Decreased Activity Level - Case 2-6: 20-Month-Old Boy
Decreased Activity Level - Case 2-6: 20-Month-Old Boy: Excerpt from Pediatric Complaints and Diagnostic Dilemmas
I. History of Present Illness
A 20-month-old boy was brought to the emergency department with decreased
activity level. He had been vomiting for the previous 3 days and had had two or
three episodes of nonbloody, nonbilious emesis per day. On the day of
presentation, he had been acting listless all day and appeared pale to the
family. There had been no diarrhea. He had just recovered from coxsackievirus
hand-foot-mouth disease 1 week before development of these symptoms. The family
denied any trauma or ingestions. There had been no fever, rhinorrhea, or cough.
II. Past Medical History
One month before this presentation, the patient's serum lead level was found to be 31 µg/dL. His past medical history was otherwise unremarkable. He had not undergone
any surgical procedure. He was not taking any medications and was not allergic
to any medications. His immunization status was up to date.
III. Physical Examination
T, 37.0°C; RR, 27/min; HR, 75 bpm; BP, 100/68 mm Hg
Weight, 10th percentile; height, 50th percentile
On examination, he was somnolent but arousable. He fell asleep as soon as he was
no longer being stimulated. His head was normocephalic and atraumatic. His
tympanic membranes were pearly gray bilaterally, without hemotympanum. His
mucous membranes were moist. His neck was supple, and there was full range of
motion. His lung and cardiac examinations were normal. His abdomen was soft.
There was no abdominal tenderness, masses, or organomegaly. His extremities
were warm and well perfused. His neurologic examination revealed a Glasgow coma
score of 13 but was otherwise normal.
IV. Diagnostic Studies
A complete blood count revealed 12,100 WBCs/mm3 (86% segmented neutrophils, 9% lymphocytes, and 5% monocytes). Hemoglobin was
7.4 g/dL, and the platelet count was 851,000/mm
3. The MCV was low at 55 fL. Basophilic stippling was noted on the peripheral
blood smear. Samples were sent for a serum lead determination and hemoglobin
electrophoresis. Serum electrolytes and transaminases were normal. A lumbar
puncture revealed WBCs, 4/mm
3; RBCs, 4,365/mm3; glucose, 82 mg/dL; and protein, 31 mg/dL. A urine toxicology screen was
negative. Additional laboratory evaluation revealed a PT of 13.0 seconds and a
PTT of 36.6 seconds.
V. Course of Illness
The child was hospitalized. Over the next several days, he awakened and began to
act normally. A head MRI performed at the time of admission suggested the
diagnosis (Fig. 2-4).
Discussion: Case 2-6
I. Differential Diagnosis
Several diagnoses are possible for this child. Given the microcytic anemia,
basophilic stippling noted on the smear, and history of increased lead levels,
lead encephalopathy is a possibility. However, intracranial hemorrhage is not
characteristic of lead encephalopathy. Other causes of intracranial bleeding,
such as accidental and nonaccidental trauma, must be considered as well. Causes
of intracranial bleeding in children include intentional injury, major trauma
(e.g., motor vehicle collision, substantial fall), aneurysms, arachnoid cysts,
cerebral infections, hematologic disorders, metabolic disorders such as
glutaric aciduria or galactosemia, and hypernatremia.
II. Diagnosis
The serum lead level was normal. The hemoglobin electrophoresis revealed normal
hemoglobin (AA2). The iron level was low, at 5
µg/dL. The head MRI revealed extensive left subdural hemorrhage that extended
over the frontal convexity, down to the temporal lobe, and posteriorly to the
occipital lobe (see Fig. 2-4). Dilated retinal examination performed by an
ophthalmologist revealed multiple bilateral retinal hemorrhages. No fractures,
either new or healing, were detected on a radiographic skeletal survey
(radiographs of all bones in his body).
The final diagnosis was child abuse and iron deficiency anemia. Social services were consulted and determined that a relative who lived in the
house had caused the nonaccidental trauma in this child.
In this child, basophilic stippling of RBCs was noted on the peripheral blood
smear. Basophilic stippling represents aggregated ribosomes and can be a
prominent feature in children with thalassemia syndromes, iron deficiency,
syndromes accompanied by ineffective erythropoiesis, pyrimidine-5
8-nucleotidase deficiency, or lead poisoning.
III. Incidence and Epidemiology
The recognition of child abuse is difficult and requires a high index of
suspicion. The exact incidence of child abuse is not known, but it is more
common than many think: estimates range from 500,000 to 4 million cases per
year in the United States. Homicide is the fifth leading cause of death in
children age 1 to 4 years. Although the exact incidence of abuse may be in
question, the number of child abuse reports filed has increased, partially due
to increased awareness, increased ease of reporting, and perhaps an increase in
abuse.
