PICU Case

Eight year old boy who was otherwise normal had a fall from school and sustained mild bruise near his right knee. On the same day evening swelling started around the injury and within hours swelling spread around the joints. He was taken to the local hospital next day morning .Doctor aspirated knee joint and drew five cc of blood and he was referred as a case of hemarthrosis , as the trauma was trivial he thought better to rule out hemophila.

At the time of admission 

 He looked sick , he had low grade fever . Pulse 86 regular good volume , BP 88 systolic .normal breathing. No jaundice, no rash no lymph nodes .mild pallor .

Swelling around right knee extending upwards to the groin and down towards the tibia , but ankles were spared. As he wanted to confirm hemarthrosis and to rule out popliteal vessel compression USG was arranged. USG ruled out hemarthrosis. Blood vessels lower limb was normal . also checked abdoen ,chest . No free fluid in peritoneum pleural cavity and no significant organomegaly or mass

Sytem examination 

were within normal limits.

Baseline investigations .

Urine Showed few RBC ,granular cast , trace albumin Sugar positive
Blood showed WBC and Platelets low count . Ocasional normoblasts .No parasites .
LDH was 1500 , Reticulocytes 3.5 Corrected reticulocyte count 1.5
Whole blood clotting time was 18 minutes. INR 2.5 APTT normal .

So , odema was of local around the knee but sprading. Not generalised one of acute onset. Other limbs and face spared. Renal function deranged. with hemolysis and thrombocytopenia.
He was referred as hemarthrosis due to hemophilia . But here no evidence of hemarthrosis. and we cant say it is spreading hematoma also , but spreading odema .
But the local odema does not go with the clearly abnormal investigation findings.There is anemia possibly hemolytic with WBC and platelets clearly on the lower side.
No significant bleeding manifestations obvious.
Is it HUS ? His output was good . Urine showed deposits. Renal function parameters deranged but minimal . Pallor plus but not severe.........So does nt support this idea fully
Is it sepsis ? Yes , as he was sick he was put on gram negative and staph cover .
By evening few blebs started first around knee and then spread over the whole limbs. Odema spread to abdomen and even to the right axilla

By next day morning his general condition deteriorated with hypotension , altered sensorium , irritable shouting. Once or twice he mentioned about snakes.

We had one of the DDs as bites. He had a fall and trauma at the knee , proceeded fast with local swelling , with impaired renal function, coagulation profile disturbed and renal function deranged. But few points again not fitting.
Any way we did nt want to miss that treatable possibility . As he was deteriorating we discussed the options with the parents and started ASV
Before that we sent for Coombs test ANA and a repeat peripheral smear .

So that is it .Acute leukemia, most probably Lympatic L2
Present picture must be bacterial infection in this situation of neutropenia. Organism may be usual organism or rarer organisms. In this context we considered possibility of staphylococus as the first possibility. Here in view of his disturebed renal function vancomycin was nt given instead he was put on linezolid and piptaz
His coombs test negative. ANA negative.
Blood and swab culture negative
Over the days he improved

When he improved we Bone marrow aspiration and trephile was done , Acute leukemia . Most of the blast seen were lymphoblasts but few myeloperoxidase positive. So mixed lineage was final diagnosis