C1348212

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Thanks for the detailed case — let’s work through a differential diagnosis (DDx) for this 7-year-old boy presenting with persistent fever (T spikes to 39°C), mildly raised inflammatory markers, transaminitis, mesenteric adenitis, and recent migration from JINDE 

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🔎 Key Clinical Features

• Fever: Persistent with spikes; latest noted 38.2°C at 1:45 AM on 20/4; now 39°C

• Recent migrant from India (endemic area for several infections)

• Mildly elevated CRP (max 17), ALT persistently high (47-60)

• AST higher than ALT (AST 79), suggests systemic process

• Mild hyponatraemia (Na 135)

• Mesenteric adenitis on US

• CXR clear, FBC and U&E largely unremarkable

• On IV ceftriaxone, still spiking temps

• Broad infectious screen ongoing

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🧠 Top Differential Diagnoses

1. Enteric fever (Typhoid/Paratyphoid)

• Common in South Asia

• May cause mesenteric adenitis, hepatomegaly, transaminitis

• FBC often normal or low WCC

• Persistent fever despite antibiotics

• Negative CXR

• Stool MC&S, blood cultures are crucial

• Check Widal test (though low specificity)

2. Tuberculosis (abdominal/mesenteric)

• Abdominal TB → mesenteric lymphadenitis, transaminitis

• Systemic symptoms (fever, weight loss, etc.)

• Latent period post-exposure possible

• Consider Quantiferon/TB gold, AFB culture, early paeds ID consult

3. Viral illness with hepatic involvement

• EBV, CMV, Dengue, Adenovirus all plausible

• Especially with AST > ALT

• Can present with mesenteric nodes, mild hepatitis

• Can cause prolonged low-grade fever

4. Brucellosis

• Zoonotic; endemic in parts of India

• Non-specific: fever, hepatosplenomegaly, arthralgia

• Transaminitis common

• Culture/serology needed

5. Inflammatory / autoimmune

• Kawasaki Disease (incomplete/atypical): prolonged fever, adenitis, raised LFTs

  • Consider ESR, echo if ongoing spikes

• HLH (rare but critical): prolonged fever, hepatosplenomegaly, high ferritin (though NAD in your labs)

6. Malaria

• Especially if not on prophylaxis or incomplete screen

• Can have transaminitis

• Repeat screen + antigen test is wise

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🧪 Investigations Already Planned – Appropriate

• Stool MC&S

• Extended NPA

• Blood culture, throat swab, ASOT

• Dengue serology, EBV, CMV

• Brucella serology

• Malaria film + antigen

• ECG for PR interval (rheumatic fever query?)

• ESR + repeat labs

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📌 Additional Suggestions

• TB screen (Quantiferon, CXR re-review, AFB if concern)

• Echocardiogram if ongoing fever & KD concern

• Consider salmonella/paratyphi PCR or serology

• Monitor LFTs and ferritin for trends

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Would you like a one-slide infographic format for this DDx to share with colleagues?