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Index of Suspicion

Abbreviations: ALT: alanine aminotransferase • AST: aspartate aminotransferase • BUN: blood urea nitrogen • CBC: complete blood count • CNS: central nervous system • CSF: cerebrospinal fluid • CT: computed tomography • ECG: electrocardiography • ED: emergency department • EEG: electroencephalography • ESR: erythrocyte sedimentation rate • GI: gastrointestinal • GU: genitourinary • Hct: hematocrit • Hgb: hemoglobin • MRI: magnetic resonance imaging • WBC: white blood cell

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

	Case 1 Presentation

 
A 14-year-old Hispanic boy is evaluated for progressive difficulty in breathing through his nose and nosebleeds over the past 9 months. In the past week, he has produced blood-streaked sputum. He has lost 8 lb. He denies fevers, rashes, vomiting, easy bruising, headaches, or vision changes. He has received medications for sinusitis and allergies without improvement of his symptoms.

Physical examination reveals a well-developed boy who looks pale and is breathing through his mouth. His temperature is 97.2°F (36.3°C), heart rate is 133 beats/min, respiratory rate is 13 breaths/min, and blood pressure is 114/50 mm Hg. His nasal turbinates are boggy, but there is no visible blood, drainage, or masses in the nasal passages. The remainder of his physical findings are normal.

Laboratory studies reveal: WBC count of 6.7x10³/mcL (6.7x10⁹/L) with 63% neutrophils, 26% lymphocytes, 9% monocytes, and 1% eosinophils; Hgb of 6.9 g/dL (69 g/L); Hct of 22.3% (0.223); and platelet count of 329x10³/mcL (329x10⁹/L). The remainder of his laboratory results, including serum electrolytes and coagulation profile, are normal. Additional evaluation leads to the diagnosis.

	Case 2 Presentation

 
A 6-year-old girl presents with gait instability. At 8 months of age, her parents observed her either slouching or swaying her back and assuming a tripod position while trying to sit. She began walking at 18 months of age, and she tended to sway back and forth or side-to-side when standing. She seems to be more stable when running than walking. The girl has had frequent ear infections, gastroenteritis, urinary tract infections, and exacerbations of asthma symptoms. She also has severe eczema. Her parents are first cousins.

On physical examination, her temperature is 98.0°F (36.7°C), heart rate is 120 beats/min, and respiratory rate is 24 breaths/min. Her weight is 16 kg (3rd . . . [Full Text of this Article]

Nicole Rizkalla, MD
Edward Hu, MD
Children's Hospital of Los Angeles, Los Angeles, Calif

Jalal Rais Dana, MD
Midwestern University, Chicago, Illinois

Poonam Sharma, MBBS
Meera Varman, MD
Creighton University School of Medicine

Joseph T. Snow, MD
Nancy E Cornish, MD
John Donovan, MD
Children's Hospital, Omaha, Neb

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