Poor Weight Gain - Case 6-6: 21-Month-Old Boy
I. History of Present Illness
A 21-month-old boy presented with weight loss and crankiness. He had been well
until 5 months before admission, when he developed otitis media. This was
treated with amoxicillin. The otitis media seemed to recur 1 month later, and
he was treated with amoxicillin-clavulanate followed by cefuroxime. At the same
time, he began to develop two to four large, mushy, foul-smelling, pale, greasy
bowel movements per day. He become a finicky eater with a very variable
appetite and also developed intermittent vomiting. He had lost approximately 3
pounds and had not had linear growth in the past 3 months. Vomiting often
occurred in the late day or evening and was nonbloody and nonbilious.
II. Past Medical History
This was a full-term infant born to a gravida 1 parity 1 mother. The pregnancy
was complicated by preterm labor at 32 weeks
' gestation. He was born through meconium-stained fluid with a birth weight of
3,700 g. He had been developing normally but recently began asking to be
carried and was not willing to walk for long periods. He tired easily but
refused to sleep. His only medication was a multivitamin. The mother was 29
years old and worked as a nurse at a nearby university. The 30-year-old father
worked as a materials manager at a pharmaceutical company. The family history
was remarkable for a maternal grandmother with ovarian cancer and a maternal
grandfather with congestive heart failure and stroke. The family had been to
Puerto Rico 5 months before presentation. The diet history revealed that the
patient was initially breast-fed, then was changed to Gerber formula with iron
at 4.5 months. Cereals were introduced at 6 months of age, followed by
vegetables, fruits, and meats. He began to refuse meats at 1 year of age.
III. Physical Examination
Weight, 8.77 kg (less than 5th percentile; 50th percentile for a 7-month-old);
height, 80.5 cm (5th percentile; 50th percentile for a 13-month-old). Vital
signs are normal.
In general, the child was pale, wasted, and irritable. There were no oral or
nasal ulcers. The neck was supple. There was only shotty cervical adenopathy.
The lungs were clear to auscultation. The abdomen was distended. There was no
hepatosplenomegaly. There was a prominent vascular pattern on the abdomen as
well as granular subcutaneous palpable patter. The genitourinary examination
was normal. The remainder of the examination was normal.
IV. Diagnostic Studies
Complete blood count revealed the following: 9,300 WBCs/mm3 (7% band forms, 28% segmented neutrophils, 52% lymphocytes, 4% atypical
lymphocytes, and 9% monocytes); hemoglobin, 12.7 g/dL; and 417,000 platelets/mm
3. The mean corpuscular volume was 83 fL, and the reticulocyte count was 1.3%.
Other findings were erythrocyte sedimentation rate, 2 mm/hour; PT, 14.2
seconds; PTT, 31.5 seconds; creatinine, 0.5 mg/dL; albumin, 3.8 mg/dL;
cholesterol, 142 mg/dL; triglycerides, 172 mg/dL; ALT, 134 IU/L; AST, 98 IU/L;
and lactate dehydrogenase, 600 U/L. A sweat test was normal.
V. Course of Illness
In the hospital, upper endoscopy revealed flat villous atrophy of the duodenum
and acute inflammation of the lamina propria.
Discussion: Case 6-6
I. Differential Diagnosis
The differential diagnosis of weight loss is very extensive and potentially
involves almost every organ system. For this child, who had grown and developed
somewhat normally, one would not expect a psychosocial cause unless there had
been some recent change in the child
's family constitution or living environment. The loss of weight and linear
growth over a short period of time suggest an organic cause. The findings of
pallor and abdominal distention also suggest narrowing of the differential
diagnosis to a disease-based cause.
II. Diagnosis
The diagnosis made in this case was celiac disease. This is a genetically predisposing disease that manifests in children who eat
gluten products or related peptides from other grains. Once the child is
exposed to gluten, there is an immunologically triggered reaction to the
absorptive surface of the small bowel.
III. Incidence and Epidemiology
With newer diagnostic tests available, the incidence of the disorder has
increased. In people of European background, it has been identified in 1 of
every 250 individuals in the general population. It has been identified all
around the world.
IV. Clinical Presentation
The clinical presentations of celiac disease are many. The classic presentation
is that of the case presented: weight loss and growth failure in the second
year of life. Table 6-11 identifies other manifestations of the disease.
V. Diagnostic Approaches
The diagnosis has been made by biopsy of the small intestine. Biopsy is the
time-proven method and should be performed if there is a clinical suspicion
despite enzyme testing. The biopsy shows flat mucosa with villous atrophy and
an increased number of lymphocytes. The serologic testing methods for the
disease have improved. Antigliaden antibodies of both IgG and IgA are measured.
Also measurable are anti-smooth muscle antibodies including anti-endomysium and
anti-reticular (IgA). The newest test shows IgA-type antibody to tissue
transglutaminase.
VI. Treatment
The therapy involves a life-long removal of gluten from the diet. This is a
difficult challenge for children and their parents but is successful.
VII. References
1. Farrell RJ, Kelly CP. Current concepts: celiac sprue. N Engl J Med 2002;346:180–188.
2. Kolsteren MMP, Koopman HM, Schalekamp GMA, et al. Health-related quality of
life in children with celiac disease.
J Pediatr 2001;138:593–595.
3. Scoglio R, Sorleti D, Magazzù G, et al. Celiac disease case finding in children in primary care. J Pediatr 2002;140:379–380.
4. Walker-Smith JA, Guandalini S, Schmitz J, et al. Revised criteria for
diagnosis of coeliac disease.
Arch Dis Child 1990;65:909–911.
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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Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2008 Williams & Wilkins.
More About Causes of Weight gain
» Next page: Poor Weight Gain - Case 6-7: 18-Month-Old Boy (Pediatric Complaints and Diagnostic Dilemmas)
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