Fever with Hepatomegaly
Q&A COUNT: 52*
Q&A COUNT: 52*
Causes of RIGOR + Fever:
- Malaria
- Filaria
- UTI
- Follicular Tonsillitis
Age required to produce RIGOR?
3-6 months
*This answer varies between different faculties. Some say that the age to develop is around 3 years. Kindly be cautious when commenting on rigor.
*This answer varies between different faculties. Some say that the age to develop is around 3 years. Kindly be cautious when commenting on rigor.
Types of Fever?
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| The above picture is taken from Aruchamy Textbook of Paediatrics |
Causes for evening rise in temperature?
1. TB
2. Typhoid
3. Malaria
4. UTI
Practically, all fevers have evening rise in temperature. This is due to physiological diurnal variation in cortisol levels (peak in morning)
2. Typhoid
3. Malaria
4. UTI
Practically, all fevers have evening rise in temperature. This is due to physiological diurnal variation in cortisol levels (peak in morning)
Liver span - variation with ages?
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| The above picture is taken from Aruchamy Textbook of Paediatrics |
Grades of Hepatomegaly
Causes of Tender hepatomegaly?
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| The above picture is taken from Aruchamy Textbook of Paediatrics |
Causes of Tender hepatomegaly?
- Dengue
- Hepatitis
- Pyemic abscess
- Infected hydatid cyst
External Markers of Liver cell failure
1. Alopecia2. Hepatic facies - sunken cheeks/ eyes with malar prominence, enlarged parotids
3. Bitot spots
4. KF ring
5. Conjuctival hemorrhage
6. Xanthalesma
7. Icterus
8. Loss of buccal pad of fat
9. Parotid enlargement
10. Foetor hepaticus
11. Spider nevi
12. Gynecomastia
13. Palmar erythema
14. Dupuytren's contracture
15. Asterixis
16. Leuconychia
17. Caput medusae
18. Testicular atrophy
19. Scratch marks/ Pruritus) Bruising
20. Loss of axillary hair
DIFFERENTIAL DIAGNOSIS:
Differential Diagnosis for Fever + Hepatomegaly or Hepatosplenomegaly:
- Malaria (Intermittent fever with chills)
- TB (Cough with sputum, loss of weight or appetite, night sweats)
- Typhoid (Fever with bradycardia, rash)
- CCF (Dyspnoea, Orthopnoea, PND)
- Storage disorders (Bleeding, Jaundice, Family history)
- Leukemia/ Lymphoma (Fever + arthritis + loss of weight/appetite + Cranial nerve involvement in ALL)
- Connective Tissue disorder (Fever + arthritis + hyperextensible large joints + eye/heart/bone disease)
- Thalassemia (Macrocephaly, Hemolytic facies, anemia)
- SLE (Fever + Butterfly rash + Anemia + family history)
- Viral Hepatitis
- Viral hemorrhagic fever (Dengue) (Retro-orbital pain + hemorrhage + thrombocytopenia + nausea/vomiting + shock)
- Kala azar (Fever + Leukopenia + Hepatosplenomegaly + Skin lesion)
- Infectious mononucleosis
- Leptospirosis (Retro-orbital pain + thrombocytopenia + jaundice)
- Infective endocarditis
Fever with Bradycardia + Hepatomegaly - DD:
1. Dengue
2. Hepatitis
3. Typhoid
Fever with Bleeding (Thrombocytopenia) + Hepatomegaly - DD:
1. Typhoid
2. Leptospirosis
3. Dengue
4. Infective endocarditis
5. Leukemia/ Lymphoma
6. Storage disorders
1. Dengue
2. Hepatitis
3. Typhoid
Fever with Bleeding (Thrombocytopenia) + Hepatomegaly - DD:
1. Typhoid
2. Leptospirosis
3. Dengue
4. Infective endocarditis
5. Leukemia/ Lymphoma
6. Storage disorders
Fever with Arthritis + Hepatomegaly:
1. Leukemia
2. Connective tissue disorders
Fever with Anemia + Hepatomegaly:
1. Malaria
2. Leptospirosis
2. Leptospirosis
3. Disseminated TB
4. Infective endocarditis
5. Leukemia/ Lymphoma
6. SLE
7. Thalassemia
4. Infective endocarditis
5. Leukemia/ Lymphoma
6. SLE
7. Thalassemia
Fever with Jaundice + Hepatomegaly - DD:
1. Viral Hepatitis