IV. Clinical Presentation
The presentation of child abuse varies according to the type of injury
inflicted, and medical personnel should be alert to any sign that may indicate
abuse. The child may have been the victim of a one-time abuse or of multiple
previous episodes of abuse. The abuse may be physical, sexual, emotional, or
neglect. The child may have marks and bruises on the body from the abuse, there
may be a change in mental status, the child may present with an intracranial
hemorrhage, the child may present in full arrest or there may be no obvious
signs that the abuse occurred. The perpetrator may not have intended to harm
the child but may have overdisciplined or punished the child, resulting in
abuse. Physical abuse represents 25% of the cases of abuse in the United
States.
Risk factors that place a child at increased risk for abuse include
parental/caretaker factors, child factors, and situational factors. Caretaker
factors that increase the risk of abuse include caretakers who are not prepared
to perform their role, have unrealistic expectations of the child, have a poor
role model, use corporal punishment, have inconsistent discipline skills, have
an unsupportive partner, have psychological issues such as impulse disorder or
depression, have been victims of abuse themselves, or have a substance abuse
problem. Children who are handicapped, have developmental delays, or have
behavioral problems are at increased risk. Economic difficulties, poor housing,
crowding, illness, and unemployment are situations that increase the likelihood
of abuse. Injuries that have occurred without any history, inconsistent
histories,
“magical” injuries, and a delay in seeking care after injury are concerning for abuse.
Physical examination findings of patterned marks, pathognomonic injuries,
multiple injuries, injuries at various stages of healing, and unexplained
injuries are concerning for abuse.
It is important to be able to determine what constitutes abuse and what does
not. Being able to differentiate osteogenesis imperfecta from fractures due to
child abuse, Mongolian spots from bruising, and ecthyma from cigarette burns
are important skills that health care professionals should learn. Normal
bruising is common in children older than 1 year of age; it typically occurs on
the lower extremities and is not associated with petechiae, purpura, or mucosal
bleeding. It is difficult to determine which injuries were sustained
accidentally and which were caused by nonaccidental trauma. If doubt exists, a
social services report should be filed.
V. Diagnostic Approach
Several studies are frequently obtained when abuse of a child is suspected.
Radiographic skeletal survey. A radiographic skeletal survey (radiographs of all the bones in the child's body) is indicated for children younger than 2 years of age.
Radionuclide bone scan. A bone scan is helpful in detecting fractures that did not show up on the
skeletal survey.
Dilated retinal examination. An ophthalmology consultation is frequently helpful in detecting retinal
hemorrhages.
Other studies. Laboratory studies are often indicated as well. A complete blood count, PT, and
PTT should be obtained if the child presents with bruising. Liver function
tests with amylase and lipase should be obtained if abdominal injury is
suspected. Urinalysis is appropriate for abdominal trauma and for the detection
of myoglobin if muscle injury has occurred. Screening for sexually transmitted
diseases and semen may be appropriate if a child presents within 24 to 72 hours
after a sexual assault. Toxicologic testing is indicated if the child presents
with altered mental status. Head CT or MRI may be indicated if the child has a
large head, to look for chronic subdural bleeds, or if there is reason to
suspect intracranial injury.
VI. Treatment
The approach to the abused child is to first treat the medical issues. Anyone
involved in the care of a child is a mandated reporter of suspected child
abuse. It is not the job of the medical team to prove abuse and then report it,
but rather to report suspected abuse and allow the social services to perform
further investigations. The criteria for reporting child abuse vary in regard
to the history, physical examination, and diagnostic results. Occasionally,
physical examination findings alone are enough to trigger the filing of a
social services report. At other times, it is the cumulative effect of the
history, physical examination, laboratory results and caretaker interactions
that trigger the filing of a report. If it is not safe for the child to be
discharged, hospitalization is warranted.
VII. References
1. Christian CW. Child Abuse. In: Schwartz MW, ed. Clinical handbook of pediatrics, 2nd ed. Philadelphia: Williams & Wilkins, 1999:179–189.
2. Kemp AM. Investigating subdural haemorrhage in infants. Arch Dis Child 2002;86:98–102.
3. Ludwig S. Child abuse. In: Fleisher GR, Ludwig S, eds. Textbook of pediatric emergency medicine, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2000:1669–1704.
4. Vora A, Makris M. An approach to investigation of easy bruising. Arch Dis Child 2001;84:488–491.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
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