Patient information: a 9-month-old female presented with a history of poor weight gain from birth, cough, and fever of 2 weeks, fast breathing of 1 week, and refusal to suck for one day. Weight loss was progressive despite adequate feeding. Cough was distressful, non-paroxysmal with no history of contact with an adult having a chronic cough. The fever was high-grade and continuous. Fast breathing was of insidious onset and had been progressive. She was unable to suckle from the breast for 24 hours prior to presentation despite her mothers  concerted effort to breastfeed her. A review of systems revealed she had orthopnea, easy fatigability, excessive sweating, no cyanosis, no body swelling, and no seizures. She was referred to another hospital where she was admitted and had a blood transfusion without remarkable improvement. Prior to this, she had no previous hospital admission. Pregnancy, birth, and neonatal period were normal. Although her mother did not remember the birth weight. She was exclusively breastfed and commenced satisfactory complementary feeds. She was also adequately immunized and her development was within normal limits. She is the third of 3 children. Both parents were in their early thirties and from a low socio-economic class.
Clinical findings: at presentation, she had dysmorphic features with upward slanting of the palpebral fissures, low-set ears, and flattened nasal bridge. She was also severely pale, in severe respiratory distress with subcoastal and intercoastal recessions, flaring alae nasi and she was saturating at 85% in room air. Her weight was 6kg (44% of expected and > -3 Z-score), height was 72cm (0.8 Z-score). She was tachypneic with a respiratory rate of 60 cycles per minute and had widespread crepitation. She also had an active precordium, apex beat was displaced to the fifth left intercostal space lateral to the mid-clavicular line, she had tachycardia with a heart rate of 160bpm and a grade 3/6 continuous systolic murmur, maximal at the left lower sternal border and radiating to the armpit. Abdominal examination showed a reducible umbilical hernia and tender hepatomegaly with liver 4cm below the right subcoastal margin. An initial working diagnosis was severe bronchopneumonia in heart failure in a child with acyanotic congenital heart disease and chromosomal abnormality probably Downs syndrome, failure to thrive with severe malnutrition.
Diagnostic assessment: full blood count showed absolute leukocytosis with a white blood cell count of 22.7 x 109/L, and anemia with a packed cell volume of 28%, electrolytes urea, and creatinine showed hypokalemia of 2.4mmol/L, hypocalcemia with non-ionic calcium of 1.09mmol/L. The retroviral screening was seronegative. Chest X-ray (Figure 1), done showed: significant perihilar mottled and fluffy opacities involving all lung zones bilaterally, cardiomegaly with a cardiothoracic ratio of 61%, splaying of the carina suggestive of cardiogenic pulmonary edema. Electrocardiograph showed: sinus tachycardia, with a heart rate of 168bpm, right (rt) atrial enlargement, rt ventricle hypertrophy, and rt axis deviation. Echocardiography showed: 0.4cm PDA with continuous left to rt shunt at 74mmHg. The malaria parasite was positive.
Therapeutic interventions: she was, commenced on parenteral antibiotics, diuretics, intranasal oxygen, nutritional rehabilitation, vitamin D supplementation, antimalarial medications, and hematinic. She was stabilized, discharged, and referred for PDA ligation which she had after 6 months. The operation was successful as there was good PDA ligation with no residual flow on the echocardiogram (Figure 2 A,B).
Follow-up and outcome of interventions: a month post-surgery she started coughing and though she had started gaining weight which was now 94% of expected, she had localized rhonchi in the left upper lung zone posteriorly, she was managed for early pneumonia with a possible localized lung obstruction as a post-PDA ligation complication. A chest X-ray was ordered which was not done although she was placed on antibiotics, and chest physiotherapy. She was managed for uncomplicated pneumonia two more times on an outpatient basis. The cough however progressively worsened over 3 months and she also developed a fever and started losing the previously gained weight. On subsequent examination, she was tachypneic, and had coarse crepitations, bilaterally. She also had tachycardia with a gallop rhythm and tender hepatomegaly. She was admitted for severe bronchopneumonia in heart failure to rule out PTB. Chest X-ray (Figure 3) showed bilateral perihilar mottled opacity. GeneXpert test showed mycobacteria tuberculosis was not detected. A diagnosis of PTB was made and she was commenced on anti-tuberculosis drugs with a good response. She has had no recurrence of pneumonia and started gaining weight adequately six months into the treatment.
Patient perspective: the mother was very satisfied and happy that her child has finally recovered.
Informed consent: a written informed consent was given by the mother to have her child s case published.