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