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American Academy of Pediatrics
Index of Suspicion

A Previously Healthy Teenager with Anasarca

Justin H. Berger, Andrea Jones, Nina Fainberg, Christopher Smith and Chitra Ravishankar
Pediatrics in Review March 2021, 42 (3) 153-157; DOI: https://doi.org/10.1542/pir.2020-0003
Justin H. Berger
*Division of Cardiology and
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Andrea Jones
*Division of Cardiology and
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Nina Fainberg
†Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA
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Christopher Smith
*Division of Cardiology and
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Chitra Ravishankar
*Division of Cardiology and
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  1. Justin H. Berger, MD, PhD*
  2. Andrea Jones, MD*
  3. Nina Fainberg, MD†
  4. Christopher Smith, MD, PhD*
  5. Chitra Ravishankar, MD*
  1. *Division of Cardiology and
  2. †Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA
  • AUTHOR DISCLOSURE

    Drs Berger, Jones, Fainberg, Smith, and Ravishankar 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 16-year-old boy with no chronic medical problems presents with several weeks of progressive lower extremity edema, facial swelling, and dyspnea on exertion, accompanied by several daily episodes of loose, nonbloody stools. There is no history of fever, upper respiratory tract symptoms, abdominal pain or nausea, joint pain, eye pain or blurry vision, rashes, or ulcers. He does have a history of facial acne for which he had previously taken isotretinoin. There has been no recent travel. On physical examination, vital signs are normal. He appears tired but in no acute distress. There is decreased aeration at both lung bases, no audible murmurs or gallops, a distended and nontender abdomen, and marked lower extremity and periorbital edema.

Laboratory studies show a mildly elevated creatinine level of 1.0 mg/dL (88 μmol/L), a low albumin level of 1.8 g/dL (18 g/L), and normal liver enzyme levels. Stool testing for α1-antitrypsin is elevated 20-fold. His electrolyte levels, urinalysis findings, coagulation markers, and inflammatory markers are normal. His chest radiograph shows a small right pleural effusion and no cardiomegaly. Based on his symptoms, presence of anasarca, and hypoalbuminemia with an elevated fecal α1-antitrypsin level, he is admitted to an outside institution for further evaluation with a working diagnosis of protein-losing enteropathy (PLE). An echocardiogram demonstrates normal intracardiac anatomy and systolic function. His electrocardiogram shows sinus rhythm with diffuse low voltages and flat T waves (Fig 1A). In the setting of stool protein loss, a more extensive gastroenterologic evaluation is undertaken, which is normal. He is started empirically on prednisone therapy and a low-fat diet but requires standing …

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Pediatrics in Review: 42 (3)
Pediatrics in Review
Vol. 42, Issue 3
1 Mar 2021
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A Previously Healthy Teenager with Anasarca
Justin H. Berger, Andrea Jones, Nina Fainberg, Christopher Smith, Chitra Ravishankar
Pediatrics in Review Mar 2021, 42 (3) 153-157; DOI: 10.1542/pir.2020-0003

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A Previously Healthy Teenager with Anasarca
Justin H. Berger, Andrea Jones, Nina Fainberg, Christopher Smith, Chitra Ravishankar
Pediatrics in Review Mar 2021, 42 (3) 153-157; DOI: 10.1542/pir.2020-0003
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More in this TOC Section

  • Previously Healthy 3-week-old Infant with Limited Right Arm Mobility
  • Dysphagia and Epigastric Pain in an Adolescent Boy
  • Refusal to Use an Upper Extremity in a 17-month-old with Facial Nerve Palsy
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