Disseminated intravascular coagulation in gastroenteritis.

Four children, 3 males and 1 female, varying in ages from 3 to 12 years, showing the shock syndrome in gastroenteritis accompanied by in­ travascular coagulation ( DIC) are reported. A ll patients developed pro­ gressive thrombocytopema, prolonged prothrombin time as well ¡as par­ tial thromboplastin time; and a decreased content of fibrinogen in the Mood several days after hospitalization was observed. The diagnosis and treatment of DIC are also discussed. Received 30th. Nov. 1974. 240 S. SETIADARMA AND T. HIMAWAN Introduction Report of cases Any severely ill child may develop the complication of disseminated in­ travascular coagulation (DIC). DIC processes may occur mostly in chil­ dren with shock, haemorrhagic, sep­ tic as well as anaphylactic and burns (Hardaway, 1966). In certain condi­ tions of bacterial or viral infections (McKay and Margaretten, 1967), in premature newborns suffering from respiratory distress syndrome — RDS — (Swyer, 1971; Weissbach et al., 1973), and in many other patho­ logical circumstances which have been extensively reviewed by Abildgaard (1969), Karpatkin (1971), McKay (1965),, and Rodriquez-Erdmann (1965), this pathological in­ travascular clotting mechanism was noted; in typhoid fever DIC is not uncommon (Setiadharma and Kho, 1973). Four patients, 3 males and 1 fe ­ male, varying in ages from 3 to 12 years, showing the shock syndrome in gastroenteritis aeeompained by DIC are reported. A ll patients had some degree of circulatory failure with developing thrombocytopenia, prolonged prothrombin time as well as partial thromboplastin time, and a decreased content of fibrinogen in the blood several days after hospi­ talization. These are valuable mea­ sure for detecting DIC. Four children, comprising 3 males and 1 female, whose ages ranged from 3 to 12 years, were studied. They were transferred to the Depar­ tment of Child Health of Sumber Waras Hospital, Jakarta, due to fe­ ver, diarrhoea, vomiting and abdomi­ nal pain of several days duration. A ll patients were severely ill on ad­ mission and had some degree of cir­ culatory failure (cold extremities, excessive transpirations, reduced systolic and diastolic pressures) and dehydration. No neurological abnor­ malities were noted on admission. Torniquet test was applied to all pa­ tients. The following coagulation studies were performed: platelet count, prothrombin time according to the one-stage method o f Lynch (1989), fibrinogen concent,ration of the iblood according to the method of Stirland (1956), the clotting time according to the method o f Lee and White (1913), and the bleeding time done by the method of Duke (Owen, 1969). A ll patients were treated with antibiotics parenterally followed by oral administration: Pat. 1 with ampiciilin 50 mg./kg. body weight daily; chloramphenicol 50 mg./kg. body weight daily given to Pats. 2 and 4; Pat. 3 with tetracycline 40 mg./kg. body weight daily. The treatment of shock was intensively carried out by infusion of Ringer’s lactate solution, D.I.C. IN GASTROENTERITIS plasma "volume expanders, and blood transfusion (to Pats. 1 and 3), besi­ des the commonly used saline, glu­ cose, and electrolytes solutions. Cor­ ticosteroids were administered to 3 patients: Celestone was given intra­ venously in a dosage of 0.25 mg./kg. body weight daily; heparin 1 mg./ kg. ¡body weight intravenously was given to Pats. 1 and 2 every 4 hours for 2 and 8 days, respectively. Tables 1 and 2 showed the clinical features, therapy and laboratory examinations respectively of the pa­ tients on admission and during hos­ pitalization. A ll patients showed a significant drop of platelets several days after hospitalization (Table 3). The partial thromboplastin time of 3 patients showed a prolongation several days after admission; in Pat. 3 it was already prolonged on the first day of hospitalization (56 se­ conds). The fibrinogen content of the blood was determined based upon the probability of intravascu­ lar clotting (Table 4). The clotting time varied from 7 to more than 15 minutes in 3 patients, while in Pat. 2 it was not measured. The bleeding time was abnormal in Pats. 1 and 4 (more than 15 minutes), in Pat. 3 it was 5 minutes on admission, while Pat. 2 showed a normal value (2’30” ) on the 4th day of hospitalization. Haematemesis and melaena were in Pats. 1 and 3 ; haematomas on the sites of injections were noted in Pat. 1. Torniquet tests were negative in all patients except one (Pat. 1). Fecal culture revealed Vibrio Eltor positi­ ve in Pat. 3, and Salmonella typhosa was confirmed positive in the blood of Pat. 4. Hospital course: * Patient 1 died on the 6th day of hospitalization after one d!ay of heparinization; probable cause of death was profuse bleeding as indicated by the fall of the hemo­ globin content of 11 gm. % on admis­ sion to 6.5 gm% on the 5th day of hospitalization, although blood trans­ fusion had been given. * In Pat. 2 (female, 3 years old) the fibrinogen content was still low (84 mg. %) after heparin administration, although the blood platelet count and prothrombin time were increasing, respectively 336,000 per cu.mm. and 64%. This patients died on the 14th day of hospitalization. * Patient 3 (male, 12 years old) with positive Eltor in the fecal culture showed a significant drop of platelet count (19,020 per cu.mm.) on the 4th day of hospitalization. Heparin was not yet administered as the pa­ tient died due to irreversible circular tory failure on the day when DIC was detected. * Patient 4 (male, 8 years old), con­ firmed typhoid fever by blood cul­ ture, did show thrombocytopenia of 78,000 cu.mm. on admission and a progressive reduction of 36,000 blood platelets/cu.mm. on the 2nd day of hospitalization, Hypofibrinogenaemia 241 242 S. SETIADARMA AND T. HIMAWAN of 44 m g.% on the 2nd. day after ad­ mission was noted. Both bleeding and clotting time were prolonged (more than 15 minutes). The patient did not show any signs of bleeding on the skin. The Rumpel-Leede test was negative. Celestone was added to the intravenous fluid and electro­ lytes administration. Heparinization was not performed in this case. The patient recovered after 16 days of hospitalization.