a nine year old girl with history of cough, high grade fever since 4 months with chills and rigor with pain in body with h/o epistaxis with hb- 4 ,platelet count 26000 tlc 17700 chest b/l ronchi . on Att for abdominal Koch's. pallet with tachycardia. ps- anisopoikilocytosis macrocytic anaemia. h/o multiple joint pain. petechiae all over face since 5 days. USG Abdomen shows hepatomegaly. CERVICAL ADENITIS tender. likely d/d and management.




Stabilize the child first Packed Red cells at least 2 to 3 units Give Platelet concentrates 4 units to keep Platelets above 50 thousands. Continue ATT. B12 & Folic Acid Levels.. Iron Profile Blood. Cultures Abdominal kocks with secondary infections Look for Widal & Brucellosis.. Dual Deficiency Anemia with Hepatomegaly..

Coombs direct (++)

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Why its hemolytic? What about retics?if high then can be coined hemolytic. Is it coined on the basis of direct coombs +ve . What about macrocytic anemia.vit b12 & folic acid is required to be done. Leukemia is high possibility as platelet is very low along with extremely low hb. Cxr regionally shows miliary nodules but lymph nodes r not enlarged. Cough .fever for long time and tender nodes along with hepatomegaly with such cxr could result from sarcoidosis though cxr lacks lnadenopathy. What about spleen ?not mentioned.it must be enlarged in this scenario but not mentioned means autosplectomy could be the reason.so sickle cell could be the possibilty for it. Mycoplasma infection or pneumonia could be cause of cough with coombs +ve hemolysis. Ebv too could lead to such presentation. Why att was initiated?could be a mistake as underlying pathology is much grave at present. So pl ivestigate accord to finally conclude.and keepupdated. Its really a mind boggling case.thanks dr abhishek.

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D/D- 1.disseminated TB involving bone marrow, liver, LNs 2. Lymphoproliferative disorders like lymphoma, leukemia 3.HS Purpura 4. ITP 5. Infectious mononucleosis 6. Evan's syndrome 7. Idiosyncratic reaction to ATDs Management: repeat complete hemogram, stool occult blood test, urine r/e, LFT, Renal function tests, USG W/A, throat swab, serum IgA, serum IgM, coagulation profile, Hep b &c and HIV serology, Bone marrow aspiration/biopsy. Rx- Hemodynamic monitoring, platelet rbc transfusion judiciously, antipyretics, review of drugs, temporary withdrawal of ATT, broad spectrum antibiotics along with gram negative coverage. Take hematologist's opinion. Steroids/immunosuppressants may be neded depending upon test results.


Orbital and pedal edema could be due to low hb and albumin.impending chf could add up. Ronchis can be explained as bronchiolitis or myplasma pneumonia. Ebv or infectious mononucleosis can have b/l orbital edema and this is a sign.check for atypical lymphocytes. Also it wold be wise to do basic immunologic invest as many can present as AIHA with viral infections as wrote. Pl mention all invest in detail.

Sir, bronchiolitis in 9 year old child and EBV, mycoplasma lasting this long? Counts not suggestive of viral and such severe anemia which is Coombs positive, mycoplasma can have cold agglutinins.

Broncheictasis Anaemia Thrombocytopenai Leucocytosis with Koch's abd Do dengue iggigm Aso test Ra test Dengue with Koch's abdomen

Opinion of haematologist

There two cell cell line depressed. Before blood and platelet transfusion Bone marrow examination should be performed. Etiological diagnosis required CBCwithperiphrel smear repeatition s. Vitamin B12and folic acid, Dengue serology, xray chest,, LFT. Review of reports.

DCT positive is certainly AIHA which can very well explain macrocytosis and with thrombocytopenia it becomes Evans The first xray done in September looks normal and subsequent X-rays show lesion only on Right side only.

Blood culture (aerobic) - no growth

I agree with Dr. Javed Iqbal Khan sir

ATT induced drug reaction and superadded viral lymphadenopathy.Chest x-Ray shows millary infiltrative nodules and BV markings diffusely raised -infective etiology .Give haemodynamic support to the child and ceftriaxone-vancomycin coverage.

First stabilize the child first packed red cells at least 4 to 5 units&5 units pletelet Continue ATT,B 12,Folic acid, iron profile, blood culture abdominal kocks , secondary infection,LFT

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