Download Case No2 Medical history, objective data and results of laboratory

Case No2
Medical history, objective data and results of laboratory analyses determine the
following differential-diagnostic possibilities:
I.
II.
III.
IV.
Adverse reaction to the vaccine;
Anaphylactic reaction;
Infection; Systemic inflammatory response syndrome (SIRS);
The coincidence of allergic reaction and infection.
I.
Since the adverse reactions to the vaccine are considered those that occur
within 72 hours after vaccination and considering the absence of symptoms and signs of
abnormalities in the first four days after the scheduled vaccination, this possibility should be
excluded.
II.
Anaphylactic reaction is possible because of the fact that the child developed
symptoms after eating strawberries (In one hour the child started vomiting of undigested food,
fever up to 37.5–38 °С, polymorphous eruption on the face, palpebral swelling and single
episode of loose stools), the positive family history(Patient’s mother has a grass pollen
allergy) and personal anamnesis (Two months ago the patient had an episode of slight cheek
hyperemia after taking garden carrent berries (not treated)). Patients with strawberry allergy
observe the signs within few minutes to two hours after eating the fruit. The most common
strawberry allergy symptoms manifest in the throat or mouth. These include tightness of the
throat, itching, swelling, burning or prickling sensations in the lips, gums, tongue or inside the
cheeks and other parts of the oral cavity. In rare cases, patients with strawberry allergy may
also observe the following skin dermatitis or eczema, pruritus - itchy and inflamed skin,
nausea, upset stomach, vomiting, diarrhea, abdominal cramps, swelling and/or pain and
anaphylaxis.
The current guidelines for the definition of anaphylaxis include fulfilling at least one
of the three existing criteria:
1. Acute onset of an illness (minutes to several hours) with involvement of
skin/mucosal tissue (e.g. hives, generalised itch/flush, swollen lips/tongue/uvula) and airway
compromise (e.g dyspnea, wheezing/bronchospasm, stridor, reduced peak expiratory flow
(PEF)) or reduced BP or associated symptoms (e.g. hypotonia, syncope).
Involvement of the skin and mucosal tissue is present, while the auscultatory findings
in the lungs are incomplete (Lung auscultation showed harsh breathing, sonorous sibilant
rales, breath rate 42 breaths per minute). The missing arterial blood pressure values (the
range of values for age 90-105 / 55-70 mmHg) interfere with the assessment of the
hypotension, which is necessary to meet the first criterion for the definition of anaphylaxis.
Therefore, the fulfillment of this criterion can not be claimed with certainty.
2. Two or more of the following after exposure to known allergen for that patient
(minutes to several hours)
a. History of severe allergic reaction of skin/mucosal tissue (e.g. hives,
generalized itch/flush, swollen lips/tongue/uvula)
b. Arway compromisation (e.g dyspnea, wheezy/bronchospasm, stridor,
reduced peak expiratory flow
c. Reduced BP or associated symptoms (e.g. hypotonia, syncope)
d. In suspected food allergy, gastrointestinal symptoms (e.g. crampy abdominal
vomiting)
Personal history of an episode of slight cheek hyperemia after eating berries could
meet 2.a. criterion, but symptomatology is not typical (Patient had an episode of slight cheek
hyperemia after taking garden carrent berries). Gastrointestinal symptoms are present (In one
hour the child started vomiting of undigested food... and single episode of loose stools).
3. Hypotension after exposure (minutes to hours) to known allergene for that
patient (infants and children: low systolic BP ( age-specific) or 30% drop in systolic BP).
Low SBP is defined as less than 70 mmHg + 2 x age for children being from 1
to 10 years old.
III.
Infection; Systemic inflammatory response syndrome (SIRS)

Enlarged tonsils (2+) covered with white exudates, fever, palpable liver
(painful on palpation), as well as the results of laboratory analyses (segmented neutrophils ↓
with 12% stab cells – the left shift, mild lymphocytosis for age, sedimentation rate ↑), support
a possible infectious etiology. Dry tongue suggests poor patient hydration.

Exudative tonsillitis (tonsillar swelling or exudate) followed by fever (up to
38C) (Clinical Scoring System, score 1) indicates a risk of 5 to 10% that the child has a
positive culture for Group A Streptococcus. The size of lymph nodes and information about
absence of cough are missing in objective data, while low fever and early age are not in favor
of group A streptococcal infection. Streptococcal pharyngitis occurs most commonly among
children between 5 and 15 years of age.

