Index of SuspicionCase 1: Decreased Arm Movement in a 5-Week-Old InfantCase 2: Periorbital Edema, Generalized Rash, and Violaceous Discoloration of Eyelids in a 5-Year-Old GirlCase 3: Gradual Abdominal Distension in an 18-Month-Old Boy

The reader is encouraged to write possible diagnoses for each case before turning to the discussion. We invite readers to contribute case presentations and discussions. Please inquire first by contacting Dr Deepak Kamat at DKamat@med.wayne.edu.

Case 1 Presentation

A 5-week-old, healthy, full-term, female infant, delivered via uncomplicated cesarean section, presents to the emergency department with a gradual decrease of right arm movement during the last 5 days. Although initially calm and comfortable, she now keeps her arm at her side and cries when the parents try to move her arm over her head. She has no history of fever, trauma, swelling, rash, or recent upper respiratory tract illness. The mother’s prenatal laboratory study results, including screening for human immunodeficiency virus, syphilis, hepatitis B, and group B streptococci (at 36 weeks), are negative.

Physical examination reveals a well-appearing infant with normal vital signs, who keeps her right arm in a neutral position at her side. There is no swelling or erythema. She cries with palpation of the lateral aspect of her right upper arm and with flexion and abduction of the shoulder.

Results of her laboratory studies include the following: white blood cell (WBC) count, 13,800/μL (13.8 × 10⁹/L) with 63% neutrophils, 27% lymphocytes, and 10% monocytes; hemoglobin, 10.2 g/dL (102 g/L); platelet count, 548 × 10³/μL(548 × 10⁹/L); erythrocyte sedimentation rate (ESR), 93 mm/h; and C-reactive protein (CRP), 6.4 mg/dL (64 mg/L). Shoulder radiography reveals a lytic lesion of the proximal right humerus (Fig 1). An additional imaging study and surgical procedure establish the diagnosis.

Case 2 Presentation

A previously healthy 5-year-old girl presents with severe fatigue, dysphagia, and swelling of the face and neck. Two weeks earlier she developed symptoms of upper respiratory tract infection, halitosis, and fever. …