PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s annual visual diagnosis competition. This year, in addition to the 10 finalists I will be presenting at the National Conference and Exhibition I will be sharing four cases online in advance of the conference. This is the first of the four cases.
This case was submitted by…
A previously healthy three year-old female presents from pediatrician’s office for evaluation of two months of weight loss. Specifically she has had a twelve pound weight loss over the last two months with decreased activity, generalized pain, rash, and bruising for the last week. She has also had daily subjective fevers for the about the last week. Her mother thinks the child is having joint pain, but the cannot localize it. She has also been to other emergency rooms in the past two months, but was told it was likely viral and to follow up both the with pediatrician.
Prior to this illness, the child was happy and playful with a good appetite. Now she only eats a few bites of food at a meal, and she seems to have trouble swallowing liquids – which she has been choking on over the last few days. She is mostly sedentary now, and becomes fatigued very easily. She also had a couple episodes of ”black” stools two weeks ago, and two days prior to ED arrival developed mild dry cough and rhinorrhea. There is no increased work of breathing, no chest pain, and no bleeding from nose or mouth. There is also no nausea, vomiting, or diarrhea. She is urinating less however. There are no sick contacts, recent travel, or tuberculosis exposures. The family is from Cuba, but patient was born in the United States.
Physical Examination
Vital signs BP 130/86 | Pulse 148 | Temp 100.1 °F | Resp 24 | Wt 14.8 kg (31.85%tile) | SpO2 96%
Constitutional Cachectic, tired-appearing, sitting in mother’s lap, not wanting to be examined
HEENT Normocephalic, normal tympanic membranes, rhinorrhea, moist mucus membranes, PERRLA, conjunctiva normal
Heart RRR, no murmurs, good perfusion, pulses strong
Pulmonary effort normal, no wheezes, no rhonchi
Abdomen soft, nontender, no distention, liver 1cm below costal margin
Musculoskeletal No point tenderness, no swelling, no deformities, no vertebral tenderness. Shuffling gait. Pain with extension/flexion of bilateral wrists and ankles. Bilateral knee swelling with erythema. Uncooperative on focal strength testing, movements of upper extremities are slow, but he is able to sit up and get off couch without assistance, does roll over from stomach to back
Lymphatic No cervical, axillary, inguinal lymphadenopathy
Skin ecchymosis over bilateral knees, right shin, right cheek, bilateral wrists. Faint purple periorbital discoloration with petechiae on upper left eyelid. Faint erythematous rash over bilateral elbows, bilateral MCPs, bilateral knees, lower abdomen. Dry, cracked areas on palmar surface of hands bilaterally at PIPs. Dry, erythematous rash over bilateral ears
Neurological no focal deficits
Labs
Abnormal findings in bold
- WBC 8.86 x 109/L – Hgb 11.4 g/L – Hct 34.6 – Platlets 236 x 109/L
- Na 138, K 4, Cl 105, CO2 25, BUN 5, Cr 0.15, Gluc 92, Mg 1.9, Ca 9
- ALT 180, AST 459, GGT 150, Bili 0.3, Lipase 95, Prealbumin 8.6
- LDH 1255, Uric Acid 2.6, CRP <0.5, CK 94, ESR 60
- INR 1.0, PT 14, PTT 40
- TSH 1.063, T4 20.6
- Urinalysis – Trace ketones, WBC 5-10, Bacteria trace, nitrite negative, protein negative
Imaging
- Abdominal ultrasound showed hepatosplenomegaly, and no additional abnormalities
- Chest X-Ray was normal
A. Child Neglect
B. Dermatomyositis
C. Celiac disease
D. Hyperthyroidism
E. Systemic lupus erythematosus
