Index of Suspicion

Case 1 Presentation

An 8-month-old boy presents to the ED after having a seizure. His mother found him in his crib with both arms and legs shaking symmetrically. He appeared pale and had a glazed look on his face. The episode lasted 10 minutes. En route to the hospital, his blood glucose measured 39 mg/dL (2.2 mmol/L), and he was given intravenous dextrose solution.

According to his mother, he had a similar episode 1 month earlier when his blood glucose concentration was found to be 40 mg/dL (2.2 mmol/L). Laboratory evaluation, including CBC and basic metabolic panel, at that time yielded otherwise normal results, and he was discharged with no clear explanation of his condition. His mother reports that he has had seizurelike episodes with increasing frequency over the past month.

The infant was born vaginally at term, and his birth was complicated by abruption during delivery that resulted in perinatal asphyxia and hypoxic-ischemic encephalopathy. He has been taking oxcarbazepine for “petit mal epilepsy” and has had no breakthrough seizures until 1 month ago. He also has taken growth hormone (GH) since 3 months of age, when he was diagnosed as having GH deficiency. He has global developmental delay.

Physical examination reveals a postictal boy in no apparent distress. His vital signs are stable. Except for the decreased muscle tone, his physical findings are normal.

An additional element of the history leads to discovery of the cause of his hypoglycemic seizures.

Case 2 Presentation

An 18-year-old Hispanic girl presents to her obstetrician for elective termination of pregnancy. She is estimated to be 14 weeks pregnant. The procedure includes the use of Laminaria japonica, a brown algae, as a dilating agent of the uterine cervical os, followed by dilatation and curettage, usually within 24 hours. The patient changes her mind regarding pregnancy termination, and the Laminaria …