PICU 5 8y/F /18 kg admitted with C/o alterd sensorium with H/O GTCS episode and fever since 5 days with cold and cough ,pain in abdomen O/E I•P•Ln•Cy•Cl• CVS CNS wnl Urine stool Wnl P/A: soft with hepatospleenegalae Temp :afebrile Cracked pot sign -ve Neck rigidity -ve Babinski sign abscent PR 118 bpm SpO2 95% RR ~ 26 bpm

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So what is the diagnosis???? By now you have ruled out 1. Malaria 2. Dengue 3. CNS Infections (viral or bacterial; based on absence of neck rigidity, no meningeal enhancement or brain edema on CT) 4. Typhoid After reviewing your history and investigations something is making sense. Lets analyse case again 1.You breifly mentioned pain abdomen in history (no details about site, severity, mass per abdomen) 2. Everyone here including me was concerned about altered sensorium; which according to you is not deep coma and pupils are sluggishly reactive 3. Lab parameters show bicytopenia with neutrophilic leukocytosis with hypoalbumenemia with elevated CRP 4. USG abdomen shows ascitis with distended gall bladder with wall thickness around 8 mm. 8 mm means hugely thickened wall (cut off is 3 mm) Its a case of acalculous cholecystitis with severe sepsis with septic encephalopathy . There is high likelyhood of perforation leading to peritonitis. Acalculous cholecystitis is caused by various infectious and non infectious causes. In this case, it fits in infectious causes. Organisms directly causing acalculous cholecystitis are 1. Campylobacter 2. Salmonella 3. Plasmodium ( you r already treating malaria) 4. Leptospira 5. Mycobacterium tuberculosis 6. Vibrio 7. Viruses, fungi (not considering in this case) Once acalculous cholecystitis is established, its secondorily infected with enteric organisms like klebsiella, Ecoli, enterococcus so antibiotics shud cover these organisms Treatment: 1. Vancomycin plus piptaz or meropenem 2. Urgent cholecystectomy (impossible in this case) or cholecystomy Prognosis: 70 percent mortality in untreated case Upto 20 to 30 percent in treated case Continue artesunate, upgrade antibiotics and urgent surgical intervention cud be life saving in this case @Dr. Dhananjay Pandey

Thanks for a brief reply I want to add something's 1.we have improved the settings of vent From fio2 60% to 50% to 40% to 30% (saturation is stable above 90% PR 102 bpm) 2.platlet is fluctuating,in today's reports its 24(previous reports attached) 3.Abdomen is soft (perforation -football sign distended abdomen??? Abdomen is soft non distended H/o peri umbilical pain)
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Dear dr . First confirm about malaria . Secondarily u mentioned altered sensorium . In children signs of meningismus like neck stiffness n kerning sign r not alwayas prominent . Seen many cases here at my centre .

Cerebral malaria is a close DD ... Viral encephalitis also can be a dd... LP and imaging studies needed

Peripheral smear for malarial parasite also needed... Iv artisunate can be started .
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DD- Viral encephalitis/ meningitis Malaria Leptospirosis Do LP, leptospira IgM..

Ddx malaria/meningitis,,post lp and ct reports if done..

Posted NCCT wnl
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Cerebral malaria.

C malaria

In this case thrombocytopenia, leukocytosis, hb loss with altered sensorium and hepatosplenomegaly and increased liver markers.Rule out scrub typhus with encephalopathy. Adv CSF exam , scrub typhus, malaria by slide, ABG, BLD culture and urine for haemoglobinuria. Add doxycycline and acyclovir in treatment.

Seeing the report low hb low platelet n low hct n altered sensorium with heptosplenomegaly gives rise to diagnosis of cerebral malaria . Do comment on peripheral blood smear to look for malarial parasite . My d/d is complicated malaria . Crp is positive with high wbc meningitis should be ruled out too .

Is it always nessesary to add meningitis in ddx if crp+ve and wbc count raised Other features as neck stiffness cracked pot sign ect are non supportive!!?
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Febrile convulsions Rx give Artesunate Vancomycin Maintain o2saturation IV fluid managed accordingly

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