Question
We recently have a 6 yr old male child admitted under us twice since past 4 weeks with complaints of persistent icterus. His initial reports were suggestive of infective hepatitis with HAV antigen positive, raised liver enzymes {SGPT 3000, SGOT 1300} and S. Bil of 15mg/dl. The liver enzymes gradually reduced {SGPT 400, SGOT 200} and so did the icterus after one week of stay.
Child was discharged but he returned back in two days with complaints of severe pallor {Hb 4.5}, deepening jaundice {S. Bil 17} and moderate grade fever with chills. Total leukocyte and differential counts are within normal limits. Reports for malarial parasite {QBC, PS}, enteric, brucella, dengue and leptospira were negative. The liver enzymes were mildly raised {2 times} except for GGT {>500 IU} and higher normal range of S. Alkaline phosphatase. Urine microscopy is also normal. Peripheral smear for type of anemia was suggestive of microcytic hypochromic anemia with thrombocytopenia {40,000} and a reticulocyte count of 4.2%. Direct Coombs test for hemolysis was also negative. Blood culture and G6PD were awaited. There were no splenomegaly, lymphadenopathy or bleeding manifestations {PT. ApTT and INR Normal}. Except for a palpable liver {4 cms below costal margin, Span 9cms}, which is persisting, no other system is involved. Empirically we started the child on antimalarials and Inj Cefotaxime, which was changed to piperacillin+tazobactum because of spiking fever. Packed cell transfusion was given twice and the Hb improved to 8. Blood culture report was normal but G6PD level was low. So the antimalarials were withheld. The child continues spiking with the S. Bil now at 22, recurrent pallor {Hb- 5}, platelet count 24000 and reticulocyte count now is 0.8%. We have also ruled out Wilson`s disease and autoimmune hepatitis {ANA, ASMA and anti LKM antibodies are negative}. There is no prior history of pallor, blood transfusion or jaundice in the patient or his family. Liver biopsy is withheld because of the child`s general condition.
Our diffential diagnosis is
1} Cholestatic phase of Hepatitis A with bone marrow suppression and G6PD deficiency
2} Hemolytic anemia with chronic active hepatitis? Wilson Disease
3} Malignancy {lymphoma}
A prompt response will be welcome in interest of the patient as the cause for fever, recurrent pallor with no cause for hemolysis and worsening icterus are perturbing.