Chief complaint: vomit in the mouth and subsequent unresponsiveness
Past medical history: no significant family or medical history
HPI: 2-year-old male presenting unresponsive with vomitus in his mouth. Three days before the presentation, he had cough, diarrhea, rhinorrhea, fatigue, vomiting without fever. On the first day of hospitalization, the patient’s condition worsened.
ROS:
- General: lethargic
- Vision: pupils of equal size, constricted with light
- Pulmonary: cough
- Neurological: bilateral clonus
- Gastrointestinal: vomiting
PE:
- Vital signs: normal for the patient’s age
- Rapid viral testing: positive for influenza A virus
- Laboratory tests: hyperammonemia, hyperbilirubinemia, azotemia, elevated C-reactive protein, hypoglycemia, increased creatine phosphokinase, decreased Apo B levels, normal gamma-glutamyl transferase.
Primary Diagnosis: Elevated ammonia blood levels and decreased Apo B levels can indicate Reye syndrome (Pagana et al., 2021). Vomiting, lethargy, and altered mental state are also indicative of this condition (Chapman & Arnold, 2022).
Differential Diagnosis: Differential diagnoses for Reye syndrome include drug toxicity, encephalitis, hypoglycemia, meningitis, intracranial bleeding, heavy metal toxicities, and mushroom toxicity (Chapman & Arnold, 2022).
Plan of Care:
- It is recommended to perform testing for the diseases of inflammatory, autoimmune, toxicologic, hematologic, metabolic, and oncologic etiology.
- Liver biopsy should be considered to support the diagnosis of Reye syndrome.
- As for supportive care, the patient can be given lactulose and rifaximin to decrease the levels of ammonia in the serum. Other suggested measures are sodium polystyrene sulfate or phenylacetate-sodium benzoate; if level of ammonia becomes greater than 500mcg/dl, the patient may require hemodialysis (Chapman & Arnold, 2022).
- In addition, the patient’s head should be elevated to 30 degrees, and fever should constantly be controlled to avoid raised cerebral metabolism (Chapman & Arnold, 2022).
References
Chapman, J., & Arnold, J. K. (2022). Reye syndrome. National Library of Medicine. Web.
Pagana, K. D., Pagana, T. J., & Pagana, T. N. (2021). Mosby’s manual of diagnostic and laboratory tests (7th ed.). Elsevier.