Case 2: Acute Onset and Worsening of Anemia in a 3-year-old Boy

Sofia Khera; Zoabe Hafeez; Amanda Padilla

doi:10.1542/pir.2017-0311

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Sofia Khera, MD*,^†
Zoabe Hafeez, MD*,^†
Amanda Padilla, MD^†,^‡

^*Pediatric Hospital Medicine and
^‡Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
^†Children’s Memorial Hermann Hospital, Houston, TX

AUTHOR DISCLOSURE
Drs Khera, Hafeez, and Padilla 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.

Presentation

A 3-year-old boy of Persian descent presents to his primary care physician with 2 days of fever to a temperature of 101.8°F (38.8°C) and a 1-day history of jaundice. A review of systems reveals that he has decreased oral intake, headache, looser stools that are orange in color, and 3 recent episodes of nonbloody, nonbilious vomiting. At the visit he has bright red urination. The patient has a brother who was treated for streptococcal pharyngitis 1.5 weeks ago. His medical history is not significant for any previous illnesses. His birth history reveals that the patient was jaundiced but did not require any phototherapy. His family history does not reveal any kidney or hematologic abnormalities except for a brother who required phototherapy at birth.

Results of abdominal ultrasonography and chest radiography are normal. The patient is admitted to the hospital with a heart rate of 98 beats/min, a blood pressure of 108/73 mm Hg, a respiratory rate of 22 breaths/min, and a temperature of 97.5°F (36.4°C). On physical examination the patient appears tired and is noted to have jaundice with mild scleral icterus. His oropharynx is clear, with mildly erythematous tonsils but no exudates, and he has serous fluid behind the right tympanic membrane. The patient has no rash, no palpable hepatosplenomegaly, and no cervical, axillary, or inguinal lymphadenopathy.

Initial laboratory tests show urine analysis with brown color, a glucose level of 250 mg/dL (13.9 mmol/L), large blood cells, ketone levels of 40 mg/dL, a protein level greater than 0.3 g/dL (>3 g/L), a urobilinogen level greater than 8.0 mg/dL (0.44 mmol/L), a moderate bilirubin level, moderate leukocyte esterase, positive …