THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
18M WITH POST COVID FULMINANAT HEPATIC FAILURE.
JANUARY 12, 2023.
18 year old male ,From Miryalguda who completed his 12th standard presented to the casualty on 12/6/2021 with chief complaints of:
Low back ache since 1 week
Generalised weakness and loss of appetite since 1week
History of fever since 5days ,subsided now
Yellowish discolouration of eyes since 3 days
High coloured urine since 1 day
History of present illness
-Patient was apparently asymptomatic one year ago, then he visited a dentist in view of toothache and got it removed in view of caries tooth
-Since 6 months, patient had history of weight loss.
-History of nocturia ,polyuria and polydipsia since 2 months.(he used to get up atleast 6-7 times after he was asleep for micturation).
-10 days ago, patient attended a marriage function along with his family and after 2 days he complained of low back ache and 2 episodes of vomitings and 3 episodes of loose stools for one day which subsided on its own
-Next day pt developed fever which was intermittent ,high grade ,no chills and rigors and subsided with medication(rm) . Associated with loss of appetite and nausea and low back ache.
-After 2 days he noticed yellowish discoloration of eyes. So he visited a nearby hospital which showed elevated total bilirubin and his sugars were 360mg/dl.
-He was started on OHA by RMP and he used it for 3 days.
-Later they visted to our casualty in view of increase in yellowish discoloration of eyes and high colored urine.
-No history of excessive salivation ,dysphagia, vomitings, and black stools or blood in stools.
-No history of constipation/ diarrhea.
-No pain abdomen or distension.
-Clay colored stools present.
-No bleeding manifestations like purpura , petechiae, bleeding gums.
-No sob, pedal edema, chest pain.
PAST HISTORY :
-No history of similar complaints in the past.
-Not a k/c/o HTN,DM,TB,ASTHMA ,EPILEPSY.
-History of febrile seizures at 9 months of age.
-He was full term baby born at hospital ,cried immediately after birth, no history of jaundice at birth/childhood.
-No developmental delay and no cognitive impairment.
DRUG HISTORY:
-No history of usage of herbal medications.
-No history of drug intoxication.
PERSONAL HISTORY:
He has mixed diet , loss of appetite present, regular bowel and bladder movements .Adequate sleep.
No addictions ( alcohol and smoking ).
NO SIGNIFICANT FAMILY HISTORY
…………………………………
GENERAL EXAMINATION
Patient was conscious .co-operative coherent.
Oriented to time place and person.
Moderately built and nourished
ICTERUS - PRESENT.
No pallor ‚cyanosis ,lymphadenopathy ,clubbing and odema .
No raised JVP
Vitals on presentation:
- BP- 110/70 mmgh supine posture in right arm
- PR - 94 bpm regular .normovolemic
- Rr - 24cpm ; spo2 - 100% on RA.
- GRBS -287mg/dI TEMP- 99 F
SYSTEMIC EXAMINATION
Head to Toe examination:
- No alopecia, bitot spots, subconjunctival hemorrhages, kayser-
Fleischer ring, no fetor hepaticus, no bleeding gums. - No spider naevi, gynecomastia, loss of axillary hair, caput medusa, testicular atrophy, dilated veins on abdomen, wasting,
- No leukonychia, palmar erythema, flapping tremor.
- No pedal edema
Systemic examination:
Per abdomen :INSPECTION
Shape of the abdomen - scaphoid
Umbilicus - central in position and inverted.
No scars ,sinus ,dilated veins.
PALPATION:
Mild Tenderness noted in right hypochondrium.
No palpable mass.
No guarding and rigidity
No organomegaly
PERCUSSION:
Liver span - 11 cms
No fluid thrill
AUSCULTATION:
Bowel sounds present.
No bruit heard
CVS - sI $2 heard . No murmurs
RS - bilateral air entry present,Normal vesicular breath sounds.,No adventitious sounds.
