Case 1: Intermittent Fevers, Persistent Vomiting, and Lethargy in a 3-year-old Boy

Archana Balamohan; Lorry G. Rubin; Peter Assaad; Stefan H.F. Hagmann

doi:10.1542/pir.2018-0071

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Archana Balamohan, MD*
Lorry G. Rubin, MD*
Peter Assaad, MD^†
Stefan H.F. Hagmann, MD, MSc*

^*Division of Pediatric Infectious Diseases and
^†Division of Pediatric Radiology, Steven and Alexandra Cohen Children’s Medical Center/Northwell Health, New Hyde Park, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY

AUTHOR DISCLOSURE
Drs Balamohan, Rubin, Assaad, and Hagmann have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

EDITOR’S NOTE

Last month, we thought globally, and Index of Suspicion included 4 cases of conditions that are more common outside of North America than they are within the United States. This month, 2 of the review articles focus on mycobacterial infections that can present anywhere in the world. Our cases include children with symptoms suggestive of mycobacterial infection, but some of these children ended up having different problems. Enjoy thinking through these cases!

Philip R. Fischer, MD

Associate Editor, Index of Suspicion

Presentation

A 35-month-old boy with a history of speech and slight motor delay is transferred to our institution with a 1-month history of intermittent fever and a 2-week history of vomiting. During this time he was noted to have poor appetite and a change in personality progressing to lethargy and generalized weakness. In addition, he has been pointing to his head for the past few days, perhaps indicating headache. He is US-born and frequently travels to Guyana, where he has been residing for the past 4 months with his maternal family. Treatment in Guyana included a 7-day course of amoxicillin-clavulanate for presumed acute otitis media and a subsequent course of an unknown antibiotic for treatment of pharyngitis and suspected bacteremia. Computed tomography of his head performed 1 month after onset of symptoms revealed hydrocephalus, and he returned 1 day later to the United States for further medical care.

At initial presentation he is afebrile (100°F [37.8°C]) with a heart rate of 128 beats/min, respiratory rate of 20 breaths/min, blood pressure of 121/92 mm Hg, and oxygen saturation of 97% in room air. He appears malnourished (weight of 10 …