Hepatosplenomegaly with fever in a child

Yesterday I got into a discussion with one of my friends about a case. He had examined a 7 year old male child who presented with fever for the last 7 days. The fever was of mild grade, continuous in type. The fever was not associated with any chills, rigor or sweating. There were no complaints of headache, vomiting, visual disturbance or convulsions. There was no history suggestive of any upper respiratory tract infection , urinary tract infection or any rash. The child complained of dark colored stool but on further inquiry it was not judged to be melaena. There was a history of mild abdominal pain, non colicky and possibly dull aching in nature (one can only get so much out of a child).

On examination the vitals were normal. There was mild, soft tender hepatomegaly and mild splenomegaly. There were no visible veins over abdomen. There was no lymphadenopathy. There was no jaundice. Rest of the examination findings were within normal limits.

Hepatomegaly - from NIH

Based on the history and examination findings the differential diagnosis consisted of

·        Acute viral hepatitis

·        Acute leukemia

·        Malaria

·        Acute hemolysis

·        Enteric fever

·        Lymphoma

·        Disseminated tuberculosis

My friend was of the opinion that the child had malaria. I disagreed.  My argument was that for a child to have malaria with hepatosplenomegaly, the duration needs to be pretty long. More over there is a correlation between jaundice and hepatomegaly in patients of malaria (1). Here the child did not have jaundice. I thought that enteric fever or acute leukaemia fits better. Mind you, neither of us had any test results at that point.

The test results came back positive for malaria and the child was started on chloroquine therapy. However, I still think based on the clinical picture, it would have been inappropriate to come to a provisional diagnosis of malaria, as there was no jaundice, the rapid course of the disease and mild grade of the fever, though certainly it was in the differential.

Interestingly, jaundice and hepatomegaly is associated with increased risk of acute renal failure in children suffering from malaria (1) but not an increase in the risk of cerebral malaria. However, in this case there was clinical finding of any abnormal renal function and the test results were within normal limits. There were also no features of CNS involvement (no headache, vomiting, visual disturbance, irritability or sleepiness), CSF examination was within normal limits.

1.  Nacher M, Treeprasertsuk S, Singhasivanon P, Silachamroon U, Vannaphan S, Gay F, Looareesuwan S, & Wilairatana P (2001). Association of hepatomegaly and jaundice with acute renal failure but not with cerebral malaria in severe falciparum malaria in Thailand. The American journal of tropical medicine and hygiene, 65 (6), 828-33 PMID: 11791981