CNS;NO FND
PROVISIONAL DIAGNOSIS
?Acute viral hepatitis
Denovo DM
INVESTIGATIONS-
From 11-6-2021 to 16-6-2021
Further drop in Hb to 11.5, total bilirubin increased to 14.
CT brain and CECT abdomen were done during his course in hospital when required.
COURSE IN THE HOSPITAL-
18 YEAR OLD MALE CAME WITH C/O LBA ,YELLOWISH DISCOLORATION OF EYES,FEVER SINCE 4-5 DAYS PT. WAS ADMITTED AND NECESSARY INVESTIGATIONS WERE SENT. Pt WAS FOUND TO HAVE ISOLATED HYPERBILIRUBINEMIA(6.7TB )PREDOMINANTLY INDIRECT AND ENZYMES WERE NORMAL .HIS URINE FOR KETONES WERE POSITIVE WITH RBS 280 AND MILD ACIDOSIS .SO TH PT WAS DIAGNOSED AND TREATED AS DKA (DENOVO DETECTED TYPE 1DM),HYPERBILIRUBINEMIA UNDER EVALUATION,WITH COAGULOPATHY.
USG ABDOMEN -LIVER NORMAL ECHOTEXTURE,CBD NORMAL ,NO EVIDENCE OF IHBRD
DAY1-
PT WAS TREATED WITH INSULIN AND IV FLUIDS,VIT K
DAY2-
HIS SUGARS CAME INTO CONTROL ON DAY2 OF ADMISSION .HIS INSULIN REQUIREMENT WAS AROUND 12 UNITS ACTRAPID PER DAY .PT CONTINUED TO HAVE LBA
XRAY LS SPINE WAS DONE WHICH WAS NORMAL
DAY3-
PT COMPLAINS OF LBA AND LOSS OF APPETITE AND DID NOT PASS STOOLS SINCE 1 DAY
SUPPORTIVE MANAGEMENT WAS GIVEN ,SYP LACTULOSE WAS GIVEN
DAY4-
PT COMPLAINED OF SEVERE GENERALISED WEAKNESS
BY AROUND EVNG 6 PM , PT BECAME DROWSY NOT RESPONDING TO VERBAL COMMANDS .HIS SENSORIUM DETERIORATED JUST OVER 1-2HOURS.(?HEPATIC ENCEPHALOPATHY) WITH ACUTE RETENTION OF URINE AND BIZARRE STAREY LOOKS ,RESPONDING TO PAINFUL STIMULI ?ABSENCE SEIZURES ,INJ. LORAZ 2CC GIVEN.VITALS WERE STABLE
SERUM ELECTROLYTES CAME NORMAL.
IN VIEW OF COAGULOPATHY CT BRAIN WAS DONE TO RULE OUT IC BLEED
CT BRAIN NORMAL
PT DID NOT PASS STOOLS SINCE 2 DAYS ,ENEMA WAS GIVEN
PT PASSED STOOLS AFTER ENEMA
FOLEYS CATHETERISATION WAS DONE ,COLA COLORED URINE OF ABOUT 1000 ML WAS COLLECTED IN UROBAG
Question: 18year old male with acute liver failure(?toxin mediated,?immune medaited) with hepatic encephalopathy, coagulopathyWith cola coloured urine(?hemoglobinuria)
Acute hemolysis ?toxin mediated
Hb dropped from 16 to 13mg/dl
LDH 888
URINE WAS SENT FOR ANALYSIS, URINE FOR PORPHOBILINOGEN NEGATIVE, NO RBCs IN URINE
