A 2 months old child admitted in the month of May, 2018 into the children emergency room, of the University of Calabar Teaching Hospital with complaints of cough of one-month duration and fever of three weeks duration. Cough was distressing and worse at night. Fever was high grade, intermittent and temporarily relieved by administration of paracetamol syrup. Pregnancy was booked at a gestational age of 13 weeks. Delivery was at a gestational age of 28 weeks via emergency lower section caesarean section. Birth weight was 1.65kg. Child was admitted into special care baby unit and managed for prematurity, neonatal sepsis and neonatal jaundice on account of antepartum haemorrhage. She had blood transfusion but no exchange blood transfusion and was discharged at a weight of 1.8kg having spent a month in special care baby unit. Child was fed with infant formula and breast milk from birth. She is the second child in a monogamous setting and has a 7-year-old male sibling. The father is a civil servant while the mother is a businesswoman.
Physical examination showed an acutely ill looking child, febrile with temperature of 38.6 C, mildly pale, dyspnoeic and tachypnoeic, with a weight of 3.7kg (3rd percentile), length of 50cm (below the 3rd percentile) and occipito frontal circumference - 38cm (z-score). Respiratory rate was 66cycles/minute, with SPO2 of 80% in room air. The heart rate was 186 beats/minutes with normal heart sounds. The abdomen had a tender hepatomegaly of 6cm and a splenomegaly of 6cm. Liver was 8cm below the right costal margin, soft and smooth. Spleen was 2cm below the left costal margin, and non-tender.
Laboratory findings showed a PCV of 21%, random blood sugar of 4.7mmol/L, HIV screening was negative, Full blood count; Total WBC of 12.6 x 109/L, Neutrophils: 65%, Lymphocytes: 33%, Platelets: 179x109/L, Malaria parasite test: positive, Gene Xpert: negative, Mantoux test: 0 mm, Chest X-ray showed hazy opacities on the right upper and middle lung lobes, with left upper lobar opacities and pneumatoceles (Figure 1). Blood culture yielded T. ptyseos. Patient was on oxygen at 2L/min and was transfused with 60mls of settled cells. Post transfusion PCV was 25%. While on admission, patient received IV Ceftriaxone and IV gentamicin and spent 5 days during which fever subsided and respiratory rate reduced, and was thereafter discharged. One week later, patient represented and was admitted on account of the same but worsening symptoms. A diagnosis of Septicaemia with heart failure was made to rule out bronchopulmonary dysplasia and pulmonary tuberculosis. Empirical antibiotic (IV Ceftriaxone, IV Gentamicin, Suspension Azithromax) therapy were commenced. IV Furosemide and tablets digoxin was also given. On the second day of admission, IV cloxacillin was commenced, as the child remained ill and IV gentamicin discontinued. 3 days into admission, child developed seizures which was generalized tonic clonic lasting about 1-2 minutes. She had two episodes. The second episode was aborted with IV diazepam. The random blood sugar at the time was 2.9mmol/L. SPO2 was 67%. Intravenous fluid was commenced at 60% maintenance and phenobarbitone was also commenced at maintenance dose. She received blood transfusion, Nil per oral and cautious intravenous fluid, and oxygen therapy. Frusemide and digoxin were also added. Despite these measures, she was still very ill and in severe respiratory distress. CSF analysis was not in keeping with meningitis. She remained very ill, had intermittent hypothermia with subnormal temperature and died 5 days after admission. Blood culture result of sample taken on the third day of admission and received 3 days after patient s demise yielded growth of T. ptyseos. Antimicrobial susceptibility test result showed sensitivity to Amikacin, intermediate to Ceftazidime and Ciprofloxacin, and resistant to Ceftriaxone, Cefuroxime, Gentamicin, Amoxicillin-Clavulanate, Cefepime, Cefoxitin and Colistin.