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Index of Suspicion

	Case 1 Presentation

 
A 1-year-old girl who has developed normally has experienced as many as 40 paroxysmal episodes daily since age 6 months. Each episode occurs while she is lying prone or is on her knees. She crouches down, pelvis pressed on the floor, lifts herself onto her extended arms, looks up, arches her back, and throws her head back; her legs shake, and she goes stiff. Her face appears strained and frightened. She sometimes dribbles, looks vacant, and stares as if "in a trance." Her eyes appear glazed but move erratically. She suddenly becomes floppy and goes to sleep. During an episode, she immediately "comes round" when spoken to.

Sometimes, as if anticipating an "attack," she runs to her mother, appearing frightened, grips her mother’s clothes intermittently, looks vacant, then becomes floppy and sleeps for a few minutes. These episodes occur primarily when she is tired or bored and never when she is playing or distracted.

On hospital admission, the girl’s mother prefers observation in a cubicle, convinced that nothing will happen if she is distracted by other children. The girl’s physical findings are normal, and no psychosocial issues are identified in the family.

Serum chemistry and metabolic studies yield normal results. Computed tomography (CT) of the head and electroencephalography (EEG) yield normal results, despite the occurrence of an episode during the EEG. There is no response to carbamazepine or valproate therapy.

	Case 2 Presentation

 
A 13-year-old boy was noted to have a lump on his back when his father was hugging him 2 weeks ago. The lump is about the size of a small fist, is located below the right scapula, and has caused no pain. It has been enlarging slowly. The boy feels well and denies fever, weight loss, other lumps, or trauma to the area.

On physical examination, the boy is awake, . . . [Full Text of this Article]

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