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Prepared by....Thipvimol Tim-aroon, M.D.*
Aurmporn Oberdorfer, MD, PhD,**
Thanyawee Puthanakit, M.D.**
Virat Sirisanthana, M.D. **
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*Chonburi Hospital, Chonburi
** Department of Pediatrics, Chiang Mai University
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| Patient: A 10-month-old Thai infant |
Address: Chiang Mai |
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| CC: High grade fever 9 days
PTA |
Present
Illness: She has been healthy before
this admission.
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> 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 |
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Figure 1 : History of the illness
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Physical examination:
On admission to this hospital (day 9 of fever)
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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. |
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Initial Laboratoy investigations:
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> 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 |
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Figure 1 Chest X-ray on the second
day of admission (day 11 of fever)
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What is the differential diagnosis?
Next
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