TREATMENTS &
RESEARCH

Search the
latest
treatment
information
here.

Dr. Huntley's
Diagnosis
Checklist

Have a symptom?
See what questions
a doctor would ask.
 
Next Prev
Symptoms » Lower abdominal pain » Book Sections
 

Abdominal Pain - Case 7-6: 2-Year-Old Girl

I. History of Present Illness

The patient, a 2-year-old girl, was well until 1 month before presentation, when she began to experience intermittent periods of abdominal pain. The pain seemed dull, was present throughout the entire abdomen, and did not awaken the patient at night. One week before presentation, she experienced mucousy diarrhea (nonbloody, occurring twice per day). Symptoms of an upper respiratory tract infection developed 2 days before presentation. A sibling had a “cold.” She presented to the primary medical doctor with complaints of fever and worsening abdominal pain. A 3-pound weight loss history was elicited. There was a strong history of pica, specifically geophagy. The family had two cats and a new puppy.

II. Past Medical History

The history was significant for breath-holding spells (none recently), with an extensive workup that included a normal EEG, normal Holter monitor results, and a normal EKG. According to her parents, the child 's growth was always “a concern.” No other information was available with regard to her growth. She had no history of surgery and no drug allergies, her immunizations were up to date, and there was no significant family history.

III. Physical Examination

T, 37.8°C; RR, 20/min; HR, 120 bpm; BP, 92/62 mm Hg
In general, the patient was an alert but pale child. The neck was supple. There was no prominent adenopathy, and the trachea was in the midline. The lung fields were clear. The cardiac examination was unremarkable, with no murmurs, rubs, or gallops. Abdominal examination revealed a soft and nontender abdomen with good bowel sounds, a palpable spleen tip, and a liver edge that was about 2 cm below the right costal margin. The patient was a Tanner I female. The rectal examination revealed good tone, no tenderness on examination, no fissures, no masses, and a small amount of stool in the vault. The neurologic examination was normal.

IV. Diagnostic Studies

A CBC revealed 39,800 WBCs/mm3, with 1% band forms, 18% segmented neutrophils, 53% eosinophils, 17% lymphocytes, and 3% basophils. The hemoglobin was 7.8g/dL. The hematocrit was 29.4%; mean corpuscular volume (MCV), 52.7fL; mean corpuscular hemoglobin content (MCHC), 29.7pg; and red cell distribution width (RDW), 19.5%. The platelet count was 1,000,000/mm3. ESR was 20 mm/hour.

V. Course of Illness

Chest and abdominal radiographs were normal; stool for ova and parasites as well as culture were pending. Serum immunoglobulins were elevated. Anti-A and anti-B isohemagglutinins were markedly elevated (1:16,000 and 1: 512, respectively). ELISA results were pending. The patient was discharged home after a normal ophthalmologic examination and was monitored as an outpatient for resolution of the eosinophilia.
Discussion: Case 7-6

I. Differential Diagnosis

Diseases that are transmitted from animals to humans are called zoonoses. The presence of pets in more than 50% of homes in the United States and the transmission of zoonoses via fecal-oral or direct contact put children at higher risk for these infections. Although this patient had a history of abdominal pain and diarrhea, the most important pieces of the history were the family 's pets and the patient's history of geophagia. Zoonotic diseases that are transmitted via the fecal-oral route and cause gastroenteritis in children include salmonellosis (Salmonella spp., approximately 5 million cases per year), campylobacteriosis (C. jejuni), cryptosporidiosis (Cryptosporidium parvum), giardiasis (Giardia spp., found in 8% of children in U.S. day care centers), dog tapeworm (Dipylidium caninum), and visceral larval migrans.

II. Diagnosis

The clinical history, together with laboratory abnormalities, supported a diagnosis of visceral larva migrans.

III. Incidence and Epidemiology

Visceral larva migrans, or toxocariasis, is caused by infection with dog ascarid ( Toxocara canis) or cat ascarid (Toxocara catis). The reservoir for latent infection is usually female dogs. The parasite requires 2 to 3 weeks after being shed from feces into soil to be infective. Shedding rates vary from 13% to 75% for dogs and 21% to 55% for cats. Areas that usually harbor infectious ova include playgrounds where children might play. The disease in humans is seen primarily in children, especially those with geophagus pica, who ingest soil that contain the larvae. In the United States, children in kindergarten have been found to have antibody prevalence rates as high as 23%, and disease is diagnosed in 3,000 to 4,000 patients per year.

