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Index of Suspicion

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

	Case 1 Presentation

 
A 3-year-old girl who has a history of short bowel syndrome is admitted to the hospital after 1 day of fever and congestion. She developed mid-gut volvulus at 2 years of age, losing 95% of her small bowel. The remaining 5 cm of jejunum and 5 cm of ileum were reanastamosed. She is dependent on parenteral nutrition (PN).

Physical examination reveals a tired-appearing girl. Her temperature is 104.0°F (40.0°C), heart rate is 140 beats/min, blood pressure is 80/40 mm Hg, respiratory rate is 26 breaths/min, and oxygen saturation is 98% on room air. Nasal congestion is present. Her chest is clear to auscultation. The central venous catheter (CVC) site has no erythema, tenderness, or discharge. No rashes or lesions are noted.

Laboratory results include: WBC count, 5.0x10³/mcL (5.0x10⁹/L) (60% neutrophils, 37% lymphocytes); Hct, 31.2% (0.312); and platelet count, 128x10³/mcL (128x10⁹/L). Liver function test results and radiography of the chest are normal. Intravenous antibiotics are started after blood and urine for culture and nasal washings for viral assessment have been obtained.

On the third hospital day, while still febrile, the girl develops prolonged bleeding from her left nostril. Laboratory results include: Hct, 26.9% (0.269), platelet count, 39x10³/mcL (39x10⁹/L); prothrombin time (PT), 14.9 seconds (normal, 9.3 to 10.6 seconds); and activated partial thromboplastin time (aPPT), 62.3 seconds (normal, 25.1 to 31.1 seconds). She is treated with nasal pressure, thrombin gel foam packing, fresh frozen plasma (FFP), and platelets until bleeding finally ceases. However, 2 days later, she develops bleeding from her right nostril and from the CVC site. Fibrinogen measures 102 mg/dL (3.0 mcmol/L) (normal, 228 to 453 mg/dL [6.7 to 13.3 mcmol/L]). Heparin platelet antibody is absent. An additional test reveals the diagnosis.

	Case 2 Presentation

 
. . . [Full Text of this Article]

Arpi Bekmezian, MD
Brigitte Gomperts, MD
Mattel Children's Hospital at the University of California Los Angeles, Los Angeles, Calif

Pedro Weisleder, MD, PhD
Nationwide Children's Hospital, Columbus, Ohio

Cynthia Patraitis, DO
Southern Maine Medical Center/PrimeCare Pediatrics, Biddeford, Me

Patrice Thibodeau, MD
Maine Medical Center, Portland, Me

Kelly Parker-Mello, MD
Maine Medical Center, Portland, Me

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