> I wonder if I could get ideas on a patient. > > Patient is a 9 mo Indian girl presenting with 4 weeks of documented fevers > to 104, persisting through most of the day, without any obvious pattern. > Past history is remarkable only for a visit to India in January and > positive throat FA or culture (not clear which) for adenovirus on her and > for Group A strep on her 3 year old brother. At admission, the child > looked quite well, playing through her fevers, though she does not look > good now. PE was unremarkable, with no cough, clear lungs, no tenderness > or organomegaly or rash. Thick and thin smears X7 have been negative for > malaria. Also negative (bacteria, mycobacteria, etc.) are blood > cultures, stool cultures, urine cultures. Eye exam and cardiac echo were > negative. All serology was negative, including CMV, EBV, parvovirus, > febrile agglutinins, toxo. (Brucella, leishmania, HAV, HBV, HCV pending). > Albumin 2.8, total protein 7.2 ; IGG 1260, IGM 128; tetanus titers > pending (was vaccinated). Bone marrow aspirate and culture of aspirate > were negative for organisms, including salmonella and AFB and for viral > inclusions/multinucleated cells. Red cell precursors were absent and > there were minimal white cell precursors, except for a plethora of > eosinophils. Hematology read it as without hemophagocytosis and without > malignancy; pathology thought they saw rare hemophagocytizing cells. CT > of chest, abdomen and pelvis showed normal sized liver and spleen but > diffuse uptake in liver. Now we come to the bizarre parts. Liver biopsy > shows large areas of necrosis and inclusions strongly suggesting > adenovirus. (FAs are being done as I write.) A flow panel on > peripheral blood showed the following: WC 1.3 with 60% lymphocytes > (780). 11.3% CD3+, 5.2% CD4+, 1.2% CD8, 18.2% CD3-CD56+, CD3-CD16+ > 19.2%, 64.6% CD19+. > > The adeno comes as quite a surprise. We had not even known about the > throat culture until today. It is odd that it is just in the liver. > Also, the LFTs were not really abnormal, at least 4 days ago, which is > also odd, given the amount of necrosis. > > We cannot help but suspect some underlying malignancy or > immunodeficiency, but there is no evidence of previous health problems. > Does anyone have any ideas re the possibility of underlying disease or > suggestions on how/whether to work this up further? Our therapeutic > options are poor, so any advice would be much appreciated. > Janine Jason, M.D. > Mailstop A25 > Assistant Branch Chief, Clinical Studies > HIV Immunology and Diagnostic Serology Branch > Division of AIDS, STDs, and Tuberculosis Laboratory Research > National Center for Infectious Diseases > Centers for Disease Control and Prevention > Telephone 404-639-3919 > FAX 404-639-2108 > E-mail JMJ1@CDC.gov >
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