A 22 year old female married for 2.5 months presented to ER with fever since 8 days low to moderate grade, intermittent.and yellowish discolouration of sclera and skin since 3/4 days and altered sensorium since 1 day. On examination: Vitals normal Pallor + Icterus +++ Rest GPE wnl Patient deeply comatosed E1V1M1 No neck rigidity no kernigs. Planter b\l flexor Liver just palpable ( span 11.5 cm) On enquiring her husband and mother, there is history of ayurvedic medicine intake for a month bt that too 2 months back for lump in left breast which seems to be a lipomatous 0.5*0.5 cm swelling. Lmp was 1.5 mnth back. History if rats in house is there. No major prev illness Husband told that she developed rashes on day 1 and 2 and as per description were maculopapular but no scars are seen now. LMP 1.5 month back UPT negative. Leptospira igM sent, hbsag hcv awaited. Reat reports attached. Started ceftriaxone , doxycycline, ppi, emset, ivf, lactulose, rt feed. Kindly give your valuable opinion for further plan.



Case of Fulminant Hepatic Failure...Rash must be purpuric or petechial Rash coz of thrombocytopenia... Apart from herbal meds as a cause...rule out infective, auto immune ,Vascular causes(Budd Chianti) Wilson's etc... Pls OMIT DOXYCYCLINE as it is Hepatotoxic... start T.Rifaxamine 550 mg be Monitor 4 hrly blood sugars for hypoglycemia and infuse with dextrose containing fluids,keep bloodsugar levels 120-180 mg/ dl Adequate nasogastric feeding Loose (lactulose)enema every 2 hourly till 2-3 normal stools have been passed Manage airway as pt Gcs is 3...if required elective invasive ventilation with t-piece to prevent aspiration Instead of ender u can give prokinetics like problem Assess bleeding status Hb%,platelets, pt/inr... vit k injections advisable In case of sudden drop in bp...check nasogastric aspiration and bleeding pr... Monitor electrolytes Rest symptomatic management

instead of emset , add prokinetics like perinorm

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Clinical Diagnosis: Acute Fulminant Hepatitis(?Drug induced/ Viral) with Hepatic Encephalopathy with severe Anaemia(?Bleeding from GI to be ruled out) with Hyperglycemia as a bad prognostic sign. Management:Hospitalization & ICU care.To be continued....

Further Investigations: 1.Reports of HAV,HBsag,HcV,HIV I ll, 2.Send Complete Coagulation profile,Repeat Electrolytes, 3.Serum levels of common metallic" Bhasams " prescribed in Ayurveda eg Iron,etc Management:on the lines of hepatic coma. 1.I/ V 10% Dextrose With 1amp MVI in 1 bottle.Correct slight hyponatremia as reported. Calculate Requirements Of 24 hours fluids & Electrolytes & infuse. 2.Inj. Hepamerz 3.RT insertion 4. Care of bowel , bladder & posture. 5 Input/ output chart 6.Liq. Lactose 1 oz. 8houry 7.Cap. Neomycin through RT 8.Inj. Rabeprazole 20 mg I/ V od 9.Avoid Hepatotoxic medications 10.Plan urgent Gastroenterologist Consultation.

Thank You so much sir for such nice description. Will keep u updated. Regards.

Following are the differential diagnosis in this patient, Leptospirosis with septic encephalopthy as the counts are elevated need to send blood culture and csf routine microscopy to rule out cns infection, 2)primary biliary cirrhosis as comon in young female, send Ana and AMA antibody, 3)viral hepatitis with septic encecphalopthy as liver enzymes are more than 5 fold,send hep e and hep c also, 4)Wilson disease send 24 hour urinary copper n slit lamp Examination for kayser Fischer ring, 5)hepatocellular carcinoma as she had breast lump ,send alpha feto protein ,hep e causes fulminat hepatic failure send hep e

Hello, good case for discussion sir. It is a case of fulminant hepatic failure. kindly upload the reports. possibilities are herbal medication ingestion, viral hepatitis but we need to rule out intentional self harm like ingestion if rat poison is highly likely to cause similar picture and many patient party will hide this history. kindly omit doxycycline, continue ceftriaxone, check electrolytes, LFT, PT/aPTT, blood cultures, intubation for airway protection. if suspicion of any position ingestion exist kindly start. N acetyl cysteine IV dosage as it needs to be given early. Rest symptomatic management to be continued.

DD S.. 1. leptospirosis 2. malaria 3.acue fulminant hepatitis 4.associated DIABETES MELLITUS also..? DKA ..


D/D 1.primary biliary cirrhosis 2. autoimmune hepatitis and the third one is viral bur I don't think it is a viral hepatitis

Contd. 11. Plan blood transfusion 12.Inj Vit K 1amp of 3days 13. Watch vitals.

Jandice parasfe tab taxiem o 200cv tab silybon syrup neohepatex inj clearliv tablet actilife tab

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