OVERWHELMEDA CASE OF PANCYTOPENIA SECONDARY TO SEPTICEMIA

SUBMITTED BY:RALPH LLEWEL D. SABANGVISAYAS COMMUNITY MEDICAL CENTERPOST-GRADUATE INTERN

2014ABSTRACTAlterations in peripheral blood counts resulting in aplastic anemia are commonly encountered in pediatric practice. Although bacterial septicemia is a serious clinical problem that can result to pancytopenia, there is relatively little discussion on this abnormality. This is a case of a 1 year old female child who presented with fever and cystic lesions in the face which eventually dried and formed crusts. Complete blood count and peripheral blood smear were consistent with moderate pancytopenia with associated hemodiluted and hypocellular bone marrow. Blood and wound cultures revealed Staphylococcus aureus. Patient received broad spectrum antibiotics with incision and drainage done on lesions which progressed to abscess formation. Detailed clinical history and meticulous physical examination along with baseline hematological investigations, provides invaluable information in the complete workup of pancytopenic patients. Bacterial septicemia with associated pancytopenia is fatal but treatable if managed expeditiously.

INTRODUCTIONPancytopenia is reduction in all three major formed elements of blood to levels below their lower normal limit leading to simultaneous presence of anemia, leukopenia, and thrombocytopenia.1 It is not a disease entity by itself, but rather a triad of findings.Alterations in peripheral blood counts resulting in pancytopenia are commonly encountered in pediatric practice. It is a striking feature of many serious and life threatening illnesses and may be caused by several disorders ranging from simple drug-induced bone marrow hypoplasia and megaloblastic anemia to fatal aplastic anemia, septicemia and leukemias. Etiologies are relatively different in the developing countries from the developed ones. Iron deficiency anemias and infections such as enteric fever, malaria, and bacterial sepsis are more common causes of pancytopenia in the developing countries like the Philippines.2 Pancytopenia secondary to drug-induced hypoplasia, megaloblastosis, and leukemias have been extensively mentioned in journals. Various infections as cause of pancytopenia have been variedly documented. Fulminant bacterial sepsis as cause of pancytopenia is scarcely reported in literature, thus the aim of this paper is to report a child who developed bacterial septicemia (S. aureus) that was complicated by pancytopenia.

OBJECTIVESThe specific objectives of this paper are as follows:1. To present a case of a 1 year old female patient with complaints of fever with associated skin lesion and pancytopenia.2. To discuss the pathophysiology of pancytopenia secondary to sepsis.3. To present a clinical approach in diagnosing patients with pancytopenia.4. To discuss treatment approach of patients with pancytopenia secondary to sepsis.

PATIENT PROFILEY., M., 1 year old female, child, Filipino, Roman catholic from Kalunasan Cebu City admitted for the first time at VCMC for fever and skin lesions.Patient was born from then 30 year old G3P2 mother who had unremarkable prenatal period delivered full term via normal spontaneous vaginal delivery in a local birth clinic assisted by a midwife. No maternal complications were noted during labor and delivery. Birth weight was 7.8 lbs with no immediate postnatal complications noted.Patient was started on breastfeeding on demand until 9months of age and then was shifted to formula milk (Bonamil) since then. Complimentary feeding was started at 6months of age. Immunizations given are as follows: BCG1, DPT3, OPV3, HepB3, HiB3, AMV1, MMR1. Patients developmental assessment is at par with age. She is currently living with her parents with mother as her primary caregiver. Patient had no known medical problems nor previous hospitalizations. Patient had an upper respiratory tract infection at 9months old were she received Amoxicillin (unrecalled dose) which offered relief. Since then, no other history of antibiotic use as claimed.There were no known heredofamilial diseases as claimed. Family has no risk factors for exposure to hazardous chemicals like lead, mercury or copper.HISTORY OF PRESENT ILLNESSFour days PTA, patient had onset of one black-brown round cystic lesion with scaly erythematous borders at the left nostril area which eventually spread to the lips the following day. The lesions were not pruritic and non-tender. Patient had no other associated symptoms like fever, bowel or bladder habit changes. Patient was still feeding well.One day PTA, lesions persisted and were now also seen at the left lower eyelid with similar characteristics. Patient then developed fever of undocumented temperature associated with decrease in appetite and irritability. Consult was done with a family physician were patient was prescribed Cloxacillin 250mg/5ml (AD 50mkD).Due to persistence of symptoms, patient was subsequently admitted.PHYSICAL EXAMINATIONGeneral Survey: awake, alert, irritable, afebrile, not in respiratory distressTemp: 36.1oCBP: 80/60mmHgHR: 156 bpmRR: 45 cpm Weight: 10kgSKIN: warm, pale, no jaundice, good turgorHEENT: normocephalic, closed anterior fontanel, pale palpebral conjunctivae, black-brown round cystic lesions with scaly erythematous borders at left nostril, left cheek, left upper lip, left lower eyelid, non-tender, (-)nikolsky sign (Appendix A)No naso-auricular discharges noted, no oropharyngeal lesions, no lymphadenopathiesC/L: equal chest expansion, clear breath sounds, no wheezing, no rales CVS: adynamic, distinct heart sounds, regular rate and rhythmABD: globular, soft, normoactive bowel sounds, palpable liver edge 4cm below right subcostal margin, spleen was palpableEXT: warm, strong pulses, CRT