Pediatrics in Review
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(Pediatrics in Review. 1999;20:273-276. doi:10.1542/10.1542/pir.20-8-273)
© 1999 American Academy of Pediatrics
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Index of Suspicion



   Case 1 Presentation
 
An 8-year-old Norwegian girl is seen by a dermatologist because of a bleeding spider angioma on her face and similar lesions on her neck and arm. Further evaluation reveals elevated levels of liver enzymes, and he refers her to you. The child has lost weight recently and has seemed weak to her parents. She is not taking medication and has traveled only in southern Europe. There is no family history of liver disease.

Findings on physical examination include the spider angiomas, mild jaundice, several enlarged cervical lymph nodes, a palpable liver edge 5 cm below the right costal margin, and a palpable spleen edge 4 cm below the left costal margin. There are no signs of ascites or impaired mental status.

Results of laboratory evaluation are: hemoglobin, 1.55 mmol/L (10 g/dL); erythrocyte sedimentation rate, 40 mm/h; albumin, 45 g/L (4.5 g/dL); total bilirubin, 47.6 mcmol/L (2.8 mg/dL); unconjugated bilirubin, 13.6 mcmol/L (0.8 mg/dL); aspartate aminotransferase, 759 U/L; alanine aminotransferase, 659 U/L; lactic dehydrogenase, 533 U/L; alkaline phosphatase, 560 U/L; gamma glutamyl transferase, 115 U/L; and immune globulin G, 35 g/L (350 mg/dL) (upper limit of normal, 15.5 g/L [1,550 mg/dL]). Ceruloplasmin, copper, and alpha-1-antitrypsin levels are normal. Serologic tests for hepatitis A, B, and C yield negative results, as does testing for antinuclear and antimitochondrial antibodies. Anti-smooth muscle antibodies are present.

The diagnosis is established by a biopsy.


   Case 2 Presentation
 
A 3-year-old Hispanic girl is brought to the office because she has had a fever for more than 3 weeks and has refused to walk for 1 day. She has complained of intermittent headache and abdominal cramping and has lost 0.9 kg since the fever began. She has not experienced vomiting or diarrhea, has had no contact with ill people, and had been well previously. The family travels to Mexico monthly but . . . [Full Text of this Article]


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