An HIV-infected boy with abdominal pain (Page 1/2)

Prepared by...Nattiya Jareewit , MD
Aurmporn Oberdorfer, MD, PhD
Virat Sirisanthana, MD
Department of Pediatrics, Chiang Mai University, Thailand


A 7-year-old boy. Address: Chiang Mai, Thailand
Chief compliant: Abdominal pain, on and off for 2 months
Present illness:
> ~2 years prior to admission he started having intermittent fever. He always took a paracetamol tablet for fever. His symptoms were on and off, but he had never been admitted in any hospital.
> 2 months prior to admission, while low grade fever persisted, he developed abdominal pain at the epigastric region. The abdominal pain has been getting worse for the past 2 weeks. He denied having vomiting or diarrhea.
> 4 days prior to admission, he refused eating due to severe pain at the abdomen. Antacid, and antispasmodic drug did not help, so his grandmother took him to the hospital. She also reported that his abdomen was getting enlarged.
Past history:
> He was born to an HIV-infected mother. His mother died due to lung disease 5 years ago. His father is still healthy.
> He lived with his grandparents. They had never been told about his HIV-status.
> He had a history of herpes zoster at his trunk twice.
> He didn't have a history of pneumonia, otitis media, or any recurrent infections.
Physical examination:
Body weight: 15.8 kg (W/A 79%), Height: 108 cm (H/A 87%), weight for height 84%
Vital signs: BT (axillary):38.6 degree celsius, PR: 100-120/mins, RR:28/min, BP 116/72 mmHg
General appearance: a cachexic boy, mild pale
HEENT: whitish patches in the oral cavity, mild pale conjunctivae, no icteric sclera,
Heart: regular, Lungs: clear
Abdomen liver: enlarged abdomen, mild generalized tenderness, rebound: negative, ill-defined mass at mid-abdomen, rubbery consistency, nodular surface diameter ~15 x 15 cm., liver 2 cm. below RCM, liver span 7 cm., no splenomegaly
Neurological examination: normal
Lymph nodes: - cervical lymph nodes, diameter 0.5-1 cm, bilaterally - inguinal lymph nodes, diameter 1-1.5 cm, bilaterally
Skin: pruritic papular eruption
CBC: Hb 8.5 Hct 27.4% Wbc 1,900 N 68% L 26% E 2% M 2% band 2%
PBS: hypochromic microcytic cells, anisocytosis 1+, no fragmented red blood cells
U/A: yellow, clear, Ph: 8, sp.gr 1.005, albumin :negative, sugar: negative, no rbc, wbc: 1-2/hpf, epithelium: 1-2/hpf
BUN/Cr = 5/0.4, Na: 143 mEq/L K: 3.1 mEq/L Cl :107 mEq/L HCO2: 20 mEq/L
LFT: TP 8.1 A/G 4/4.1, AP 103, Cholesterol 84, AST 63, ALT 18, TB 0.33, DB 0.09
Anti-HIV antibody: positive
CD4 = 2% (10 cells/ccmm), CD8 = 41% (210 cells/ccmm), helper/suppressor ratio = 0.05
BM aspiration - WNL, no organism seen.
Stool examination: positive for AFB organism (figure 1)
Tuberculin skin test: no induration (negative)
Gastric washing for AFB x3 days: negative
CT abdomen including lower part of the chest: multiple retroperitoneal and mesenteric lymphadenopathy, multiple adenopathy at para-aortic and aortocaral region (figure 2)
Figure 1: Stool: AFB stain
Figure 2: CT abdomen
Gastroduodenoscopy: 1) esophageal candidiasis and 2) several white plague and nodules at the duodenum

Summery of the medical problems:

An HIV-infected boy with clinical category C and severely immunesuppressed
Abdominal lymphadenopathy
Oral and esophageal candidiasis
What is the cause of abdomial pain? Next to Page 2
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