UROLOGY REFERRAL WAS TAKEN IN VIEW OF 5MM RIGHT RENAL CALCULUS ,ADVISED FOR XRAY KUB AFTER STABILISATION
DENGUE SEROLOGY NEGATIVE,SMEAR FOR MP
?AUTOIMMUNE HEMOLYTIC ANEMIA
DCT ICT NEGATIVE
DAY5-
GCS- E2V2M3
PT COMATOSED WITH B/L REACTING PUPILS, DILATED
VITALS STABLE, DEEP TENDON REFLEXES NORMAL WITH B/L EXTENSOR PLANTAR
WITH SUSPICION OF CEREBRAL MALARIA ,INJ.FALCIGO 120 MG STAT. GIVEN(0----12---24--48 HRS), 4 DOSES GIVEN,INJ. LEVIPIL 500 MG BD WAS STARTED ,INJ. DOXYCYCLINE 100 MG BD WAS STARTED
OTHER SUPPORTIVE MEASURES WERE GIVEN SUCH AS IV FLUIDS ,SYP.LACTULOSE,ENEMA WERE GIVEN
HIS TB SHOOT UP TO 15 ,DB 6,IB 9,AST 18,ALT 22 ,ALP 138,TP 7.6,ALB 4,HB 13,(IT WAS 16 GM AT THE TIME OF ADMISSION )
DIFFERENTIAL DIAGNOSIS-
?CEREBRAL MALARIA
?ACUTE HEMOLYSIS(INTRAVASCULAR)
? ACUTE LIVER FAILURE
? ACUTE INTERMITTENT PORPJHYRIA
HEPATIC ENCEPHALOPATHY WITH METABOLIC SEIZURES AND COAGULOPATHY
DKA (RESOLVED),DENOVO DETECTED ?TYPE 1 DM
DAY 6-
GCS-E2V1M3 WITH B/L REACTIVE PUPILS AND VITALS STABLE
SERUM LDH-237
SERUM IRON 150 ,SERUM FERRITIN> 1500,HBA1C 6.6,TSH 1
TRIPLE PHASE CT ABDOMEN WAS DONE TO RULE OBSTRUCTIVE PATHOLOGY WHICH SHOWED FATTY LIVER NO IHBRD ,NORMAL CBD ,NORMAL HEPATIC VEINS IVC,INCIDENTALLY DETECTED SMALL BOWEL INTUSUSSCEPTION
AS THERE IS NO OBSTRUCTIVE PATHOLOGY,THE REASON FOR RAISING INDIRECT BILIRUBIN ,FALL IN HB,RAISE IN SERUM LDH CAN BE CONSIDERED AS COOMBS NEGATIVE HEMOLYTIC ANEMIA AND THE REASON FOR RAISE IN DIRECT BILIRUBIN DUE TO INTRA HEPATIC CHOLESTASIS
PERIPHERAL SMEAR -NORMOCYTIC,NORMOCHROMIC
SICKLING TEST NEGATIVE
FREE T3 3.86,FREE T4-1.41
D DIMER 2160
DAY 7-
GCS-E2V2M3
INJ. CEFTRAIXONE 1 GM IV BD STARTED
IN VIEW OF UNEXPLAINED LIVER FAILURE N ACETYL CYSTEINE ,IV INFUSION WAS STARTED (600 MG)
WITH SUSPICION OF ANY CEREBRAL EDEMA ,3% NACL INFUSION WAS GIVEN FOR 1 DAY
GASTROENTEROLOGY REFERRAL WAS TAKEN : ACUTE FULMINANT HEPATIC FAILURE ,ADVISED FOR LIVER TRANSPLANTATION BUT PT ATTENDERS WERE NOT AFFORDABLE
DAY 8-
GCS-E1V1M3,VITALS STABLE
IN VIEW OF ACUTE FULMINANT LIVER FAILURE, HEPATIC ENCEPHALOPATHY PROBABILITY OF MULTISYSTEM INFLAMMATORY SYNDROME (POST COVID) WAS CONSIDERED.