The clinical presentation of exudative tonsillitis, early age, reactive enlarged
liver, stentorious breathing and lung auscultation findings suggest a viral infection.
Adenovirus infection typically affects children from infancy to school age, but children of any
age may be affected, including neonates. Fever, rhinorrhea, cough, and sore throat, usually
lasting 3-5 days, are typical symptoms of adenoviral ARD. Causes of sore throat may include
pharyngitis, adenoiditis, or tonsillitis. Lower respiratory tract infections, including
tracheobronchitis, bronchiolitis, and pneumonia, may mimic respiratory syncytial virus
infection or influenza. Notably, conjunctivitis in the presence of bronchitis suggests
adenoviral infection.
There is no information about rhinorrhea and/or conjunctivitis in objective data, what
also could suggest viral infection.

Lung auscultation findings correspond to the hypersecretion that occurs during
infections and allergic reactions. Objective data do not determine localization. Local findings
suggest pneumonia, while the diffuse fit bronchitis.

Such symptomatology of the digestive tract can be present during allergic
reaction, drug reaction, existing viral infection. An enlarged and painful liver can be the result
of transient toxic reaction during viral infection. The normal color of urine excludes biliary
retention syndrome.

Negative Nikolsky's sign excludes autoimmune background of skin changes
(e.g. Pemphigus dermatoses) and drug-induced toxic epidermolysis.

Considering the objective findings of the patient, the existence of systemic
inflammatory response syndrome (SIRS) should be discussed. The patient meets a major
(more than 10% stab cells) and one minor (respiratory rate >34 breaths per minute) criterion.
Therefore, we conclude that the patient meets SIRS criteria (2/4).
IV.
The coincidence of allergic reaction and infection
Considering objective data collected within the intensive care unit (All the body
surface is covered with exudative erythema multiforme accompanied with itching,
scratching), we conclude that the eruptions of the skin are the type of Erythema multiforme,
which is considered to be a type IV hypersensitivity reaction associated with certain
infections, medications, and other various triggers. Viral infections include Adenovirus,
Coxsackievirus, Cytomegalovirus, Echoviruses, Enterovirus, Epstein-Barr virus, Hepatitis
viruses, HSV, Influenza, Measles, Mumps, Paravaccinia, Parvovirus B19, Poliomyelitis,
Varicella-zoster virus. Causative antibiotics include penicillin, ampicillin, tetracyclines,
amoxicillin, cefotaxime, cefaclor, cephalexin, ciprofloxacin, erythromycin, minocycline,
sulfonamides, trimethoprim-sulfamethoxazole, vancomycin. The concomitant use of
antibiotics during viral infection increases the occurrence of skin eruptions. The skin
eruptions are mostly diffuse, symmetric maculopapular exanthems on the whole body. Drug
induced classic maculopapular drug eruptions are considered to be delayed type
hypersensitivity reactions. It is also quite common for patients with Infectious mononucleosis
to develop a maculopapular rash and this is especially the case if the patient is inadvertently
treated with a beta-lactam antibiotic such as Ampicillin or Amoxicillin. Although IM is most
commonly caused by EBV, EBV infection does not always cause IM, it can be asymptomatic
or just a mild febrile illness especially in early childhood. The severity of EBV infection
appears to increase the later it is acquired, adults are more likely to get IM than children,
probably as a result of a more intense immune response.
Missing data
Based on the data collected during clinical examination, we can point at inadequate
initial clinical assessment of the patient. The lack of arterial blood pressure and capillary refill
time values interferes with the assessment of hypovolemia and/or shock. These parameters
could enable more complete assessment of severity of patient's state.
Respiratory rate (42 breaths per minute) is tachypnea for age (N 20-30), but there is no
information about oxygen saturation (pulse oximetry), which is very important.
Analysis of acid-base status would enable an orientation about homeostasis of the
internal environment and the conclusion about presence of respiratory acidosis/alkalosis.
CONCLUSION
After careful analysis of clinical presentation, we can conclude that the child is most
likely to have strawberry allergy, in this case manifesting within already existing respiratory
infection, most probably of viral etiology. Amoxicillin is a trigger factor of deterioration and
generalization of skin eruptions.
Described clinical presentation is most probably a result of combined, synergistic
effect of allergic reaction to strawberries (mild clinical picture of anaphylaxis), infection and
amoxicillin-induced hypersensitivity.
Optimal range of investigations:
1.
All vital parameters (respiratory and heart rate, TC, arterial blood
pressure, capillary refill time). Continuous non-invasive monitoring of vital functions is
necessary.
2.
Complete blood count with platelets (better assessment of possible
coagulation disorders and septic condition). Normal platelet count is expected, while
thrombocytopenia could point to severe disorders.
3.
More complete parameters of inflammation, C-reactive protein (CRP) and
procalcitonin levels, allow better insight into inflammatory condition. In accordance with the
clinical presentation, increased levels of these markers are expected.
4.
Biochemical analyses that include assessment of the liver (AST, ALT, GGT,
total protein, albumin, bilirubin) and the kidney (urea, creatinine, electrolytes) function.
Lysis of hepatocytes causes an increase in transaminases, while the low total protein and
albumin levels suggest inadequate synthetic function.
5.
Rapid antigen detection test (when the streptococcal infection is suspected)
and antistreptolysin O titer. Expected to be negative. The specificity of rapid antigendetection tests is 95% or greater and thus a positive result can be considered to be definitive
and to obviate the need for culture. If the rapid antigen-detect test is negative, most guidelines
recommend obtaining a throat culture.
6.
Throat culture, Blood culture, Stool culture. The isolation of the pathogen is
of importance in deciding on antibiotic therapy and emergency treatment.
7.
Virological testing (ELISA or PCR) to determine the causal agents of
infection. Taking into account the clinical presentation and the most common causal agents of
this age, we point out the possible increase in antiviral antibody titer. Polymerase chain
reaction (PCR) is being used with high specificity on various specimens (e.g. respiratory,
tissue, urine, blood).
8.
Ultrasound of liver and spleen, in order to determine more specific size and
structure of these organs.
9.
Total IgE (marker of hereditary atopic constitution) and specific IgE level
(standard screening panel of nutritional and inhalant allergens), considering history of allergic
reaction to currant berries and positive family history (mother's allergy to grass pollen). An
increase in titar of specific IgE would confirm an allergic status and point to sensitization.
Rational treatment measures:

