Dr Mohan Babu

Dr S.Balasubramanian

KKCTH

Case details 1

3yrs, Female

c/o Fever x 6days

Vomiting & Abdominal pain x 2days

Loose stool 1 x day

On examination: Toxic, Febrile

Hemodynamically stable

Hepatosplenomegaly

During Hospital stay fever & loose stool persisting later developed abdominal distension & Periorbital puffiness.

Investigations:

CBC:

TC:2500 cell/cmm

DC: P 40 ; L 59

Hb : 7.5mg/dl

PCV:22%

Platelet : 50000/cmm

CRP : 140 mg/l

Leukopenia

Thrombocytopenia

Elevated CRP

Contd..

CXR : Pleural Fluid- Rt side

USG Abdomen : Mild HSM

Moderate Free Fluid in Abdomen

Mild Pleural fluid-Rt side

Dengue IgM : Positive

Treatment i.v Ceftriaxone

Supportive Measures

child became afebrile after 7days

Blood culture – Salmonella typhi

FINAL DIAGNOSIS: Typhoid confirmed with

?coinfection DHF.

Case details 2 8 yrs Female

Fever x 7 days

Abdominal pain, lethargy x 2 days

On e/o : Sick looking

Facial Puffiness

Hypotensive Shock

Abdomen distended - free fluid & HSM

Child was resuscitated with fluids & shifted to PICU

Investigations.. TC – 4000

DC : L -87; P-13

PCV- 42

Platelet- 95000

SGOT- 4110 IU/lit

SGPT – 2020 IU/lit

Bili(T)- 2.7 mg/dl

Albumin- 2 gm

contd..

CXR : Rt Pleural effusion

USG Abdomen : HSM

free fluid

minimal pleural fluid –Rt side

Blood C/S : no growth

WIDAL : S.typhi O: 1:640

H: 1:640

Dengue IgM/IgG : negative

Treatment Child was managed in PICU- Ventilated

Ionotropes

i.v Abx(ceftriaxone)

Final diagnosis:

Probable Typhoid with Hepatitis with third spacing

Child became afebrile after 7days & completely recovered

3rd Spacing Third spacing is the physiological concept that body

fluids may collect in a "third" body compartment that isn't normally perfused with fluids

Third spacing takes fluid away from the normal fluid compartments and causes the patient to have hypovolemia.

Causes Severe Burns

Trauma

Liver failure

Pancreatitis

Sepsis syndrome

Heart Failure

Viral and Bacterial infections

Major Surgery

Hypoalbuminemia

Lymphatic obstruction

Signs&Symptoms.. The patient will manifest symptoms of volume

depletion and will be hypovolemic and dehydrated due to a shift of fluid from the intravascular compartment to the third space.

Tachycardia/ Tachypnoea

Feeble pulses

Hypotension

Decreased urine output

Shock

Increased Hct, Hb

Treatment..

Treating the underlying illness rather than giving more fluids to correct the electrolyte and protein imbalances, since that will only help relieve the symptoms in the short term.

Though patient may be edematous and is total body fluid overloaded, it should be realized that the patient is paradoxically often "dehydrated" or under filled in their intravascular space.

Aggressive diuresis should be avoided,as it may lead to pre renal azotemia.

Diagnostic Dilemma

During Dengue season any febrile child with third spacing first diagnosis is Dengue , However it is worth while to remember other causes of third spacing which are amenable to therapy

Literature review ASCITES — An Under-reported Finding in Enteric Fever?

Rajiv Sinha,et.al, India-INDIAN PEDIATRICS VOLUME 41__SEPTEMBER 17, 2004

series of four cases of typhoid fever with mild hepatic dysfunction&ascites

There is no similar report in Indian literature

.

Couple of case reports available in international literature.

Chiu, et al.(3) reported an incidenceof 4% of ascites or pleural effusio among 71childrenwith typhoid

Judet, et al.(4) reported two cases of peritoneal effusion in patients with typhoid fever and suggested that typhoid fever should be considered when ultrasonography shows an isolated peritoneal effusion in a febrile child

Take home massage

Third spacing is not synonymous with Dengue

Any child with prolonged fever ,toxicity & atypical features think of treatable causes like Typhoid

THANK YOU