One-year-old healthy child presented with a history of fever, diarrhea, and cold for five days, and erythema at the BCG inoculation site
A one-year-old previously healthy child presented to the general practitioner (GP) with a history of fever, diarrhea, and cold for five days, and erythema at the BCG inoculation site for one-day duration. She had been initially treated as bacillary dysentery with oral cotrimoxazole. While on treatment, she developed strawberry tongue and swelling of hands and feet along with the appearance of conjunctivitis and persistent high fever. The child was admitted only on day 12 of illness with suspicion of Steven Johnson syndrome secondary to cotrimoxazole. Further, the child had poor feeding and watery discharge from her right ear. She had age-appropriate immunization and there was no history of allergy to drugs, food, and environmental allergens. Physical examination revealed that she was ill, febrile (above 102 F), irritable, dehydrated, and had bilateral conjunctivitis without discharge. There was cervical lymphadenopathy measuring 2 cm in size. Feet and hands were swollen. Lips were cracked with beefy red tongue and a well-defined erythematous reaction was evident at the BCG inoculation site. Other systems examination was normal apart from having mild right hypochondrial tenderness.
Investigations revealed a high white blood count (18x103 /cumm (normal range - 6x103 -17x103/cumm) with neutrophil 75%), low haemoglobin (8.9 g/dl - normal range 11.3 g/dl - 14.1 g/dl), normal platelets (350x103/cumm), high C-reactive protein (CRP-148 mg/dl - normal range - less than 5 mg/dl ), and high ESR (120 mm/hour).
Blood picture showed evidence of either infection or inflammation with the left shift of neutrophils. Urinalysis showed microscopic haematuria (5-8/HPF) and pyuria (10-14/HPF).
The cerebrospinal fluid analysis revealed normal findings including cultures apart from showing slightly high protein (60mg/dL). Serum sodium was 134meq/l, and potassium was 4.2meq/l. Serum total protein was 60mg/dl, and albumin was 35mg/dl. Aspartate transaminase (154 IU/l) and alanine transaminase (104 IU/L) were elevated. Alkaline phosphatase was normal (300 IU/L). Renal functions had been normal except for elevated blood urea (70mgdl). Throat swab showed no organisms, and blood and urine cultures were sterile. Rheumatoid factor was negative. Antistreptolysin O titer (ASOT) was less than 200 IU/L. antibody to leptospira, mycoplasma, Epstein Barr virus, and scrub typhus were negative. Chest X-ray was normal. Ultrasound abdomen showed hydrops of the gall bladder, and otherwise findings were normal. Echocardiogram and electrocardiogram revealed normal findings with no evidence of coronary aneurysms. The ophthalmological examination had been normal. What do you think?
