Contemporary Pediatrics - September 2008 - (Page 47)

Puzzler While awaiting the results of the flow cytometry, you Heavy metal levels (arsenic, mercury, and lead) in urine decide to initiate physical therapy to increase his range and blood were normal. His normal vitamin A level of motion and muscle tone. He does not do well, due to rules out hypervitaminosis A. Of note, his ESR had extreme and, at times, hysterical fits of pain. After climbed to 57 mm/hr (normal 0 to 13 mm/hr). enduring another week in the hospital, his mother As for the petechiae, you know it could be caused by notes that he is becoming progressively more irritable either a platelet disorder or a problem with the blood towards her and the nurses. He also is not eating very vessels. But which? He does not have thrombocytopewell, just picking at his hospital food. nia. He has normal coagulation studShe asks if she can bring in his food ies, so you determine it most likely be from home. She also asks if you can capillary fragility causing the petechistart him on a multivitamin, since she One point in the history ae. So how does that fit with his bone is worried he is losing weight. disease? that interests the You go in to evaluate him again, You are now perplexed, and and sure enough, his pallor is decide to involve your hospital’s Diagnostic Referral increasing and he looks gaunt and Diagnostic Referral Service. They tired. You inform them that the flow Service is the food specialize in complex diagnostic cytometry from the bone marrow has cases, and you feel that this case is aversion that his mother finally returned, but reveals no moncertainly not malignancy-based on oclonality or aberrant immunophe- keeps mentioning. the bone marrow biopsy. Once again, notypic expression. The biopsy they start from scratch. On physical showed marrow with some hemorexam, they noted that his petechiae rhagic changes but no evidence of are peculiar in that they were easily malignancy, and woven bone with some non-specific palpable and strictly perifollicular. His irritability at reactive changes. In short, he does not have leukemia. this point was also rather impressive. Because of this confusing picture, a second marrow and One point in the history that struck their interest was a bone biopsy of the lesion in the left tibia is performed. the food aversion that his mother is recurrently bringThis also showed reactive changes, but no leukemia. ing up in your conversations. It appears that it started when he was around 1 year old, when he would refuse A change in direction to eat meat, fruits, and vegetables. He would gag and cry You are left wondering what else could possibly cause when eating them. He was diagnosed with gastroethese reactive changes in the bones. How about the sophageal reflux and started on ranitidine, but feeding petechiae? There is definitely an active process going on habits did not improve. He was evaluated in a feeding that is interfering with his normal bone growth. Could and swallowing disorder clinic, but because he would he have had some sort of toxic ingestion or a metabolic take some foods during the therapy and he was growing disorder? It would seem that a metabolic disorder well, he was discharged from the clinic after just a few would have presented much earlier in life. Would sessions. He had not had any therapy since he was 5 parathyroid dysfunction or a vitamin deficiency present years old. in this way? Could there be some toxic exposure? His current diet consisted of strawberry Pop Tarts You go back to his mother with more extensive quesand whole milk for breakfast, peanut butter on white tions. He lives on a farm, where his father is a vegetable bread and whole milk for lunch, and pasta with butter farmer and his mother stays at home. He has a younger or an occasional slice of pizza (once or twice a month) sister and an older half-sister, both of whom are for dinner. His preferred snack was cheese curls, and healthy. There are no risk factors for lead intoxication preferred drink was whole milk with an occasional and no heavy metal exposures (which could also soda. His mother says he never deviates from this diet, >> p.48 explain the MRI changes). You order more lab tests. even having specific brand preferences. SEPTEMBER 2008 CONTEMPORARY PEDIATRICS 47

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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