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Case of the Month - April 2018

From a poison to an infection

Helena Rabie1, Marlize Kunneke2, Penny Rose1

1Tygerberg Hospital
2Worcester Hospital

A 3 year old girl presented with a short history of rapidly progressive decreasing level of consciousness at a day care center. She was taken to the local level one hospital where she was intubated and transferred to the local level 2 and subsequently level 3 hospital.

She was a previously well, HIV uninfected child that was well that morning prior to attending daycare. She lives in an informal settlement in a small town in the Boland. All her vaccinations were up to date. She had no history of recent travel or relevant animal exposure, her food was purchased from the local supermarket and her house has piped water. There were no children with a similar illness in the community.

On examination she was well nourished. She was febrile with a temperature of 38.5°C. Her pulse rate was 190 per minute with normal blood pressure. Neurological assessment revealed a deeply comatose child with no spontaneous breathing or and no motor response to painful stimulation.
  • The pupils where constricted and unresponsive.
  • Dolls’ eye and gag reflexes were absent
  • She was flaccid with absent deep tendon reflexes.
  • No spontaneous movement was observed.
Systemic examination was normal apart from significant crackles and rales in both lung fields. On general overview
  • No rash or mucosal lesions, flushing or sweating was noted,
  • There were several old and fresh small wounds, some with secondary infection as well as impetigo on her legs
  • No cellulitis or arthritis.
Significant laboratory results:
  • Sodium 118 mmol/L (N = 136 – 145) with other electrolytes, urea and creatinine normal initially
  • First CRP 160 mg/L (N<10)
  • Initial full blood count was normal apart from slightly raised platelet count
  • Creatine kinase 1560U/L (N= 2-134)

Question 1: What is your differential diagnosis? Outline the initial management of this case?

Continue to Answer 1