2. Leptospirosis
3. Malaria
4. Kala azar
5. CCF
6. Storage disorders
Fever with Rash + Hepatomegaly - DD:
1. Typhoid
2. Dengue
3. Viral hepatitis
4. Infectious Mononucleosis
5. SLE
Frequency of cases in Stanley Medical College, Chennai:
Thalassemia - once a month
SLE - once every 2-3 months
Storage disorder - once a year
INVESTIGATIONS:
1. Complete Blood count
2. Peripheral blood smear - Malaria, Kala azar, Leukemia
3. Antigens for Dengue (NS1 antigen), Leptospirosis, anti rK39 antibody (Kala azar)
4. Ultrasound abdomen - organomegaly, mesenteric lymphadenitis
5. Quantitative Buffy Coat and Rapid Diagnostic Test for Malaria
6. Blood culture - any bacteria, IE
7. LFT
8. Chest X ray, Mantoux test - for TB
9. HbsAg, HIV serology
10. Urine microscopy and culture
11. Lymph node biopsy
FEVER:
IV Antibiotics - dosage
IV Cefotaxime 100-200 mg/kg/day TDS
IV Ceftriaxone 75-100 mg/kg/day OD or BD
Remember: 1 vial of both drugs contains 1 gram of them
INVESTIGATIONS:
1. Complete Blood count
2. Peripheral blood smear - Malaria, Kala azar, Leukemia
3. Antigens for Dengue (NS1 antigen), Leptospirosis, anti rK39 antibody (Kala azar)
4. Ultrasound abdomen - organomegaly, mesenteric lymphadenitis
5. Quantitative Buffy Coat and Rapid Diagnostic Test for Malaria
6. Blood culture - any bacteria, IE
7. LFT
8. Chest X ray, Mantoux test - for TB
9. HbsAg, HIV serology
10. Urine microscopy and culture
11. Lymph node biopsy
FEVER:
Paracetamol - Dose
15 mg/kg per dose QDS (6th hourly) (note that it is calculated per dose* - not per day)
Formulations (forms) of Paracetamol
1. Tablets
2. Capsules
3. Syrups
4. Suppositories
Syrup formulation for less than 1 year (1 ml contains 25 mg)
Tablet formulation for more than 1 year (1 tab contains 500 mg)
Routes of Paracetamol
1. Oral
2. Rectal suppositories
3. IV
IV Antibiotics - dosage
IV Cefotaxime 100-200 mg/kg/day TDS
IV Ceftriaxone 75-100 mg/kg/day OD or BD
Remember: 1 vial of both drugs contains 1 gram of them
MALARIA:
Tests for Malaria:
1. Rapid Diagnostic Test (Card test)
2. Quantitative Buffy Coat (QBC)
3. Peripheral Smear (thick and thin smear)
4. PCR
5. OptiMAL test - a type of RDT (detects parasite's LDH enzyme)
Purpose of Thick and Thin smear in Malaria diagnosis:
Thick smear - parasites seen or not
Thin smear - to identify type of parasite
Gold standard for Malaria diagnosis - Peripheral Smear
Complications of Malaria:
- Anemia
- Jaundice
- Cerebral malaria
- Hypoglycemia
- Renal failure
- Metabolic acidosis
Name some antimalarials
Chloroquine
Primaquine
Mefloquine
Amodiaquine
Tafenoquine
Quinine, Quinidine
Trimethoprim + Sulfadoxine
Lumefantrine, Halofantrine
Artemesinin/ Artesunate
Primaquine
Mefloquine
Amodiaquine
Tafenoquine
Quinine, Quinidine
Trimethoprim + Sulfadoxine
Lumefantrine, Halofantrine
Artemesinin/ Artesunate
Treatment for Vivax Malaria
1) CHLOROQUINE
Total dose 25 mg/kg
3 day Course:
Artemether - Lumefantrine combination is the most commonly used ACT drug combo.
One tablet contains 20 mg Artemether + 120 mg Lumefantrine
Dosage is Weight Range based*
Treatment for Complicated Falciparum Malaria (3 steps)
Step 1: Parenteral
PARENTERAL ARTESUNATE IV (reconstituted with sodium bicarbonate)
<20 kg: 3 mg/kg
>20 kg: 2.4 mg/kg
(Or)
Parenteral ARTEMETHER IM
3.2 mg/kg stat and then repeated after 12 and 24 hours and then daily
+
Management of complications (Coma, acidosis, shock, hypoglycemia, pulmonary edema, hyperparasitemia)
+
IV Paracetamol for fever
Step 2: Oral ACT
1 full course of Oral ACT administered, as given for uncomplicated falciparum malaria
Step 3: Primaquine
At the end of malarial therapy, a single gametocidal dose of primaquine 0.75 mg/kg is recommended to reduce community transmission.
