Methods (Differential diagnosis, investigation and treatment)
Laboratory tests revealed a five-fold increase in liver transaminases, and a decrease in serum albumin, creatinine, and uric acid levels. Furthermore, discrete increase in D-dimers and fibrinogen and very low levels of 25-OH-vitamin D (15 nmol/l) were observed. Elevation of procalcitonin (three times above normal), C-reactive protein and serum IgE level (> 2500 IU/ml) were noted. The ALEX combined allergy test (295 allergens) revealed evidence of sensitization to birch, alder, hazelnut, beech, strawberry, dog, and cat. The child was not found to have allergic symptoms during the pollen season or allergic reactions to foods or medications. The child has no atopic predisposition, in that there is no family history of asthma, eczema, and hay fever. Citrobacter spp was isolated from nasal and wound swabs examined as an outpatient. Staphylococcus aureus was isolated from throat swabs and hemoculture during hospitalization. Consultation with a pediatric gastroenterologist revealed that the increase in serum transaminases was most likely during the course of infection. Echocardiography showed mild subaortic stenosis, not advanced in its dynamics, with mild hypertrophy of the left ventricle and upper diastolic size of the same. Mild aortic regurgitation, mitral valve prolapse with mild mitral regurgitation; preserved ventricular function. The child has no cognitive impairment or developmental delay.
Treatment with an intravenous antibiotic for 7 days, an oral antihistamine, and emollients was given. It was continued at home with an oral antibiotic and antifungal, a probiotic, and oral vitamin D administration. Because of the subjective discomfort the child experienced with topical application of methylprednisolone aceponate milk, therapy with a cooling cream containing clobetasol propionate cream once daily and an emollient once daily was recommended. Administration of IVIG was suggested as part of the systemic therapy.
In a period without underlying infection, immunologic status was examined, which showed a total T lymphocyte count in the reference range with an increase in the cytotoxic suppressor subpopulation. While B lymphocytes and NK cells were within reference ranges, there was increased percentage of CD57+CD8+ cells. Serum immunoglobulins were normal with the exception of greatly increased IgE levels. The accumulation of CD8+CD57+ T cells was attributed to repeated antigen stimulation during chronic infection, these cells being the most effective ones to fight chronic viral infections due to their high expression of interferon-γ, granzyme B, and perforin, as well as their marked cytolytic activity.8