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BACKGROUND
A 14-month-old boy is brought to the emergency
department by his parents for an evaluation of
persistent fever, vomiting, and diarrhea that has lasted
for 3 days. The mother states that her son's
pediatrician examined him 2 days ago for a "viral
illness." However, the child has appeared increasingly
ill since then. He has become irritable, and he has been
minimally active and feeding poorly. He has had normal
stool output and appearance and his normal number of wet
diapers. The parents deny observing a runny nose, cough,
and wheezing or stridor. The child lives at home with
his parents, he is not in day care, and he has had no
contacts with people who are sick.
On
physical examination, the boy is crying, fussy, and
poorly consoled. His vital signs include a rectal
temperature of 101°F, a respiratory rate of 32 breaths
per minute, a blood pressure of 98/56 mm Hg, and a heart
rate of 168 beats per minute. His oxygen saturation is
100% while he is breathing room air. The patient's
weight is 10 kg. Palpation reveals diffuse abdominal
tenderness without rigidity or guarding. The patient has
diffusely hypoactive bowel sounds. His stool is negative
for occult blood. The rest of the physical findings are
otherwise unremarkable.
Abdominal
conventional radiography and CT are performed (see
Images). Laboratory investigation reveals the following
results: WBC count 19.4 X 109/L with a
predominance of neutrophils, hemoglobin 8.4 g/dL,
hematocrit 26.6%, platelets 310 X 109/L, Na
136 mmol/L, K 3.8 mmol/L, Cl 105 mmol/L, CO2
20 mmol/L, BUN 6 mmol/L, creatinine 17.7 µmol/L (0.2
mg/dL), and glucose 4.1 mmol/L (73 mg/dL). Urinalysis
shows trace ketones, but the results are otherwise
normal.
What is the diagnosis?
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Hint
The patient's symptoms developed approximately 2
days after the mother dropped a box of pins on the
carpet at home. |
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Authors:
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Anusuya Mokashi,
Medical Student,
New York Medical College, Valhalla
Justin Weir,
Medical Student,
New York Medical College, Valhalla
Margaret D. Smith, MD,
Program Director,
Department of Medicine,
St. Vincent Catholic Medical Centers (SVCMC) St. Vincent's Hospital
Manhattan,
Senior Associate Dean and Associate Professor of Clinical Medicine,
New York Medical College,
St. Vincent's Hospital Manhattan
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eMedicine Editor:
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Erik D. Schraga, MD,
Staff Physician,
Kaiser Permanente,
Santa Clara Medical Center, Calif
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