1) CHLOROQUINE
Total dose 25 mg/kg
3 day Course:
Day 1 - 10 mg/kg
Day 2 - 10 mg/kg
Day 3 - 5 mg/kg
2) Paracetamol for fever
3) Radical therapy with Primaquine 0.25-0.3 mg/kg/day for 14 days
RADICAL THERAPY for Vivax Malaria
Given for P.vivax malaria (due to its exoerythrocytic stages in liver causing relapse)
Primaquine given as "radical therapy" to prevent relapse
Dosage:
1) No G6PD deficiency: PRIMAQUINE 0.25-0.3 mg/kg/day for 14 days
2) Mild G6PD deficiency: PRIMAQUINE 0.75 mg/kg once a WEEK for 8 weeks
3) Severe G6PD deficiency: CHLOROQUINE 10 mg/kg weekly for 3-6 months
Treatment for uncomplicated P.falciparum malaria
ACT - Artemisinin Combination Therapy is the treatment of choice. Paracetamol is initially given to control fever2) Paracetamol for fever
3) Radical therapy with Primaquine 0.25-0.3 mg/kg/day for 14 days
What is 4-4-2 regimen?
1 Chloroquine tablet strength: 150 mg
For a 60 kg body weight person:
Day 1 - 10 mg/kg (600 mg for 60 kg, which requires 4 tablets)
Day 2 - 10 mg/kg (600 mg for 60 kg, which requires 4 tablets)
Day 3 - 5 mg/kg (300 mg for 60 kg, which requires 2 tablets)
10 tablets given in total as 4+4+2 regimen in day 1-2-3 respectively
Complications of Chloroquine:
- Hypoglycemia
- Tinnitus and Vertigo
- Color vision - abnormal colors seen
- Bull's eye maculopathy
RADICAL THERAPY for Vivax Malaria
Given for P.vivax malaria (due to its exoerythrocytic stages in liver causing relapse)
Primaquine given as "radical therapy" to prevent relapse
Dosage:
1) No G6PD deficiency: PRIMAQUINE 0.25-0.3 mg/kg/day for 14 days
2) Mild G6PD deficiency: PRIMAQUINE 0.75 mg/kg once a WEEK for 8 weeks
3) Severe G6PD deficiency: CHLOROQUINE 10 mg/kg weekly for 3-6 months
What is ACT?
ARTEMESININ combination therapy
Treatment for uncomplicated P.falciparum malaria
Artemether - Lumefantrine combination is the most commonly used ACT drug combo.
One tablet contains 20 mg Artemether + 120 mg Lumefantrine
Dosage is Weight Range based*
For 5-14 kg: 1 tablet
For 15-24 kg: 2 tablets
For 25-34 kg: 3 tablets
For >34 kg: 4 tablets
Give tablets every 12 hours upto 60 hours (at 0th, 12th, 24th, 36th, 48th, 60th hour)*
Duration of therapy is thus 3 days.
At the end of malarial therapy, a single gametocidal dose of primaquine 0.75 mg/kg is recommended to reduce community transmission.
Give tablets every 12 hours upto 60 hours (at 0th, 12th, 24th, 36th, 48th, 60th hour)*
Duration of therapy is thus 3 days.
At the end of malarial therapy, a single gametocidal dose of primaquine 0.75 mg/kg is recommended to reduce community transmission.
Is ACT weight based?
No. ACT is WEIGHT RANGE BASED. Not weight based:
For 5-14 kg: 1 tablet
For 15-24 kg: 2 tablets
For 25-34 kg: 3 tablets
For >34 kg: 4 tablets
Treatment for Complicated Falciparum Malaria (3 steps)
Step 1: Parenteral
PARENTERAL ARTESUNATE IV (reconstituted with sodium bicarbonate)
<20 kg: 3 mg/kg
>20 kg: 2.4 mg/kg
(Or)
Parenteral ARTEMETHER IM
3.2 mg/kg stat and then repeated after 12 and 24 hours and then daily
+
Management of complications (Coma, acidosis, shock, hypoglycemia, pulmonary edema, hyperparasitemia)
+
IV Paracetamol for fever
Step 2: Oral ACT
1 full course of Oral ACT administered, as given for uncomplicated falciparum malaria
Step 3: Primaquine
At the end of malarial therapy, a single gametocidal dose of primaquine 0.75 mg/kg is recommended to reduce community transmission.