COVID ANTIBODIES WERE SENT WHICH SHOWED COVID ANTIBODY IGG >150(NORMAL IS <1), COVID ANTIBODY TOTAL VIA ELISA 5.85(NORMAL IS <0.8)
TB-12.6, DB-6.5, IB-6.1, AST 402, ALT 82, TP 6.8, ALB 4.1, HB 12.6,TLC 5300, PLT 1.31
AFTER 4 DAYS OF HEPATIC COMA WITH RAISING BILIRUBIN ATTENDERS WERE COUNSELLED ABOUT POOR PROGNOSIS BUT TO OUR SURPRISE BY EVNG 7 PM ON DAY 8 OF ADMISSION PT SENSORIUM IMPROVED DRASTICALLY, SUDDENLY PATIENT WOKE UP AND PT WAS IRRITABLE AND COMPLETELY CAME INTO CONSCIOUS
PT WAS PASSING 2-3 STOOLS /DAY
GCS-E4V3M6
……………………..
DAY 9-
PT RESPONDED TO COMMANDS, ORIENTED TO TIME, PLACE, PERSON, VITALS STABLE
SERUM AMMONIA (sent on day 7 )-108(NORMAL)
RTPCR COVID NEGATIVE (done on day 7)
3% NACL WAS STOPPED AND REST ALL OTHER TREATMENT WAS CONTINUED
AT AROUND 6 PM, PT HAD 1 EPISODE OF TRANSIENT ABNORMAL BEHAVIOUR WITH VISUAL HALLUCINATIONS WHICH SUBSIDED AFTER FEW MINUTES.
DAY 10-
POST COVID ACUTE FULMINANT HEPATIC FAILURE? MISC
?COOMBS NEGATIVE HEMOLYTIC ANEMIA
HEAPTIC ENCEPHALOPATHY RESOLVED
COAGULOPATHY REOLVED
DKA RESOLVED
THROMBOCYTOPENIA RESOLVING
METABOLIC SEIZURES(RESOLVED)
PT SLEPT WELL YESTERDAY NIGHT .NO EPISODES OF ABSENCE SEIZURES, NO HALLUCINATIONS ,PASSED STOOLS 2 TIMES YESTERDAY AND ONCE TODAY MRNG
SERIAL LFT MONITORING WAS DONE(TB 12)
DAY 11-
PT HAD NO COMPLAINTS
PT WAS AMBULATED, REST ALL OTHER TREATMENT CONTINUED
DAY 12-
NO FRESH COMPLAINTS, PASSED STOOLS 2 TIMES PER DAY, SAME TREATMENT CONTINUED
On day 13
On day 15
DAY 13,14,15-
NO FRESH COMPLAINTS, PASSED STOOLS 2-3 TIMES A DAY, SAME TREATMENT CONTINUED AND VITALS STABLE
DAY 16-
ON THE DAY OF DISCHARGE, PT IS CONSCIOUS, COHERENT AND VITALS STABLE
TB 4.08, DB 3.62, AST 51, ALT 142, ALP 205, TP 6.6, ALB 2.9
PT WAS ADVISED TO TAKE EGG WHITES, TO PASS STOOLS 2-3 TIMES /DAY AND REVIEW AFTER 1 WEEK WITH CBP, LFT, PT INR AND APTT
ADVICE AT DISCHARGE-
ORAL FLUIDS 2-3 LTS/DAY
TAB LEVIPIL 500 MG BD
TAB.UDILIV 300 MG BD FOR 5 DAYS
TAB.RIFAGUT 550 MG BD
TAB PANTOP 40 MG OD
SYP. HEPAMERZ 10 ML BD
SYP LACTULOSE 10 ML BD( TO PASS 2-3 STOOLS /DAY)
INJ. HAI SC 6U TID
FINAL DIAGNOSIS:
POST COVID
ACUTE FULMINANT HEPATIC FAILURE WITH INTRA HEPATIC CHOLESTASIS
?MULTI SYSTEMIC INFLAMMATORY SYNDROME IN CHILDREN
?COOMBS NEGATIVE HEMOLYTIC ANEMIA
HEAPTIC ENCEPHALOPATHY RESOLVED
COAGULOPATHY REOLVED
DKA RESOLVED
THROMBOCYTOPENIA RESOLVING
METABOLIC SEIZURES(RESOLVED)
PPM 1: 👍
No comments:
Post a Comment