Dengue with ?Meningism

Chief complaints:-

Complaint of fever since 2 days.

Complaint of body pain since 2 days.

Complaint of vomiting since yesterday (4 episodes).

Complaint of abdominal pain since yesterday.

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History of Present Illness:-

Fever: Insidious in onset, gradually progressive, intermittent type, relieved by medication.

Body Pain: Generalized myalgia since 2 days,affecting both lower limbs.

Vomiting: Since yesterday, non-projectile, non-bilious, non-blood tinged, contains food particles.

Abdominal Pain: Since 2 days, tenderness present in the epigastric region.

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Past Medical History

Admitted 15 days ago for viral fever.

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Birth History

Born via Normal Vaginal Delivery (NVD), birth weight: 3.2 kg.

No NICU admission.

Development History

Development appropriate for age.

Family History

No contributory medical history (NCM).

Immunization History

Immunized up to date.

Physical Examination

Vitals:

Pulse Rate (PR): 120 BPM

Blood Pressure (BP): 104/60 mmHg

Temperature: 98°F

Respiratory Rate (RR): 24 CPM

Anthropometry:

Weight: 29.7 kg

Head-to-Toe Examination:

Skin: Normal

Hair: Normal

No congenital anomalies.

External genitalia: Male.

Spine: Normal.

ENT: Normal.

Tenderness over both thigh regions, no redness or swelling.

Systemic Examination

Cardiovascular System (CVS): S1S2 heard, no murmur.

Respiratory System (R/S): Bilateral air entry (+), no added sounds.

Central Nervous System (CNS):

Power: 5/5

Plantar flexion

Tone: Normal

Per Abdomen (P/A):

Inspection: Normal umbilicus position and shape, equal movement of all quadrants, no engorged veins, scars, or sinuses.

Palpation: No local rise of temperature, tenderness in the epigastric region.

Percussion: Tympanic note except for liver dullness.

Auscultation: Bowel sounds heard.

Laboratory Results

9/9/2024:

Hemoglobin (HB): 12

Total Leukocyte Count (TLC): 16,200

Differential Leukocyte Count (DLC): 90/6

Platelets (PLT): 3.60

RBC: 4.6

Hematocrit (HCT): 33.4

PT: 17.1/11.8

INR: 1.5

APTT: 58.4/28.7

MCV: 71.6

MCH: 25.8

MCHC: 36

10/9/2024:

Hemoglobin (HB): 11.6

TLC: 14,270

DLC: 85/10

Platelets (PLT): 3.05

RBC: 4.8

Hematocrit (HCT): 34.8

Indirect Bilirubin (IB): 0.5

Total Bilirubin (TB): 0.7

Direct Bilirubin (DB): 0.2

Total Protein (TP): 7.8

Albumin (ALB): 4.6

Globulin: 3.2

SGOT: 34

SGPT: 15.6

Alkaline Phosphatase (ALP): 175.6

A:G ratio: 1.5

GGT: 33

11/9/2024:

Hemoglobin (HB): 10.8

TLC: 16,230

DLC: 82/11

Platelets (PLT): 4.33

RBC: 4.5

Hematocrit (HCT): 32.4

PT: 13.8/11.8

INR: 1.1

APTT: 45.4/28.7

MCV: 78.2

MCH: 23.9

MCHC: 30.6

Dengue NS1, IgM, IgG: Positive

Urine Routine:

Pus cells: 2-3/HPF

Epithelial cells (EC): 1-2/HPF

All other components: Absent

Course of Treatment in Hospital:

Presenting Complaints:Age/Sex: 8-year-old male child with Fever with difficulty in walking, pain in lower limbs, and vomiting

Episodes of fever on and off for the past 15 days (treated and relieved).

Developed difficulty in walking and severe pain in both lower limbs and back.

Vomiting for the past week, non-projectile, bilious in nature.

No History of:

Headache

Tightness in limbs

Recent injury

On Examination:

General Condition:

Conscious, obeys commands

Pupils bilaterally reactive to light

Lower Limbs:

Flexion posture at hip and knee

Restricted movements in all directions

Severe pain on attempting to move the legs (Left > Right)

Deep Tendon Reflexes (DTR): 3+

Plantar Reflex: Bilateral flexors

Sensory: Normal

Neurological Findings:

Neck stiffness present

Paraspinal muscle tenderness present

Specialist Reviews:

Neurology Review:

MRI brain & Spine : Normal

CSF analysis: Normal

Autoimmune panel and anti-GAD sent

Ophthalmology Examination:

No evidence of raised Intracranial Tension (ICT) changes

Investigations:

MRI: Normal

CSF Analysis: Normal

Autoimmune Encephalitis Mosaic and Paraneoplastic Neuronal Antibodies: Sent to NIMHANS, Bangalore

Vitamin B12: 201 (low, started on Syrup Bifolate)

Urine Porphobilinogen: Sent for analysis

Treatment Administered:

Intravenous Fluids (IVF): Normal saline (NS) at 90 mL/hour

Medications:

Inj. Ceftriaxone 1g IV (administered for 8 days and stopped)

Inj. Cewar 1g (1-0-1)

Tab Calpol 500mg (SOS)

Inj. Ondem 4mg (SOS)

Inj. Pantop 30mg (1-0-0)

Tab Clonazepam 0.25mg (1/2-1/2-1/2)

Syrup Leofen 2.5mL (1-1-1)

Syrup Bifolate (started after Vitamin B12 deficiency identified)

Condition on Discharge:

Vitals: Stable

Oral Intake: Child is eating well

Urine Output: Adequate

Clinical Condition: Improved

Hemodynamically Stable

Discharge Advice:

1. Review with:

Autoimmune Encephalitis Mosaic and Paraneoplastic Neuronal Antibodies report

Urine Porphobilinogen report

2. Danger Signs explained

3. Hydration: Take plenty of fluids

4. Preventative Advice: Avoid mosquito bites