An eleven-month-old infant is brought to the emergency center after a 3-day history of fever, vomiting, diarrhea and anorexia. Physical examination reveals: patient is apathetic, 10% body weight lost, skin turgor is decrised, skin pinch goes back very slowly (recoil>2 seconds), mucous membranes are parched, eyes are deeply sunken, hepatosplenomegaly, liquid greenish stools (like “swampy slime”) containing mucus.
Scatological test: undigested cellulose (+), undigested muscle fiber (+), mucus (+++), leucocytes 60-80 in the visual field, erythrocytes 30 in the visual field, intestinal epithelium 4-5 in the visual field.
Questions:
What is your diagnosis?
Estimate the data of the laboratory examination. What type of diarrhea is it?
This case involves an eleven-month-old infant presenting with a 3-day history of fever, vomiting, diarrhea, and anorexia. The infant exhibits several clinical symptoms and laboratory findings that provide crucial insights into the diagnosis.
Based on the clinical presentation and laboratory findings, the diagnosis for this infant is acute watery diarrhea with severe dehydration. Several key indicators support this diagnosis:
Clinical Symptoms: The infant’s clinical symptoms include fever, vomiting, diarrhea, apathy, and significant weight loss (10%). The physical examination reveals a delayed skin pinch recoil, sunken eyes, and hepatosplenomegaly. These clinical features are characteristic of severe dehydration, a common complication of acute diarrhea.
Laboratory Findings: The scatological test provides important information about the characteristics of the diarrhea. The presence of undigested cellulose and muscle fibers, as well as mucus (+++), leukocytes (60-80 in the visual field), erythrocytes (30 in the visual field), and intestinal epithelium (4-5 in the visual field) in the stool indicates inflammatory diarrhea, often caused by infections. The presence of mucus and leukocytes suggests an inflammatory response in the intestines, further supporting the diagnosis.
The type of diarrhea in this case is classified as inflammatory diarrhea. Inflammatory diarrhea is characterized by the presence of inflammatory cells (leukocytes) and mucus in the stool, indicating an underlying infection or inflammation in the gastrointestinal tract. The presence of undigested cellulose and muscle fibers may suggest malabsorption and an impaired digestive process.
This case highlights the diagnosis of an eleven-month-old infant with acute watery diarrhea complicated by severe dehydration. The clinical symptoms and laboratory findings, including the scatological test results, support the diagnosis of inflammatory diarrhea. Prompt management and rehydration therapy are essential to address the dehydration and underlying cause of diarrhea in the infant.
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