Pediatrics in Review
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(Pediatrics in Review. 1997;18:283-286.)
© 1997 American Academy of Pediatrics

Index of Suspicion

Gheorghe R. Ganea, MD*
Gregory Conners, MD{dagger}
Daniel Nussbaum, II, MD
* Bronx-Lebanon Hospital Center, Bronx, NY

{dagger} University of Rochester School of Medicine & Dentistry, Rochester, NY
Oak Orchard Community Health Center, Brockport, NY

   Case 1 Presentation
 
A 9-year-old Hispanic boy is brought to the emergency department because of fever, headache, muscle aches, and abdominal pain for 2 days. He says that he has had no cough, vomiting, diarrhea, constipation, or urinary symptoms. There is no history of skin rash, trauma, or distant traveling. The other family members have been healthy. Two weeks prior to this episode the patient had been evaluated for fever and severe abdominal pain. He was observed for 8 hours, acute appendicitis was ruled out, and his symptoms resolved within 48 hours.

Physical examination reveals a temperature of 38.8°C (102°F), heart rate of 146 beats/min, diffuse abdominal tenderness without signs of peritoneal irritation, pain on palpation of the calves of both legs, and pain in the right ankle with passive movement (but no erythema, heat, or swelling). His pharynx is free of erythema and exudate. There are no skin lesions. The neurologic examination reveals generalized weakness of the muscles of all extremities, but deep tendon reflexes are normal.

The following laboratory data become available: leukocyte count, 10,500/mm3; hemoglobin 14 g/dL; platelet count, 665,000/mm3; erythrocyte sedimentation rate (ESR), 100 mm/h; and creatine phosphokinase (CPK) level, 70 U/L. A rapid streptococcal antigen detection test is negative, and an abdominal radiograph is read as normal.

The patient is kept in the emergency department and re-evaluated periodically. Twelve hours later, results of his cardiac examination have changed. The pulse rate is 160 beats/min and the apical impulse is hyperdynamic, felt best in the sixth intercostal space, on the left anterior axillary line. A holosystolic, high-pitched, blowing murmur is heard at the apex. The murmur is 3/6 in intensity, transmitted to the left axilla, and loudest when the patient assumes the left decubitus position. The second sound is widely split and fixed, and an accentuated third . . . [Full Text of this Article]






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Pediatrics Pediatrics in Review
Copyright © 1997 by the American Academy of Pediatrics.