NVBDCP Protocol for Malaria Treatment
What is Hyperparasitemia?
>2% of blood with parasites
How to treat Hyperparasitemia?
EXCHANGE TRANSFUSION
EXCHANGE TRANSFUSION
Drugs for Resistant and Cerebral malaria:
- Doxycycline
- Clindamycin
- Artesunate
Define "Optimal response to therapy" in Malaria
Parasite counts on day 1 < day 0
Count on day 3 < 25% of day 0
No fever after day 3 of therapy
No parasites are seen after day 3 and persists the same upto 28 days
Reasons for Malaria fever, existing after 72 hours of therapy:
1. IV thrombophlebitis
2. Secondary bacterial infections
3. Co-infections (such as typhoid)
Define "Relapse" in a case of Malaria
Previously attained optimal response to therapy, relapses again
Common in P.vivax, due to exoerythrocytic stages in liver
Primaquine given as "radical therapy" to prevent relapse
Define "Recrudescence" in a case of Malaria
Reappearance of parasites within 28 days of treatment is defined as recrudescence or late treatment failure
Common in falciparum malaria
Treatment: Optimizing drug therapy or switch to alternate regimen
Parasite counts on day 1 < day 0
Count on day 3 < 25% of day 0
No fever after day 3 of therapy
No parasites are seen after day 3 and persists the same upto 28 days
Reasons for Malaria fever, existing after 72 hours of therapy:
1. IV thrombophlebitis
2. Secondary bacterial infections
3. Co-infections (such as typhoid)
Define "Relapse" in a case of Malaria
Previously attained optimal response to therapy, relapses again
Common in P.vivax, due to exoerythrocytic stages in liver
Primaquine given as "radical therapy" to prevent relapse
Define "Recrudescence" in a case of Malaria
Reappearance of parasites within 28 days of treatment is defined as recrudescence or late treatment failure
Common in falciparum malaria
Treatment: Optimizing drug therapy or switch to alternate regimen
Chemoprophylaxis for Malaria
CHLOROQUINE
Given:
Started atleast 1 week before travel
Given upto 4 week after travel
For Travellers to India - MEFLOQUINE 5 mg/kg once a week (or) Daily Atovaquone-Proguanil
For Travellers to India - MEFLOQUINE 5 mg/kg once a week (or) Daily Atovaquone-Proguanil
TYPHOID or ENTERIC FEVER:
Investigations for Typhoid Fever:
1. CBC - anemia, leukocytosis, thrombocytopenia
2. LFT - elevated
3. Ultrasound abdomen - splenomegaly and mesenteric adenitis*
4. Blood culture - gold standard for diagnosis
5. WIDAL test (serology)
Treatment for Typhoid:
Uncomplicated Typhoid - Oral CEFIXIME 20 mg/kg/day (ceiling dose 1200 mg)
Complicated Typhoid - IV CEFTRIAXONE or CEFOTAXIME 100 mg/kg/day and 200 mg/kg/day respectively; then switch to oral tablets once resolved.
Total duration of therapy - 14 days
LEPTOSPIROSIS:
Diagnosis of Leptospirosis:
By Serology: MAT (Microscopic Agglutination Test), IgM ELISA
or
Microscopy or PCR or culture
Other findings:
LFT enzymes elevated
CBC - anemia, thrombocytopenia, leukocytosis
Treatment for Leptospirosis:
IV PENICILLIN G: 6-8 million U/sq.m/24 hours for 7 days
Oral treatment: Amoxicillin 50 mg/kg/day in 2 divided doses
In child above 8 years: Doxycycline 6 mg/kg/day in 2 divided doses
Diagnosis of Leptospirosis:
By Serology: MAT (Microscopic Agglutination Test), IgM ELISA
or
Microscopy or PCR or culture
Other findings:
LFT enzymes elevated
CBC - anemia, thrombocytopenia, leukocytosis
Treatment for Leptospirosis:
IV PENICILLIN G: 6-8 million U/sq.m/24 hours for 7 days
Oral treatment: Amoxicillin 50 mg/kg/day in 2 divided doses
In child above 8 years: Doxycycline 6 mg/kg/day in 2 divided doses
About Leptospirosis
DENGUE:
WHO TYPES OF DENGUE:
Pathophysiology of Dengue?
