A
febrile
8-year-old
boy
with
skin
lesions
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Prepared
by...
Virat
Sirisanthana,
M.D.
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|
Department
of
Pediatrics,
Faculty
of
Medicine,
Chiang
Mai
University
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A
8-old-boy
was
admitted
at
CMU
hospital
in
June
2001.
Address:
Chiang
Mai |
|
CC:
fever
for
7
days
PI:
7
days
PTA
he
had
gradual
onset
of
high
fever
with
purulent
discharge
from
his
Rt
ear.
Small
papular
lesions
were
also
noted
on
his
face
and
extremities.
3
days
PTA
he
developed
swollen
hands,
elbows,
ankles
and
feet.
Past
History:
Two
months
ago
he
was
brought
for
a
check
up
at
Sexually
Transmitted
Disease
Center
for
his
chronic
skin
lesions
at
his
extremities.
His
blood
test
was
positive
for
HIV
disease.
According
to
his
grandfather
he
has
been
well,
except
for
his
"off
and
on"
skin
lesions
at
the
extremities.
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|
Significant
PE:
pale,
but
fully
conscious
and
co-operated.
BW
18
kg
(5-10%tile
for
age),
T.
39.5
C.,
HR
120-140/min,
RR
28-40/min,
BP
100/60
mmHg,
HEENT:
small
papular
lesions
on
the
face
(fig
1,
2),
some
with
central
necrosis.
Pus
in
the
rt.
ear
canel.
Thrush
in
his
mouth.
Cheast:
wnl
Abdomen:
liver
2cm.
below
RCM,spleen
not
palpable.
Extremities:
Old
scars
of
impetigo....
as
hypo-
and
hyper-pigmented
areas.
Swollen
hands
(see
fig.3),
feet
and
elbows
with
warmness
and
tenderness
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Figure
3
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Initial
laboratory
investigations:
on
admission
CBC:
Hb
7
gm%,
Hct23%,
WBC
3,640/cbmm
(N
76%,
L
20%,
Mono
1%),
platelet
count
145,000/cbmm.
PBS:
RBC
normochromic
normocytic
UA:
WNL
CXR:
WNL
Nicking
of
the
lesion
at
his
face:
Wright
stain
:
see
figure
5
X-ray
of
hands,
feet
and
elbows
on
admission
show
osteolytic
lesions
at
most
of
phalanges
(hands
and
toes)
as
shown
in
figure
6,
7
and
8
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Figure
5
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Figure
6
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Summery
of
problems.
1.
Known
case
of
HIV-infected
boy
2.
High
intermittent
fever
for
7
days
3.
Skin
lesions
at
the
face
as
shown
in
fig
1,
2.
Smear
and
Wright
stain
as
shown
in
figure
5
4.
Swollen
hands
(see
fig.3),
feet
and
elbows
with
warmness
and
tenderness
5.
Hepatomegaly
(
liver
2
cm.
below
RCM)
6.
Chronic
otitis
media,
thrush,
pruritic
purpurra
eruption
at
the
extremities |
|
Further
Investigations:
ESR
(60min)
110
mm.
BM
aspiration
and
smear:
show
the
same
organism
as
in
the
skin
lesion
smear.
Hemoculture:
Penicillium
marneffei
BM
culture:
Penicillium
marneffei
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Course
in
the
hospital:
Specific
treatment:
amphotericin
B
iv
for
5
weeks,
then
continued
with
itraconazole
15
MKD.
Supportive
and
symptomatic
treatment
including:
Packed
red
blood
cell
transfusion.
Ear
toilet
and
ear
drops.
The
fever
pesisted
for
5
weeks,
then
gradually
subsided.
He
was
given
IV
amphotericin
B
for
6
weeks,
then
followed
by
itraconazole
orally.
His
swollen
hands,
elbows
and
feet
also
gradually
dissapeared.
He
was
discharged
home
with
itraconazole
15
MKD
and
will
be
followed
up
in
the
out-patient-department.
|
| Diagnosis
:
Disseminated
Penicilliosis
in
HIV-infected
boy |
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