IV. Clinical Presentation

The clinical manifestations of visceral larva migrans vary from subclinical to primarily visceral to primarily ocular. Apparently, ingestion of infectious eggs leads to penetration of gastric mucosa, followed by incorporation into the portal circulatory system and then into the systemic circulation. Damage from traveling larvae and the marked eosinophilic response cause the clinical manifestations, which can include fever, hepatomegaly, irritability, malaise, and pruritic rash. Pulmonary involvement is observed in up to 86% of infected children and can be severe. Ocular complaints can occur alone, and the subsequent strabismus, failing vision, uveitis, or endophthalmitis can occur secondary to local inflammatory response to the infection. The myocardium and central nervous system are also rarely affected.

V. Diagnostic Approach

Age of the child, history of contact with dogs, and geophagus are all important historical clues to the diagnosis. Definitive diagnosis by biopsy of affected tissue is rarely warranted. With a high index of suspicion and supportive laboratory data, the diagnosis can be made. Elevated serum gammaglobulins, a high WBC count with eosinophilia, and elevated titers of anti-A or anti-B isohemagglutinins (50% of patients) are most common.

VI. Treatment

Although there are reports of success with steroids as well as antiparasitic agents in severe cases, the disease is self-limited. Therapy should focus on avoidance of re-infection.

VII. References

 1. Glaser C, Lewis P, Wong S. Pet-, animal-, and vector-borne infections. Pediatr Rev 2000;21:219–232.
2. Weller PF. Visceral larva migrans. Available at: https://store.utdol.com/app/index.asp.
3. Despommier D. Toxocariasis: clinical aspects, epidemiology, medical ecology, and molecular aspects. Clin Microbiol Rev 2003;16:265–272.
4. Tan JS. Human zoonotic infection transmitted by cats and dogs. Arch Intern Med 1997;157:1933–1943.

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.

Other Book Chapters Related to Lower abdominal pain

Read excerpts from these other book chapters related to Lower abdominal pain:

Medical Books Excerpts
  • FLANK PAIN
  • "Algorithmic Diagnosis of Symptoms and Signs" (2003)
  • [ read ]
  • Dyspepsia
  • "Handbook of Signs & Symptoms (Third Edition)" (2006)
  • [ read ]
  • Flank pain
  • "Handbook of Signs & Symptoms (Third Edition)" (2006)
  • [ read ]
  • Dyspepsia
  • "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
  • [ read ]
  • Flank pain
  • "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
  • [ read ]
  • Abdominal Pain
  • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
  • [ read ]
  • Abdominal pain
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
  • [ read ]
  • Flank pain
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
  • [ read ]
  • Dyspepsia
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
  • [ read ]
  • Flank pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
  • [ read ]
  • Abdominal Pain
  • "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
  • [ read ]
  • Dyspepsia
  • "Nursing: Interpreting Signs and Symptoms" (2007)
  • [ read ]
  • Flank pain
  • "Nursing: Interpreting Signs and Symptoms" (2007)
  • [ read ]
 

Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2008 Williams & Wilkins.

More About Causes of Lower abdominal pain



More About This Book:
Title: Pediatric Complaints and Diagnostic Dilemmas
Authors: Samir S Shah MD; Stephen Ludwig MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 0-7817-4188-2

 » Next page: Abdominal Pain - Case 7-7: 3-Year-Old Girl (Pediatric Complaints and Diagnostic Dilemmas)

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

Tools & Services:

Medical Articles:

Forums & Message Boards
 
HONcode We subscribe to the HONcode principles

By using this site you agree to our Terms of Use. Information provided on this site is for informational purposes only; it is not intended as a substitute for advice from your own medical team. The information on this site is not to be used for diagnosing or treating any health concerns you may have - please contact your physician or health care professional for all your medical needs. Please see our Terms of Use.

Home | Symptoms | Diseases | Diagnosis | Videos | Tools | Forum | About Us | Terms of Use | Privacy Policy | Site Map | Advertise

Copyright © 2009 Health Grades Inc. All rights reserved.