A 10-month-old girl with prolonged fever (page 1/2)
Prepared by....Thipvimol Tim-aroon, M.D.*
Aurmporn Oberdorfer, MD, PhD,**
Thanyawee Puthanakit, M.D.**
Virat Sirisanthana, M.D. **
*Chonburi Hospital, Chonburi
** Department of Pediatrics, Chiang Mai University
Patient: A 10-month-old Thai infant Address: Chiang Mai
CC: High grade fever 9 days PTA
Present Illness: She has been healthy before this admission.
  > 9 days PTA: She developed high-grade fever with non-productive cough. She was taken to a primary health care center where she received paracetamol, expectorant and decongestant.
> 6 days PTA: She developed erythematous rash along her face, neck, trunk and spreaded to all extremities in a few days.
> 5 days PTA: She was taken to a community hospital because of persistent fever and rash. The CBC showed Hct 36%, WBC 7,100 (N 16%, L 70%, M 14%), Plt. 201,000/mm3.
> 4 days PTA: Her doctor suggested that she might have dengue infection, so she was hospitalized for IV fluid. During admission, she had persistent high grade fever. There was no edema, no conjunctivitis, no coryza. She still had rash and occational cough. She was referred to Chiangmai University Hospital becasue of persistent high grade fever.
Past Medical History:
Perinatal Hx.: C/S due to breech presentation . Birth weight 3,300 gm.
Immunization: MMR at 9 month old (10 days prior to the onset of fever ).
Growth & Development: appropriate for age
Family History: No history of concurrent illness in the family
Travel history: none
Figure 1 : History of the illness
Physical examination: On admission to this hospital (day 9 of fever)
  GA: An active infant, BW 8.5 kg (50 percentile), HT 71 cm (50 percentile)
Vital signs: , V/S: BT 39.5 C, PR 160/min, RR 52 /min, BP 80/40 mmHg.
HEENT: Not pale, no jaundice, no injected conjunctivae, no oral thrush, no redness of lips, no injected pharynx and tonsils.
Lymph nodes: No cervical, axillary, or inguinal lymphnode enlargement.
Heart: normal S1,S2, no murmur.
Lungs: clear, no adventitious sound
Abdomen: soft, normal bowel sound, liver and spleen were not palpable
Extremities: Mild edema at both hands and feet
Skin: Erythematous maculopapular rash at both upper/ lower extremities, no eschar lesion, no petechiae.
Neuroexam: No stiffness of neck.
Initial Laboratoy investigations:
  > CBC: Hb 9.2 g/dL, Hct 27.9%, WBC 7,100/mm3 (N50%, L40%, M10%). Platelet 87,000/mm3
> UA: Spgr 1.025, alb negative, sugar negative, pH 6.0, no wbc, no rbc
> CXR: as in figure 1 : mild perihilar infiltration
 
Figure 1 Chest X-ray on the second day of admission (day 11 of fever)
What is the differential diagnosis?
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