TOURNIQUET TEST
Done for clinical diagnosis of hemorrhagic fever (Dengue)
1. Measure Systolic and Diastolic BP
2. Inflate the blood pressure cuff to midpoint between systolic and diastolic pressure for 5 minutes
3. The test is considered positive when 10 or more petechiae per 2.5 x 2.5 cm (1 inch square) are observed. In DHF, usually 20 or more petechiae will be seen.
MANAGEMENT OF DENGUE:
Volume replacement algorithm is given below - starting amount of fluid varies according to stage of Dengue
IV CRYSTALLOIDS is the treatment of choice and amount of fluids given will be based on the stage of Dengue*
Stage 1,2 Dengue: Started at 6 ml/kg/hour for 1-2 hours. Repeat once by increasing fluids to 10 ml/kg/hour for 2 hours if not improved.
Stage 3 Dengue: Started at 10-20 ml/kg/hour for 1 hour. Repeat bolus once, in case of no improvement.
Stage 4 Dengue: Give Oxygen. Started at 10-20 ml/kg for 15-30 mins RAPID bolus (stage 4). Repeat bolus once, in case of no improvement.
For all stages: If there is IMPROVEMENT, the further management will be step by step fluid reduction*
If doesnt improve, go for Blood Transfusion*
Improvement: Improvement is defined as stable PR, stable BP, rise in urine output and FALL IN HEMATOCRIT*
Step by Step Fluid reduction: 10-6 ml/kg/hour for 1-2 hours followed by 6-3 ml/kg/hour for 2-4 hours followed by 3-1.5 ml/kg/hour (for stages 1 and 2: 6-3 ml/kg/hour for 2-4 hours followed by 3-1.5 ml/kg/hour)
Blood Transfusion: If IV fluids fail, suspect internal hemorrhage and go for blood transfusion (10 ml/kg for whole blood or 5 ml/kg for packed RBC)
Usually, stage 1 and 2 Dengue fever improves by transfusion itself!
IV INOTROPES: If blood transfusion doesn't improve, go for IV INOTROPES with Crystalloids for maintenance!
The same above content is given as flowchart:
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| Copyrights of this picture belong to PCOD app |
DENGUE:
WHO TYPES OF DENGUE:
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| The above picture is taken from Park Textbook of Preventive and Social Medicine |
Pathophysiology of Dengue?
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| Copyrights of this picture belong to SPM Mnemonics app by Srinath KM |
TOURNIQUET TEST
Done for clinical diagnosis of hemorrhagic fever (Dengue)
1. Measure Systolic and Diastolic BP
2. Inflate the blood pressure cuff to midpoint between systolic and diastolic pressure for 5 minutes
3. The test is considered positive when 10 or more petechiae per 2.5 x 2.5 cm (1 inch square) are observed. In DHF, usually 20 or more petechiae will be seen.
MANAGEMENT OF DENGUE:
Volume replacement algorithm is given below - starting amount of fluid varies according to stage of Dengue
IV CRYSTALLOIDS is the treatment of choice and amount of fluids given will be based on the stage of Dengue*
Stage 1,2 Dengue: Started at 6 ml/kg/hour for 1-2 hours. Repeat once by increasing fluids to 10 ml/kg/hour for 2 hours if not improved.
Stage 3 Dengue: Started at 10-20 ml/kg/hour for 1 hour. Repeat bolus once, in case of no improvement.
Stage 4 Dengue: Give Oxygen. Started at 10-20 ml/kg for 15-30 mins RAPID bolus (stage 4). Repeat bolus once, in case of no improvement.
For all stages: If there is IMPROVEMENT, the further management will be step by step fluid reduction*
If doesnt improve, go for Blood Transfusion*
Improvement: Improvement is defined as stable PR, stable BP, rise in urine output and FALL IN HEMATOCRIT*
Step by Step Fluid reduction: 10-6 ml/kg/hour for 1-2 hours followed by 6-3 ml/kg/hour for 2-4 hours followed by 3-1.5 ml/kg/hour (for stages 1 and 2: 6-3 ml/kg/hour for 2-4 hours followed by 3-1.5 ml/kg/hour)
Blood Transfusion: If IV fluids fail, suspect internal hemorrhage and go for blood transfusion (10 ml/kg for whole blood or 5 ml/kg for packed RBC)
Usually, stage 1 and 2 Dengue fever improves by transfusion itself!
IV INOTROPES: If blood transfusion doesn't improve, go for IV INOTROPES with Crystalloids for maintenance!
The same above content is given as flowchart:
 |
| Copyrights of this picture belong to PCOD app |