A 5-year-old male is admitted to the hospital following a 3-week history of spiking fevers and fatigue. Your examination reveals pale mucous membranes and skin. You also find splenomegaly.You are concerned about a possible malignancy. What is the most common malignancy of childhood?
Answer(s): C
The most common malignancy in childhood is leukemia/lymphoma. The most common solid tumors of childhood are CNS tumors, followed by neuroblastoma and Wilms tumors. The mildly elevated WBC with lymphocyte predominance with the presence of "atypical" lymphocytes would indicate that his child most likely has acute EBV infection (infectious mononucleosis). This acute EBV infection is usually subclinical in younger children, but can be manifested by acute hemolytic anemia and splenomegaly. Testing for the diagnosis of EBV includes EBV DNA PCR and heterophile antibody response testing (monospot test). Diagnosis usually is made based upon serology testing for anti-EBV IgG and IgM levels. There is no specific therapy indicated for the acute EBV infections. Acute Lyme disease is very uncommon in children. The early stage of acute Lyme disease is characterized by a distinctive rash (erythema migrans). This is then followed by a multiple annular rash of disseminated Lyme disease. Often seen in this stage is cranial nerve palsies, specifically facial nerve (CN VII) palsy. Late Lyme disease is characterized by recurrent arthritis and arthralgia. Serologic testing is only recommended if there is a very high clinical index of suspicion, unlike this child. Acute systemic-onset JRA (Still disease) can present in a child of this age in a nonspecific manner (i.e., fever of unknown origin). Children with Still disease will typically have dramatic elevations in acute- phase reactants (i.e., ESR). This child's ESR being 5 would go against JRA.
A 5-year-old male is admitted to the hospital following a 3-week history of spiking fevers and fatigue. Your examination reveals pale mucous membranes and skin. You also find splenomegaly.This child has an extensive evaluation by the Hematology-Oncology consultants. Their evaluation excludes the presence of a malignancy. The extensive evaluation did reveal that the child has a WBC count of 22,000 with 41% monocytes and 12% "atypical" lymphocytes. His hematocrit is 28% and erythrocyte sedimentation rate (ESR) is 5.This child likely has which of the following diseases?
Answer(s): B
A 5-year-old male is admitted to the hospital following a 3-week history of spiking fevers and fatigue. Your examination reveals pale mucous membranes and skin. You also find splenomegaly.The best course of care for this young man would be which of the following?
Answer(s): E
While in the emergency department you see a 3-week-old infant. The mother says that the child felt warm earlier in the day and has not been eating very well. The infant has a temperature of 100.9°F and has mildly decreased tone. What is the most appropriate initial management?
A fever in the first 46 weeks of life needs to be treated very aggressively. There are no reliable clinical or laboratory findings currently available that can discriminate between a nominal viral illness and a serious bacterial infection. In the newborn period, fever may be the only indicator of bacteremia or meningitis. Any rectal temperature greater than 100.5°F should trig ger a full sepsis workup. This should include cultures of the blood, urine, and spinal fluid. In this age range, empiric antimicrobials should be initiated that should cover for GBS, E. coli, and Listeria monocytogenes. A commonly used regimen is ampicillin and gentamicin. Many would also include empiric acyclovir in this age range. In infants, the routine use of antipyretics should be discouraged. A blood culture alone is not an adequate screening tool for meningitis. While a urinary tract infection (UTI) is a common cause of infection in infants, a more complete evaluation would be warranted.
You see a 2-month-old infant in the emergency department for vomiting. The mother says that the baby has been spitting up more over the past few days and has become more irritable. She denies any fever, diarrhea, or change in formula. The mother tells you that there is a family history of "heartburn" and that her other children have all spit up. The infant has some emesis in the emergency department that seems to be formula mixed with some bile. The infant is intermittently irritable and sleepy.What is the most concerning diagnosis that this could be?
Bilious emesis in an infant is malrotation until proven otherwise. Malrotation can lead to a midgut volvulus. The volvulus can result in bowel ischemia and necrosis. This makes bilious emesis in a newborn a concerning finding. Pyloric stenosis would cause nonbilious emesis. Imperforate anus would present with the failure of stool passage. Diaphragmatic hernia will present with poor feeding, drooling, and respiratory embarrassment The best radiographic test in the diagnosis of malrotation is an UGI contrast study with small bowel follow through. This will identify the duodenum and its location relative to the ligament of Treitz. The characteristic finding in a midgut volvulus is the "corkscrew" sign, which is seen as contrast media traverses the kinked intestine. An abdominal CT may show malrotation but is less specific for it. Barium enema and radionuclide scans have no role in the diagnosis of malrotation.
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