count
S. Albumin
LFT
RFT
Katex Ag detection in urine(has prognostic value)
THANK YOU