Example case: Chronic dyspnea in a child
1. Introduction to the Case
Chronic dyspnea in a child
Patient: Edy Saussage, a 4-year-old boy
Presenting complaints: Mother explains that her son has been ill for 2½ months with fever, dyspnea and loss of appetite. She is worried because the boy's condition is now deteriorating since the past 2 days with high fever, non-productive cough and increasing dyspnea.
Recent medical history
The boy has not been growing well and was hospitalized 4 times. During the last admission, 2 months ago, he was diagnosed with pulmonary tuberculosis for the second time and was started on anti-TB treatment (ATT) accordingly. The boy's HIV test turned out to be positive and he was therefore referred to the 'hospital de dia'. Antiretroviral treatment has not yet been initiated. The first treatment episode for TB was 9 months before the restart of ATT. Both times, diagnosis was made on the basis of clinical symptoms and chest X-ray. As far as the mother knows, the child has never been in contact with persons with tuberculosis.
Isoniazide (H), Rifampicin (R), Pyrazinamide (Z) 3 times/week according to the local protocol.
Poor general condition, weight 11.3 kg, body temperature 38.7°C, tachypnea with respiratory rate 54/minute, no cyanosis, oral thrush, generalized lymphadenopathy, bronchial breathing left lower lobe. Hepato-spenomegaly.
Please see figures 2 and 3 to see the looks and the growth of this child
ESR 130 mm/1h, WBC 18.9 x109/l, Hb 7,6 mmol/l, thrombocytes 594. HIV test result (2 parallel rapid ELISA's) from 2 months earlier was confirmed to be positive. No CD4 count (%) available.
Symmetrical, bilateral reticular infiltrates. Enlarged mediastinal and hilar lymph nodes.
1. What is your differential diagnosis and why?
2. Would you continue ATT? And, if you decide not to, do you feel the patient would need treatment for latent tuberculosis? Please motivate your answer.
3. Would you start any other treatment and if so, what kind of treatment? What would you do to get as much evidence as possible for your most probable diagnosis?
4. Does the patient qualify for ART according to the national guidelines? Name CDC and WHO classification, assuming that the CD4 count is 18%.
5. If you think the patient does not qualify, explain why. If you decide that the patient indeed qualifies, what ART drug regimen would you choose using the national guidelines and when should the patient start
6. Do you have any other concerns?
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19 Nov 2013 12:12
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