DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: This (XX)-year-old girl with sickle cell anemia was admitted because of marked direct hyperbilirubinemia and elevated liver enzymes. She had been admitted briefly in late February and then for several days in early March. On one admission, she had relatively modest elevation of liver enzymes but was improving. She was transfused the first week of March because of dropping hemoglobin and hematocrit. She complained of severe headaches and malaise. She was seen by her pediatrician on about the middle of March with signs and symptoms of sinusitis. She was prescribed Omnicef.
A week to 10 days later, Dr. John Doe called us to discuss the patient. The child had severe generalized itching rash consistent with drug rash. It was agreed to stop Omnicef and give her a brief course of Orapred 1 mg/kg/day to alleviate the rash. He re-examined the child the next day to be sure she was not worse. The child’s mother called Dr. John Doe the morning of admission and described the child as much more jaundiced and seeming weak and complaining of abdominal pain. Dr. John Doe instructed her to bring the child for evaluation and probable admission.
MEDICATIONS: Other medications in addition to prednisone were Pepcid 10 mg two times a day, Zyrtec at bedtime, and folic acid 1 mg daily.
PHYSICAL EXAMINATION: GENERAL: On arrival, the child was obviously markedly icteric with sclerae and palate very yellow. VITAL SIGNS: Temperature 99.8 degrees, heart rate 112, respiratory rate 22, blood pressure 122/84, weight 23.8 kilograms, and oxygen saturation 92% on room air. ABDOMEN: In addition to jaundice and protuberant and distended abdomen, which was soft with definite hepatomegaly, her liver edge was felt at least 7 cm below the right costal margin. The rest of the physical examination was not particularly remarkable.
LABORATORY DATA: Quite significant. Total bilirubin was 20.8, direct was greater than 10. Albumin was 4.8, total protein 8.6, alkaline phosphatase 450, SGOT 1022, and SGPT 774. Amylase and lipase were normal. Basic metabolic profile was unremarkable. The urine showed large bilirubin. CBC showed white blood cell count of 12,500, hemoglobin 8.4, hematocrit 24, and platelet count 526,000, 70 segs, 5 bands, 22 lymphs, 3 monos, 26 nucleated red blood cells per 100 white cells and a reticulocyte cell count of 14.2%.
HOSPITAL COURSE: It was noted that she had had an abdominal ultrasound in February that showed no gallstones and no gallbladder abnormality. It seemed very unlikely that this was a biliary obstruction and more likely that it was intrahepatic sickling. Pediatric gastroenterology consult was sought. They suggested getting an immediate abdominal ultrasound and planned for the followup.
By the morning after admission, she felt somewhat better and was no longer complaining of abdominal pain. She had no fever and said she was hungry. Total bilirubin was 4.8, direct 2.4, SGOT 320, SGPT 520, alkaline phosphatase 400. PT 15.6, PTT 29.2, and fibrinogen 272. Hepatomegaly was about 7 cm. No enlarged spleen was felt. She looked a little less jaundiced but was still definitely icteric, and it was noted that with minimal intervention, that was just hydration overnight, bilirubin had improved remarkably. The abdominal ultrasound showed no specific abnormality.
The pediatric gastroenterologist saw her and her ultrasound and felt that this finding of the sudden jaundice with the rash was most consistent with an adverse drug reaction to the Omnicef that she had received. Omnicef can cause cholestatic jaundice. She developed an itching rash on her legs, again in the hospital, and had an episode of sweating. She was given Benadryl for the itching. There was a concern that this could be a flare-up of the drug rash. She was observed to see if the rash was stable or getting worse.
Two days before discharge, there was concern that the rash was worse. She was observed carefully. On the day before discharge, she had a low-grade fever. She was continued on hydration. She was watched off any antipyretics with a plan if she developed fever above 101, to obtain blood cultures and then start clindamycin. Fortunately, she did not spike fever but indeed became afebrile. Total bilirubin went down to 3.3 with a direct of 1.6, SGOT 90, and SGPT 40. It was noted that serum IgG was 1276, IgM 154, and IgA 254. Since she had resolved almost all of her problems by the date of discharge, she was discharged to home.
DISCHARGE DIAGNOSES:
1. Cholestatic jaundice, probably caused by an adverse reaction to Omnicef.
2. Sickle cell anemia.
3. Allergic rash to Omnicef.
The patient had an abdominal ultrasound and red cell transfusion during her admission. As noted before, at the time of admission, her total bilirubin was 20.8 with markedly elevated SGOT and SGPT. During her admission, additional tests were sent. An acute hepatitis panel was negative for any evidence of active hepatitis B, hepatitis A, or hepatitis C. Coagulation studies, as noted, were not particularly remarkable. Bilirubin did resolve.
