Index of Suspicion

Amir Mian; David Becton; Douglas P. Blackall

doi:10.1542/pir.30-4-139

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Amir Mian, MD
David Becton, MD
Douglas P. Blackall, MD

University of Arkansas for Medical Sciences, Little Rock, Ark

Case 1 Presentation

A 16-month-old boy had been diagnosed with B-cell acute lymphoblastic leukemia (ALL). Past medical and birth histories were unremarkable. Over the past 48 hours, he received and tolerated a slow transfusion of packed red blood cells for an Hgb concentration of 4.9 g/dL (49 g/L). Currently, he is receiving maintenance intravenous hydration. Physical examination shows no evidence of distress. His temperature is 97.5°F (36.4°C), respirations are 24 breaths/min, heart rate is 126 beats/min, blood pressure is 95/64 mm Hg, and oxygen saturation is 98% on room air. His chest is clear to auscultation, with normal heart sounds. Abdominal examination shows mild hepatosplenomegaly. He has scattered petechiae. Current laboratory results are: WBC count of 14.8×10³/mcL (14.8×10⁹/L), Hgb of 10.4 g/dL (104 g/L), Hct of 28.9% (0.29), and platelet count of 48×10³/mcL (48×10⁹/L). The values for serum electrolytes, BUN, creatinine, liver enzymes, and uric acid as well as results of coagulation studies are within normal limits. Chest radiography reveals normal findings. Prior to surgery for central line placement, he receives 1 unit of irradiated, leukocyte-reduced platelets.

A central line is placed without difficulty. Within 2 hours of the platelet transfusion, he experiences acute cardiorespiratory deterioration (heart rate 165 beats/min, blood pressure 65/42 mm Hg, respiratory rate 48 breaths/min, oxygen saturation 78% on room air, and temperature 99°F [37.2°C]). Examination reveals symmetrically decreased breath sounds and diffuse crackles bilaterally, with normal heart sounds and capillary refill. Repeat radiography shows extensive “diffuse bilateral infiltrates consistent with pulmonary edema.” He is intubated and transferred to the intensive care unit. Additional evaluations reveal the diagnosis.

Case 2 Presentation

A 13-month-old boy presents with a history of fever for 2 days and nonbloody diarrhea for 2 weeks. Other family members also report diarrhea over the past 2 weeks. He has been healthy, …