Neonatal Hepatitis with Toxoplasmosis
A 2-month-old girl born of nonconsanguineous marriage, 2nd of twins, was referred for incidentally detected jaundice. The first twin had neonatal cholestasis with increased galactose and lactose on urine organic acids and had died subsequently. Both babies were small in size at birth as per the mother (exact birth weight is not known). The mother had no fever or rash during pregnancy and there was no exposure to animals. On examination, the child had hepatosplenomegaly with jaundice, while the other systems were normal. Investigations showed hemoglobin of 10.1 gm%, WBC count of 16,800/cumm and platelets were adequate on smear. Bilirubin was 5.1 mg/dL (normal <1.2 mg/dL), with direct bilirubin of 2.5 mg/dL, SGOT=144 IU/L (normal=5-40 IU/L), SGPT=88 IU/L (normal=5-25 IU/L), alkaline phosphatase of 3050 IU/L (normal <650 IU/L), GGTP of 27 IU/L (normal), total proteins of 7.4 gm/dL and albumin of 3.5 gm/dL. Prothrombin time and partial thromboplastin time were normal. Urine reducing substance was negative and ultrasound abdomen showed hepatosplenomegaly and presence of gall bladder. Hepatobiliary iminodiacetic acid scan (HIDA) scan was normal. Toxoplasmosis, other (syphilis), rubella, cytomegalovirus and herpes (TORCH) titres showed positive Toxoplasma IgG (40 IU/mL, negative <10 IU/mL), cytomegalovirus IgG (40 IU/mL, negative <10 IU/mL) and rubella IgG (75 IU/L, negative <10 IU/mL). On repeating the TORCH titres after 3 weeks, Toxoplasma IgG was 60 IU/mL and Toxoplasma IgM was also positive. Parents were advised regarding testing for galactosemia and PCR for Toxoplasma and CMV, but they could not afford the same. (Testing for galactosemia costs Rs 2250, PCR for Toxoplasma is not available in India and CMV PCR test costs Rs 4000.) Ultrasound of the skull showed mild prominence of both lateral ventricles. No other neuroimaging tests were done due to nonaffordability. Cerebrospinal fluid examination was not done and neurological examination was normal. The child was started on Sulphadoxine (20 mg/kg/day) and Pyrimethamine (1 mg/kg/day), and this was given for 1 year. The child had normal achievement of milestones during the year and jaundice resolved by 5 months of age. At the end of 1 year, her weight was 6.5 kg, she had mild hepatomegaly on ultrasound and examination, head circumference was 42.2 cm, length was 70 cm and hemogram and liver function tests as well as ultrasound of skull were normal. Her hearing and ophthalmology examination was also normal.