importance
Aggressive monitoring and replacement of fluids and electrolytes are of great

Nutritional support and parenteral nutrition, if needed

Pulmonary support
Supportive respiratory care, including suctioning and postural drainage, as needed.
Usage of analgetics as needed to control pain, which may be severe. Patients with
tracheobronchial involvement may present with hyperventilation and mild hypoxemia.
Careful monitoring and aggressive pulmonary support may lead to early detection and
treatment of diffuse interstitial pneumonitis and thus prevent the development of acute
respiratory distress syndrome (ARDS)

Maintaining of thermoregulation by keeping the environmental temperature at
30-32°C, administering only warm fluids, and using heating lamps or warming blankets

The use of a pressure support surface, an air or gel mattress, or a specialty bed
is recommended to prevent pressure sores. Administration of antacids, proton pump
inhibitors, or histamine 2 blockers for prevention of stress ulceration

Empiric antibiotics administration if clinical evidence of secondary infection
exists

Antihistamines are usually recommended for temporary relief of itching,
swelling, headaches or runny noses. There are, however, specific over-the counter
medications that can soothe down different symptoms. Placing a hot compress over the
affected area of the skin helps greatly in soothing down inflammation and pain

Treatment of Erythema multiforme begins with identification and removal of
the trigger factor, however that is not always possible. EM minor is typically asymptomatic
and therefore needs no treatment, as the lesions will clear up by themselves within 2-4 weeks

Corticosteroid creams are an effective treatment for allergic skin conditions.
Over-the-counter hydrocortisone creams or prescribed corticosteroid lotions may be used to
reduce inflammation and itching. Systemic corticosteroid therapy is controversial in Erythema
multiforme, because these agents do not improve prognosis and may increase risk of
complications

Strawberries are members of the Rosaceae family. Other fruits in this family
include: pears, peaches, cherries, apples, blackberries. These fruits should be eliminated from
the diet
Consultation with the following specialists may be necessary:

if indicated;
Dermatologists: For diagnosis, management and performance of skin biopsies,

Infectious disease specialists: For evaluation of intercurrent infections and
treatment recommendations;

Ophthalmologists: For early consultation in the evaluation and management of
ocular involvement; daily examinations for signs of ocular involvement; if necessary,
disruption of synechiae can be accomplished by administration of wetting or antibiotic
eyedrops.