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Index of Suspicion

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

	Case 1 Presentation

 
A newborn girl has a mass protruding from her introitus. She was born at an estimated gestational age of 39 weeks to a mother who is 26 years old and gravida 6 (term 2, preterm 1, abortion 2) and had received prenatal care. The mother's blood type is O+, she is rubella immune and hepatitis B surface antigen-negative, and she has had a negative serologic test for syphilis. Prenatal screening showed a decreased alpha-fetoprotein value. The infant was delivered vaginally and had Apgar scores of 9 at both 1 and 5 minutes.

On genitourinary examination, the baby has normal labia majora and minora. A cauliflower-like tissue mass measuring 1.5x2 cm appears to arise from the anterior wall of the vagina and protrudes when the baby cries. No other malformations are noted. A catheter can be inserted into the urethra without any difficulty or evidence of obstruction, and the baby urinates normally. Abdominal ultrasonography yields normal findings.

	Case 2 Presentation

 
A 4-year-old girl whose only health problem is eczema has had headaches that have increased in frequency and intensity and subjective fever for 4 days; she also has vomited once. At a local ED, her temperature is 100.6°F (38.1°C), and she experiences a seizure that resolves following administration of lorazepam. CT scan of the head yields normal findings, as does a CBC. Lumbar puncture shows an elevated opening pressure. Her CSF demonstrates 8 WBCs and 946 erythrocytes per high-power field, a glucose value of 75 mg/dL (4.2 mmol/L), a protein concentration of 68 mg/dL, xanthochromia, and gram-positive cocci in clusters on Gram stain. She is given vancomycin and ceftriaxone and transferred to the children's hospital.

On admission, the child is alert and afebrile and appears well. Her neck is supple. She has excoriations over her chest, abdomen, and extremities and an abrasion . . . [Full Text of this Article]

Reham El Gammal, MD
Christina Fernandez, MD
Shahab Abdessalam, MD
Nebraska Medical Center, Omaha, Neb

Lindsay Chase, MD
Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Ga

Rebecca Scherr, MD
Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Ga

Jeffrey M. Karp, DMD, MS
University of Rochester School of Medicine and Dentistry, Rochester, NY

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