Index of Suspicion

Case 1 Presentation

A 3-month-old boy is evaluated for a posturing episode suggestive of seizures. He experienced two episodes of nonbilious emesis last night and today has been progressively more irritable, arching his back in association with feeding. Thirty minutes following his last meal, he became stiff, developed clenched fists and deviated eyes, and was unresponsive to his parents’ stimulation. Although his respirations were irregular, no cyanosis was noted. The tonic posturing persisted for almost 30 minutes, and the infant was brought to the emergency department.

His past medical history is significant for gastroesophageal reflux, diagnosed at 3 weeks of age on the basis of symptoms. Medications initially included ranitidine and sucralfate but were changed to omeprazole. Metoclopramide was added 2 days prior to admission.

Physical examination reveals a pale infant who has tonic stiffening of all four extremities. No clonic movements are observed. His heart rate is 180 beats/min, respirations are 34 breaths/min and irregular, and temperature is normal. The patient is treated with 2 mg of intravenous diazepam, but the posturing persists. After administration of 20 mg/kg of phenobarbital, the abnormal activity stops. His white blood cell count is 22×10³/mcL (22×10⁹/L), and electrolyte concentrations and liver function test results are normal. A radiograph of his chest and computed tomography of the head yield normal results.

Case 2 Presentation

A 3-year-old boy presents to the emergency department with a 2-day history of cough and rhinorrhea. His cough is weak, and he is not clearing his secretions. There is no history of fever, wheezing, or cyanosis. While being examined, he develops a coughing episode with cyanosis that is unresponsive to 100% oxygen delivered by face mask. He requires endotracheal intubation because of cyanosis and weak respiratory effort and is admitted to the intensive care unit.

Physical examination reveals a well-developed child who …