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Index of Suspicion

The first 300 words of the full text of this article appear below.

	Case 1 Presentation

 
Thirteen-day-old African-American twin boys are brought to the ED because of fussiness and inconsolable crying for several hours. Twin A’s signs began first, with decreased feedings and one episode of nonbilious, nonbloody emesis of formula. Neither infant has a history of fever. Both are having normal stool and urine frequency, without evidence of blood or mucus in the stool. Delivery was by urgent caesarean section at 36 weeks’ gestation for "poor blood flow" to twin B, which was noted on routine ultrasonography. The mother had no symptomatic infections during her pregnancy. She recalls that studies were performed to look for infection but did not know the results.

Physical examination of twin A reveals a mildly fussy infant who cries during the examination; he is consolable with a pacifier, but takes it somewhat reluctantly. Twin A cries and draws up his legs during palpation of his abdomen, which is soft and not distended. Twin B also appears somewhat fussy but consolable, makes good eye contact, and falls asleep easily. The remainder of the examination findings, including vital signs, is normal for both twins.

A CBC on twin A shows a WBC count of 21.1x10³/mcL (21.1x10⁹/L) (65% neutrophils, 5% bands, 15% lymphocytes, 14% monocytes, 1% eosinophils); Hgb of 14.7 g/dL (147 g/L); and platelet count of 330x10³/mcL (330x10⁹/L). A blood culture is drawn. An abdominal radiograph of twin A is read as normal. Because of the poor feeding, crying, and 36-week gestation, twin A is admitted for observation. Twin B also is admitted for further observation.

Further evaluation of both twins reveals the diagnosis.

	Case 2 Presentation

 
A 16-year-old boy had two generalized tonic seizures 1 week apart. Since starting carbamazepine, he has had no further events. The boy denies recent illness; fever; . . . [Full Text of this Article]

Mark Riederer, MD
Children’s Hospital of Michigan, Detroit, Mich

James A. Phalen, MD
Paul G. Moe, MD
The Children’s Hospital, Denver, Colo

Maria Lourdes Salazar, MD
Lea S. Eiland, PharmD
University of Alabama School of Medicine, Huntsville, Ala

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