Hot Seat #41: 14 y.o. with hemorrhagic conjunctivitis
Posted on: August 19, 2014, by : Lenore Jarvis MD MEd
By Lenore Jarvis, Children’s National
with Jamil Madati, Children’s National
The Case:
14 yo male hx of hepatitis (thought resolved by family) who recently moved from El Salvador presenting as a referral from the PCP for hyperbilirubinemia, fever, hemorrhagic conjunctivitis, hand desquamation, and sore throat. Five days PTA, he had fevers 102-104F and a sore throat. Fever lasted 2 days only; no fevers x 3 days. The sore throat continued. NBNB emesis (~3 times per day) x 5 days but is still tolerating fluids. Hand peeling and non-painful eye redness both started 3 days ago. No other rashes reported. No change in vision. Has had mild headaches without neck pain.
Pt seen at PCP 3 days ago and had labs done. Patient returned to PCP today because of the hemorrhagic conjunctivitis and hand desquamation.
ROS: No rhinorrhea, cough, SOB, abdominal pain, constipation/diarrhea, dysuria, hematuria
PMH: Hepatitis dx age 3 in El Salvador per family thought resolved
Imm: Not UTD, last vaccines at age 4 in El Salvador
Exam: VS: 36.6, HR 107, BP 125/76, RR 20, 100% RA
Gen: Alert. Mildly uncomfortable, but not ill-appearing.
Skin: Palmar and toe skin desquamation. No hand/foot edema. No other rashes.
HEENT: PERRL/EOMI. Bilateral severely hemorrhagic conjuctivae. No discharge. Vision grossly normal. Oral mucosa moist. No pharyngeal erythema or exudate. Neck is supple with mild anterior tenderness to palpation. B/l shotty cervical LAD.
CV: Mild tachycardia, regular rhythm. No murmur or gallop. Normal peripheral perfusion.
Resp: CTAB.
Abd: soft NTND, no HSM (exam limited by obesity)
Labs done at PCP (3 days PTA):
CBC: WBC 17, 14.4/43.5, plts 154
Hepatitis (A/B/C) panels negative/NR
Total Bili 6.4, AST 60, ALT 118
You obtain labs, which are essentially unchanged from those at the PCP. Coags are WNL. GGT 148 (high), direct bili 0.1.
Abdominal US: thickened gallbladder, nodule on pancreas measuring 1.3 cm and splenomegaly 13 cm.
GI was consulted and feels he is stable for dc home with close follow-up and PCP to trend labs. Patient’s condition is otherwise unchanged.
You are able to contact the PCP who can see the patient in 2 days.
The patient has limited transportation options.
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
Come back later for the denouement of this case.
Kudos to Lenore and Todd for the updated format. !
Whenever i have a febrile return traveller, i look on the CDC website for outbreaks in those areas. It’s important to isolate the patients (and families) in your ED accordingly until you know more information about potential exposures for staff. Probably a negative pressure room especially if febrile. Typically i think about typhoid, malaria, dengue, and hepatitis for causes of fever in return travellers….but there are certainly others not named Ebola. This doesn’t sound parasitc in nature, but i would at least think about that as a possibility.
Frankly, this case sounds more like a kawasaki variant. non-purulent red eyes, desquamating hands/feet, gall bladder hydrops (hyperbili)………….but without fever makes the disposition a little tricky. It would be easy if the child was febrile to send off Dengue titers and admit for consideration of Kawasaki treatment in an older patient (14yo). But without fever or a definitive diagnosis it’s more challenging to make an ED disposition.
So I would probably do the following:
–look on CDC website for potential outbreaks. I’m pretty sure Dengue is big in El Salvador.
–do a more thorough history for exposures during travel and sick contacts
–repeat basic labs including inflammatory markers, CBC, CMP
–send titers for potential causes (Dengue, EBV/CMV, etc)
–do an EKG (he is tachycardic without fever)
–do a CXR
–give IV fluids
–consult Infectious Diseases
–observe in the ED.
–if truly afebrile and no potential risky (communicable) exposures AND there is not a significant change in labs to suggest acute blood loss or coagulopathy/DIC AND his tachycardia is improved with hydration AND he doesn’t have signs of cardiomegaly on CXR…,i would discharge with close follow-up with PCP/ID
Great thoughts Dave! We did check the CDC website:
http://wwwnc.cdc.gov/travel/destinations/traveler/none/el-salvador
This patient is at risk for Hepatitis A, Typhoid, Malaria, Yellow Fever, and Chikungunya.
