Index of Suspicion

Case 1 Presentation

A12-month-old girl is brought to the ED after a seizurelike episode. On awakening from a nap, she screamed and then became stiff. Her eyes rolled back, and she began to shake. Both arms and legs were involved symmetrically. The episode lasted 2 minutes, after which she appeared tired. She has been well recently, with no fever or respiratory symptoms.

Her mother reports a history of similar episodes over the last 3 months, with increasing frequency in the last week (up to 10/d), but no medical attention has been sought until now. The child has had no serious illnesses, is receiving no medications, has no allergies, and has not been immunized (by parental choice). She walked at 10 months of age, but in the last week has become unsteady, stumbling when walking. The family history is noncontributory.

The physical examination reveals an alert child who has normal tone, strength, reflexes, and vital signs. All other physical findings also are normal; specifically, no focus of infection is evident.

Blood chemistry levels include: sodium, 137 mEq/L (137 mmol/L); potassium, 5.4 mEq/L (5.4 mmol/L); calcium, 10.4 mg/dL (2.60 mmol/L); and magnesium, 2.43 mg/dL (1.00 mmol/L). The blood glucose level is 37.8 mg/dL (2.1 mmol/L), and liver function test results are normal. The WBC count is 11.5×10³/mcL (11.5×10⁹/L), Hgb level is 12.2 g/dL (122 g/L), and platelet count is 347×10³/mcL (347 ×10⁹/L). A full evaluation for sepsis is negative. CT of the head shows normal findings. Additional testing confirms the diagnosis.

Case 2 Presentation

A 71/2-year-old boy is brought to the ED with a 4-day history of subjective fever, abdominal pain, and vomiting. The abdominal pain is described as diffuse and crampy. There is no history of respiratory illness or diarrhea. The family moved from Pakistan 6 weeks ago, and …