Fever for 45 days indicates possibilities of chronic infections including HIV and TB, Connective Tissue Disorders or Malignancies. The presence of cough, respiratory distress and crepts indicate involvement of the lung parenchyma like pneumonia or an infiltrative disorder. Skin rash described as petechiae and purpura indicates a possible thrombocytopenia secondary to a viral or drug or bone marrow hypoplasia or peripheral destruction of the platelets or even vasculitis. The scalp lesions described as seborrheic dermatitis at the age of 1 year makes one immediately suspicious of Histiocytosis or immunodeficiency disorders. The presence of icterus, non-pale stools and acholuric urine indicates a hemolytic process causing jaundice. Lymphadenopathy, hepatosplenomegaly all indicate reticuloendothelial system hyperplasia secondary to a septicemia - bacterial or viral, Histiocytosis or lymphoproliferative malignancy or a Virus associated Hemophagocytosis like syndrome. Of course disseminated TB and HIV infection still lingers at the back of my mind. Anemia, thrombocytopenia and a shift to the left of WBCs confirm the involvement of the hematological system. Could it be low counts because of hemolysis or bone marrow problems? At this stage of skin, hematological, hepatitis, reticuloendothelial and pulmonary involvement, I am thinking of Childhood Disseminated Histiocytosis, HIV or a Lymphoreticular malignancy. TB is unlikely in view of the extent of the hematological involvement in 45 days and Connective Tissue Disorders seem less likely in view of the nature of skin and scalp lesions and will remain a disease of exclusion. What I need to know is an HIV ELISA (as a screening test), Fundi (chorioretinitis), reticulocyte count (hemolysis, bone marrow function), peripheral smear (nature of anemia, atypical cells), skull X-ray (punched out osteolytic lesions) and a bone marrow aspiration and biopsy (Histiocytosis, malignancy). A Chest X-ray is essential to look for a bronchopneumonia or infiltration.
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