HOT SEAT ATTENDING RESPONSE:
You had to hit me with the hemorrhagic conjunctivitis in a traveler. Just to get it off the table, I would check the CDC website for any reports of Ebola virus in the Latin America region.
Because he “recently” arrived from El Salvador, it would be important to get a detailed travel history. How long ago was he in El Salvador? If it was within a 3-4 weeks I would be more concerned about something infectious he might have picked up there. Coming from Central America makes me think about Malaria but would expect him to be more febrile or at least ‘cyclically’ febrile. Also important to ask about drinking water (well vs sanitized water) thinking about parasites/worms in the intestinal tract that could lead to hepato-biliary disease. I seem to recall a worm (ascaris?) whose life cycle involved the GI tract and liver/biliary tract. Would have to check the aforementioned CDC website for endemic parasites that may cause the patient’s multitude of symptoms.
Speaking of symptoms, his constellation of symptoms are very interesting: fever (now resolved), hemorrhagic conjunctivitis, palm and sole skin desquamation, sorethroat, vomiting headache with no neck stiffness. Important to note that the PE states that the patient is “mildly uncomfortable but NOT ill-appearing” which makes me think that I have time to think a little more about what could be going on as opposed to a crashing kid. Also, vital signs, except for the mild tachycardia, are relatively normal. Something about these many symptoms (except the desquamation) in a non-ill appearing child that screams ‘viral’ to me. Adenovirus? Influenza? Maybe EBV (pharyngitis with mild hepatitis)? Kawasaki disease crossed my mind briefly but no significant lymphadenopathy, no fever for the requisite amount of time and no peri-limbic sparing conjunctivitis (never heard of KD causing ‘hemorrhagic’ conjunctivitis). But one can see a mild hepatitis and hydrops of the gallbladder with KD.
In terms of bacterial etiologies, Group A Strep jumps to the top of my list which can explain the fever, pharyngitis (although not so impressive on the PE) and skin desquamation. But GAS doesn’t really explain the hepatobiliary changes and splenomegaly seen on US. Also would worry about ascending cholangitis with the fever, elevated tranaminases and TB (although he hasn’t had any abd pain).
A few remarks on the PCP’s labs: No notable anemia (suggesting a relatively acute process). Would like to see if there was eosinophilia in the Diff that might suggest a parasitic etiology. Mild thrombocytopenia (Platlets trapped in spleen perhaps?). Mildly elevated tranaminases and Total Bili (elevated Indirect Bili with normal Direct Bili) suggesting either a high RBC turnover/hemolytic process or a dysfunctional liver (cirrhosis) that is unable to conjugate all that indirect bili. But patient is not anemic and Coags are normal suggesting normal liver function i.e. no significant liver damage yet. No note of jaundice or icterus on exam so perhaps this is still early in the disease process.
What I would do for him: I voted for GGT and Direct Bili but would also get the abdominal US simultaneously with focus on the gall bladder and liver. US finding of “nodule on pancreas and splenomegaly” are clearly concerning for me (tumor? Infectious abscess?), but why am I not surprised that GI doesn’t want to admit?!? I’d be reticent to send him home with outpatient follow up since I feel whatever is going on is relatively acute and he has the potential to get worse before getting better. I’d probably want to admit for ID (for possible parasitic etiology eval) and GI consult (to figure out why he has HSM and splenic nodule with mildly elevated tranaminases and TB). Would probably trend the AST/ALT, T/D Bili and GGT as an inpatient, consider adding inflammatory markers (CRP, ESR) also for trending purposes and if febrile again send blood cultures and probably thick/thin smear for malaria. Continue supportive treatment for now with fluids, pain meds PRN. Would NOT start any antibiotics until I had a better idea of what I was treating. If the kid started to become ill appearing (recurrent fevers, increased jaundice, increase abd pain), I’d be more concerned about Cholangitis and would start antibiotics to cover for enteric flora.
Gosh, what an interesting case!
I agree with Dave, Atypical kawasaki is in the differential, as are adenovirus and a host of tropical diseases such as typhoid as mentioned above. Dengue does not scream at me without petechial rash, which can present in mild cases without platelet abnormality, or bone pain, which can also present with normal labs,