A 9-year-old girl from a rural area of the department Ledesma, province of Jujuy, presented to the consultation with a clinical picture of four days of evolution characterized by dry abdominal fever and headaches.
On physical examination, it was observed a pharynx hypernasal flutter (5475 intercostal fever), bilateral diffuse rhinosinusitis, auscultation diffuse rales, capillary refill, tachycardia (140 per minute), tachypnea 80% respiration.
The laboratory revealed: hemoglobin 14 g/dl, white blood cells 18600/mm3 (61% neutrophils, 4% immunoblasts), platelets 54,000/mm3, C-reactive protein (Pc-R) +-6 ++ white blood cells,
Chest X-ray showed bilateral interstitial infiltrates with normal cardiac silhouette.
Empirical treatment with cefotaxime, gentamicin and clarithromycin was indicated.
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After admission, the patient had a left hemibody tonic-clonic seizure and was transferred to intensive care.
Physical examination revealed a Glasgow score of 11/15, poor peripheral perfusion, hypotension (70/40 mmHg).
The laboratory showed: natraemia 134 mEq/ l, caliemia 5.1 mEq/l, chloremia 99 mEq/l, bicarbonatemia 12 mEq/l, blood glucose 82 mg/dl, ionic calcaemia dl 110 albumin l
Cerebrospinal fluid showed lymphocytic pleocytosis with normal glucose and protein levels.
Due to progressive deterioration of consciousness mechanical ventilation was initiated.
Two expansions were made with physiological solution at 20 cm3/kg each. Intravenous furosemide at 0.2 mg/kg/h, dopamine at 5 μg/kg/min and generalized dobutamine at 15 μg/kg/h were indicated.
Progressively, petechiae appeared in trunk and lower limbs ecchymotic and necrotic areas with hemorrhagic blisters.
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The laboratory showed: fibrinogen 165 mg/dl (vn: 200-400 mg/dl), creatinine clearance 1,500 mg/ml (vn: Doppler 1,7 ng/ml), KPTT 55 seconds (vn: 17 seconds).
Goteo was started with epinephrine at 0.1 μg/kg/min replacing dobutamine and two units of sedimented red blood cells and one of platelets were administered.
After a few hours, the child had a cardiac arrest that reverted in less than 5 minutes with cardiac massage, the laboratory showed a caliemia of 7.5 mEq/l, peritoneal dialysis infusion was started 10%.
Renal ultrasound showed hyperechogenicity and bilateral nephromegaly.
Percutaneous renal biopsy showed tubular dilation with abundant protein and helium casts; interstitial and vascular areas showed no remarkable alterations; immunofluorescence was negative.
A biopsy of a petechial lesion showed epidermal necrosis without signs of vasculitis.
The patient developed progressive coma, refractory hypotension, cardiomegaly and anuria.
Standard computerized tomography revealed bilateral frontooccipital hypodense areas involving predominantly white matter and partially cortex.
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The increase in maximum inotropic doses was ineffective and death occurred two weeks after admission.
Other studies yielded negative results: antinuclear antibodies (ANF), anticardiolipins, peritoneal voiding urine culture for glomerular blood and cerebrospinal fluid, anticytoplasmic (C-P-ankle), lupus anticoagulant, anti-DNA,
No serology for candidiasis was requested.
Ten days after admission, a positive ELISA test for IgM and negative IgG for hantavirus were received from the National Institute of Infectious Diseases "Dr. Carlos G. Malbrán" in Buenos Aires.
The patient's parents were asked to authorize the autopsy study, but it was rejected.
