A 8.5 months old infant brought by mother on 12 Sep 2016 with history of Fever for 2 day duration, with common cold. Examination didn't revealed any significant finding. CBC and NS1 Ag, IgM & IgG for Dengue, MP and Paracheck was advised. Syp PCM and ORS were given and called to report back with report on next day. Mother brought the child on 14 Sep 2016 at 1300 hr with report of NS1 Ag, which was positive, although IgM & IgG for Dengue was negative. Though Fever was not there and baby was active and playful along with normal vitals, still child was admitted for observation and in view of young age, positive NS1, absence of CBC especially platelet count report and highly endemic region. Once baby reached to the ward where sample were collected. While securing canula and sampling, baby was crying, so staff nurse advised to console n feed the baby. Then suddenly baby started threwing seizure in form of tonic posturing with uprolling of eyeball, which led to gasping respiration and cardiorespiratory arrest. Baby was immediately resuscitated with initial bag and mask ventilation followed by endotracheal intubation. There was severe bradycardia which was not responded to adequate resuscitative effort and expired at 1550 hrs. Duration of hospital stay - 2hrs 50 min. While resuscitation the following cranial images were taken. Sorry for the quality of images as theae were taken while resuscitative action was on. Initially it was thought it's a severe thrombocytopenia which led to this intracranial hemorrhage. But later on post demise CBC report is as under:- Hb 9.2, TLC 3700, DLC P30L62M2E6, Platelet 338x10^3, Kindly Review this case and discuss critically without mercy.



No significant finding on physical examination.. Active playful child.. denote some acute event.. Platelet counts are against DHF/DSS. We can just make guesses here. So may be it's febrile convulsion or stroke or viral encephalitis or BHS leading to seizures and ?aspiration. Death may be due to asphyxia and intracranial hemorrhage. Dengue may have added/made child prone to this acute insult.

Age 8 plus months, Fever for 2 days with cold, Review on 4th day of illness, NS1Ag +be. Seizures & Cardio Respiratory Arrest. Resuscitation with Bag & mask, Endotracheal intubation done, but Child had CRArrest. Dx : SEIZURES WITH C.R. ARREST. CAUSE OF SEIZURES : ASPIRATION. HYPOXIA. IVH ENCEPHALITIS VIRAL D.F.HEMORRHGIC DISORDER REY SYNDROME. This case needed POST--MORTEM Dx. as there is lot of GREY AREA IN Dx.

In the initial 1 week of dengue fever only NSI antigen is positive IgM becomes positive later That's exactly the reason why we do NSI antigen The cardio respiratory arrest must be due to the seizure

Dear dr Manish I can understand its very difficult situation when you have just admitted the child and immediately child went in to cardio respiratory arrest. The irony is doctor will also be as curious as parents that what suddenly happen to their child. But you have limited time and tools during this type of critical situation to arrive at the diagnostic. We can't conclude but only can assume what could be the possibilities. In dengue, encephalitis is seen early in the illness, even before thrombocytopenia is apparent. So it might be one possibility that child went into seizures due to encephalitis which led to aspiration and then hypoxia and cardio respiratory arrest. Seizures can also be just simple febrile seizure with similar consequences. And usually survival is better in in-hospital cardio respiratory arrest but may be hypoxia was a major factor effecting your resuscitative measures. Only PM examination can give you the right answer.

In dengue convulsant phase baby may have thrombocytopenia and child has got febrile status that may caused the cardio respiratory arrest. Because of defervance child went into shock that may be the cause for death.

only Ns1ag positive,whereas IgG&particularly IgM being negative with thisplatelets,niddle of suspicion goes other than Dengue. Any way further work out including better clinical assessment could have perhaps helped in reaching diagnosis.

Yes I agree wth u.

Hmm very difficult to pick up cases like this. We ve to think if a case comes to clinic and what happens next. one thing i can think here is what caused ICH whuch is the cause of death. IS it due to dengue. Late HDN.

@Dr. Manish Verma ?

ns1 antigen +ve is related to dengue its prestage of developing severe dengue spcly when +ve from 5 day


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