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A 1-year-old girl is recovering in the pediatric intensive
care unit. One week earlier, she was admitted after
being found to have a high fever, lethargy, and evidence
of meningeal inflammation. A lumbar puncture confirmed
the diagnosis of bacterial meningitis, and a
rapid test revealed the organism to be Haemophilus
influenzae type B. The mother and father admit that
they have not had their child immunized because they
were worried about the risks of immunizations causing
autism. The patient was treated with cefotaxime and
has slowly improved. However, the intern taking care of
the child has noticed that she is not easily startled. On a
hunch, the intern orders a formal audiometry evaluation,
which reveals bilateral sensorineural hearing loss.
In addition to immunization, a treatment that may
have prevented this patient’s hearing loss is
(A) acyclovir
(B) ampicillin
© cefuroxime
(D) dexamethasone
(E) rifampin

Two weeks after birth it was noted that an infant girl
was jaundiced. The girl had been born at full term and
was apparently healthy, although the mother had not
had any prenatal care. Laboratory studies performed at
that time showed a total bilirubin of 6 mg/dL, with 4
mg/dL direct and 2 mg/dL indirect, and mild elevations
of the alkaline phosphatase and transaminases. A presumptive
diagnosis of neonatal hepatitis was made and
a follow-up visit was scheduled. The mother does not
bring the girl back until she is 6 weeks old, at which
time the jaundice is obviously more severe. New laboratory
studies show the total bilirubin to be 18 mg/dL,
with 12 mg/dL direct and 6 mg/dL indirect. The
transaminases remain only modestly elevated, but the
alkaline phosphatase is five times the upper limit of
normal. A more extensive workup is undertaken.
Toxoplasmosis, rubella, cytomegalovirus, and herpes
infections are ruled out. A sonogram does not show
dilated biliary ducts and is negative for choledochal
cyst. The infant is placed on phenobarbital and a week
later an IDA scan is done. Radioactive material is
detected in the liver but not in the intestine. The most
appropriate next step in management is to
(A) continue phenobarbital therapy for another month
(B) order endoscopic retrograde cholangiopancreatography
(ERCP)
© send her for an exploratory laparotomy
(D) send her for a percutaneous transhepatic cholangiogram
(PTC)
(E) wait list for liver transplant

1. D

2. E

B.
D.

dexamethasone and second answer is C for billiary atresia

@ parag414,

can u please explain answer of 2nd question.. that will help

thanks

The presumptive diagnosis is
biliary atresia. If the ducts are found to be patent at
surgery, the operation is terminated. If the atresia is
confirmed, an effort is made to anastomose proximal
biliary ducts to intestine. If that is not possible (or if it
fails after it has been done), liver transplant becomes
the only remaining alternative.
The phenobarbital was not used for “therapy,” as
implied in choice A. It was used to induce choleresis,
and thus made the IDA scan more diagnostic. Wasting
another month might make eventual biliary derivation
impossible, or make liver damage irreversible.
ERCP (choice B) would be very difficult to do at this age.
PTC (choice D) cannot be done without dilated intrahepatic
ducts.

thanks.. good luck