Contemporary Pediatrics - September 2008 - (Page 46)

Puzzler Figure 1 you think, from being in the hospital. His head is normocephalic, pupils equal and reactive to light, tympanic membranes normal in appearance, and pharynx is not erythematous. There is an area of slight bleeding from the upper gums, but only between his central incisors. He has scattered petechiae on his palate. Thyroid gland is not palpable. His heart exam is regular without murmurs, and lungs are clear. His abdomen is soft with normal bowel sounds, is nontender, and no organomegaly or masses appreciated. Genital exam is normal for his age. His upper and lower extremities are warm and well-perfused, with good distal pulses. You appreciate no warmth, redness or effusions in any of his lower extremity joints. He refuses to actively move his hips and knees, and cries out when passively rotated. He has about 15 degrees of limited internal rotation of the left hip. There is a flexion contracture of the left knee, and his right foot is held in plantar flexion. He is tender in both knees, and along the shafts of both tibias. He refuses to bear weight or ambulate. His patellar and Achilles reflexes are normal, and he has a normal Babinski reflex. Skin examination reveals a small patch of petechiae over his right scapula, scattered petechiae on his right upper extremity, and on both lower extremities. You start to discuss with his mother the proposed events of the next several days. There will be more labs to look for tumor lysis syndrome, and CT (computed tomography) scans to look for tumor. Over the next 24 hours you begin to get some test results back. His lactate dehydrogenase and uric acid levels are normal. His WBC count is normal at 5.5K/µL (normal 3.6 to 11.8 K/µL) but his hemoglobin level is slowly dropping and is now 10.1 g/dL (normal 11.5 to 15.5 g/dL). A basic metabolic panel with transaminases is unremarkable except for a slightly low albumin level at 3.3 g/dL. His CT scans are completely normal and, surprisingly, fail to reveal lytic or blastic disease of the bone that was apparent on the MRI done earlier that week. At this point, it was clear that a bone marrow biopsy would be needed to rule out leukemia. This was performed the next day, and initial pathology was normal. It would take up to a week to get flow cytometry >> p.47 results back. Image showing decreased signal intensity in the proximal bilateral tibias Your turn at this case Armed with the MRI results, you return to the patient’s room to take a more extensive history from the boy’s mother. She is overwhelmed with the events of the last week and frustrated because she is still without an answer to her son’s pain. She relates the same history that has been recorded in his chart. He had no history of trauma to the knee or hip. In addition, he had no fever, no redness or swelling of any joint. He had not had any bug bites or scratches in the area of the pain. His only past medical problem besides normal childhood infections was a history of certain food and texture avoidances. As a result, he had been to an eating clinic as a toddler. It was determined he did not need further therapy at that time, since he was growing normally. He is in second grade and plays baseball. He does well both academically and physically. He has a strong family history for various adult-onset malignancies including breast, ovarian, oral, kidney, prostate, and uterine cancers, as well as childhood leukemia. You notice that he is lying in bed and refusing to move any part of his lower body. He appears to be a well-developed thin boy. He is remarkably irritable, 46 www.contemporarypediatrics.com Vol. 25, No. 9 IMAGE: COURTESY OF DR. RAAB http://www.contemporarypediatrics.com

Table of Contents Feed for the Digital Edition of Contemporary Pediatrics - September 2008

Contemporary Pediatrics - September 2008 Contents Editorial Your Voice Clinical Tip News Updates Eye on Washington Puzzler Dermatology: What’s your Dx? Behavior Cover Story: ECC Epidemic Parent Guides Discipline Techniques: The 12-Month-Old Exercise-induced Bronchospasm: Keeping Our Patients Active Food Safety Parent Guide CPR--Food Safety Malnutrition Links Surgeon General Links Hospice Links Childhood Cancer Links Rx for a Healthy Practice Rx for a Healthy Practice New Products Author Guidelines Journal Club Events Calendar Classifieds Index of Advertisers Postscript

Contemporary Pediatrics - September 2008

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