GRAND ROUNDS AND TEACHING FILES

Encephalopathy

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Clinical Problem:

Ira Shah
Medical Sciences Department, Pediatric Oncall, Mumbai, India

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056

A 10 month old boy born of non consanguineous marriage presented with fever for 5 days, refusal of feeds for 3 days and drowsiness for 1 day. On examination, vital parameters were normal. He had pallor, drowsiness and hepatosplenomegaly. There was no icterus. Deep tendon reflexes were brisk and tone was normal. There was no focal neurological deficit, meningeal signs and other systems were normal. Investigations showed:

• Hemoglobin = 8.4 gm, dl
• WBC = 5,500, cumm {32 percent neutrophils, 67 percent lymphocytes, 1 percent eosinophils}
• Platelet count = 57,000, cumm
• S.electrolytes = Normal
• SGOT = 244 IU, L, SGPT = 138 IU, L
• Bilirubin = 0.8 mg percent
• Total proteins = 5.8 gm percent {albumin = 2.8 gm percent}
• No acidosis
• Blood sugar = 45 mg percent
• Serum ammonia = 465 µg, dl
• CRP = Negative
• Urine = Normal. No Ketones
• PT = 16.2 sec {elevated}, PTT = more than 2 min.

Patient was started on IV Fluids, Lactulose and Metronidazole and responded within 24 hours. His sensorium improved and abnormal parameters improved in next 3 days. However, hemoglobin dropped from 8.4 to 7.5 gm percent and platelet count dropped to 8000, cumm.

What is the diagnosis_?