unfortunate medical care

1. CASE PRESENTATION
AHUMUZA DENIS .K S-clerk pediatrics
4/14/2018
Department of pediatrics and child Health.
BUFHS

2.  Name NA
 Age 8/12
 Sex M
 Address Bugema /Mbale
 N.O.K NS (mother)
 Tribe Muganda
 Religion Moslem
 Wt. 5.1kg
 D.O.A 23rd Jan 2018
 D.O.D 3rd Feb 2018 (escape case)
DEMOGRAPHIC INFO

3.  Cough *4/12
 Fever *3/12
 Weight loss * 3/12
Presenting complaint

4.  An 8 months old HIV exposed child who never
had attended the EID clinic ,with hx of close
contact with a person who had a chronic
cough. Was fairly well until at 4 months of age
when he developed gradual onset persistent
non productive cough that had progressively
worsened over the past 2 months, associated
with fast breathing , mildly relieved by some
herbal oral remedy, however with no hx of
DIB, no hx of coughing up blood ,
HxPC

5. no hx of easy fatigability and no hx of any body
swelling.
Mother also reported an equal duration hx of
high grade fever which was on and off at its
onset that gradually become constant over the
past month , worse in the evening and
temporarily relived by tabs paracetamol.
However with no hx of drenching night sweats,
no hx of LOC or any convulsions
Conti…

6. child also had 3/12 hx of progressive weight loss
despite having a good appetite according to
the mother. With no other GIT symptoms.
He was managed for Pneumonia and malaria in
several clinics on both intravenous and oral
medications with no relief of symptoms., which
prompted the mother to seek care at MRRH
Conti…

7.  HEENT. Mother reported a 1/12 hx of child having a
fowl smelling thick greenish nasal discharge. On and
off. With no complaints in EET
 GUS. Reported reduced urine out put a week prior to
admission( 2-3 times in 24hrs), yellow in color
however was of normal smell and the child did not cry
while passing the urine.
 MSS . Had no complaint . SKIN. No complaint.
Review of systems

8.  Mother never attended ANC
 Suffered 2 episodes of febrile illness in early pregnancy.
 Had a home delivery at term. child cried immediately
 Cord was poorly tired and bled . child rushed to a nearby
hospital(mukono) where he was treated on oxygen and
glucose for about 24hours
 Child didn’t suffer jaundice , no fever in early life
 Breast fed after 24hours
 Mother suffered no birth related complications
Gestation and delivery Hx

9.  Child exclusively breast fed for up to 5 months of age
 After which was introduced to cows milk, plain tea
and passion fruit juice. Had aprox 5 feeds a day
served by the mother
 an attempt was made on other home foods which the
child refused to take .
 Currently the child survived on the above drinks and
breast milk and reportedly had a very good appetite
Nutritional Hx

10.  Social smile at 3 months
 Head support 3 month
 Turning in bed 3 month , supine to prone.
 Sat with support 4month without support at 5
months
and this is his current level of motor development
Developmental hx

11.  Child had Zero immunization
Immunizations hx

12.  HIV exposed child , not attending EID clinic. has been
admitted several times to clinics and hospitals where
he was treated majorly for pneumonia and malaria.
 Suffered measles at 6.5 months of age, treated at a
health facility in Mukono,
 child was not on any chronic medication ,
 Had no known allergy to any foods or any medicines
PMHx

13.  Was unremarkable ,
Never received BT
Never undergone any surgical
procedure.
PSHX

14.  Reported no familial illness known to her
among the child's paternal and maternal
relatives like DM , heart disease , asthma etc.
 Mother is known is known ISS pt , who had
been on HAART for 8 yrs. gets her HIV care
from a H/C in mukono. Had no recent viral
load/ CD4 count done on her.
Family hx

15.  Child is the 5th born to his mother, 3 of his older
siblings are born to another father , and are
reportedly in a good health condition. Child stays with
mother and father and 3 other children in a one
roomed house, which has one window and door.
 Mother is a canteen attendant, and father sales man
in a supermarket around town
 Neither of the child's parents drinks alcohol or
smokes cigarette or any other elicit drugs
Social hx

16. NA an 8/12 months old male HIV exposed child
was, whose mother had not enrolled for
PTMCT, brought in with 3 months hx persistent
non productive cough, associated with fast
breathing and an equal duration hx of high
grade fever with associated progressive weight
loss. However with no hx of hemoptysis , DIB
and no history of drenching night sweats.
Summery

17. A. HIV exposed child with PTB in view of
 Hx of potential exposure.
 Long standing Hx of B symptoms.(cough , fever and weight loss)
 Un responsive to conventional therapy for alternative Dxs
B Severe acute malnutrition (SAM) in view of :
 Hx of weight loss and failure to gain weight
 Developmental delay ( evidenced by his current mile stones)
 Poor nutritional hx
C Pneumonia in vie w of cough ,fast breathing and cough
D malignant process ?? Lymphoma … B symptoms
R/O Malaria.
R/O Septicemia.
The above signs and symptoms were
suggestive of

18. On examination
G/E
 Child was visibly wasted
(prominent zygomas)
 Total Boldness
 With a wide anterior fontanel.
Neither sunken nor bulging
 Febrile to touch
 Eyes not sunken , no jaundice.
With no eye signs of vit A defi
 Pale conjunctiva
 Lips were dry
 Had no central cyanosis
 No oral lesions , has only 2 lower
central incisors, with no any visible
gingival bleeding.
 Had generalized palpable
lymphadenopathy , largest were Lf
anterior cervical , discrete, soft and
mobile.
 No finger clubbing
 Capillary refill time <2 seconds
 Had normal skin turgor with
multiple hyper pigmented macules
 Had no edema

19. Conti…
Anthropometry
 Weight 5.1kg
 Length not taken
 MUAC 10.1cm
 Z score < -3 SD… this score
score diagnostic of SAM
 Head and chest
circumferences …weren't
taken.
Vitals at admission
 RR 60 cycles /min
 HR 145 b/min
 BP not taken
 Temp 39.1 C
 PSO2 95 %
 RBS……

20. Systems Exam
RS
 Child had no signs of distress
 Ribs were prominent however
with no rachitic rosary
Harrison's sulcus?
 Chest wall symmetrical
 Moving regularly with
respiration . (tachypnea) and
symmetrically expanding.
 Trachea was central
 chest wall non tender
 Had normal tactile fremitus
 Chest wall resonant to
percussion.
 with brochovascular with
breath sounds, no wheezes
and no crackles.

21. Cont..
CVS
 Pulse small volume , regular
at a rate of 145b/m and
synchronous radial-radial
and radial-femoral
 BP……..….
 Neck vessels not distended
 Precordium normal active,
apex 4ICS MAL
 HS I & II heard . No added
sounds
CNS
 Child was alert ,
 Not lethargic
 Neck was soft (no signs of
meningeal irritation)
 No obvious cranialpathies
 Motor -child had normal
tone , normal reflexes
 Sensory - intact

22. Cont..
PER ABDOMEN
Significant findings
 Distended however
symmetrical .
 Non tender to palpation
 No organs or any masses
were palpable
 Hyper resonant to
percussion .
 Bowel sounds present 3-5
every 10 min
MSS
Was un remarkable

23. Investigations
Hematologic
 RBS – for the glycemic
status.
 CBC- WBCs , RBCs and there
differential counts + PLT
 BS for MPS to R/O malaria
 Serum electrolytes- look out
for any derangements
 DBS for PCR - confirm HIV
Sero-status of the child.
 Blood culture &sensitivity
Sputum analysis
 G/s , culture and sensitivity…
 ZN & Gene x-pert for TB/Ref
Urine analysis. R/O the gut as a
potential infection focus.
Radiological
 plain CXR for radiologic signs
suggestive if PTB or alternative
conditions like pneumonia

24. Investigation results
Hematologic
24th Jan.
BS for MPS – no MPs seen
RFTs - urea 15.5mg/dl N
- Cr 0.181mg low
Serum electrolytes
high -[k] 6.8mmol/L
-[Na] 137mmol/L
 CBC 27th Jan
-WBC 15.94x10^9
-RBC normal rang
- HB 9.0g/dl
-MCV 65.4 FL
-MCH 20.5pg
-PLT 373x10^9
Lymphocytosis 48%
Neutrophils 41%
Monocytosis ……..

25. Conti…
Radiologic
 CXR – only significant
finding was Hilar
lymphadenopathy
29th Jan
Urine TB-LAM- Reactive
DBS for HIV PCR sample
taken … result to be
received after 2 weeks.
Dx
 HIV exposed child with
PTB.
 HIV infection highly likely
 Non edematous SAM
 Microcytic hypochromic
anemia ?? ACD

26. 23rd JAN
 Child was admitted on ACU
 Started on stabilization phase of SAM
 IV D10 25 mls stat
 F75 55mls every 2hrs for 24hrs then 84mls every
3hours.
 IV antibiotics ampicillin + gentamicin
 Rectal paracetamol q6
 Oxygen therapy 2L/min by nasal prongs
Management while on ward

27.  Subsequently he was started on anti TBs induction
phase HERZ + B6 x2/52 . On the basis of CXR findings
and a positive urine TB LAM (27th Jan)
 We continued mgt for SAM with ITC (in patient
therapeutic care protocol.) to go on for at least 2/52
 Child had spiking fever > 39C though the attendant
always reported improvement in his symptoms
 Requested for a discharged on the 1st Feb , which we
advised her against as had to monitor the child on
therapy for at least 14day/or until he was stable for
Out Pt Mgt.
Follow up

28.  Mother and child were not found on ward….
3rd Feb

29. Thanks for listening