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(Pediatrics in Review. 2007;28:139-145.)
© 2007 American Academy of Pediatrics

Index of Suspicion

The first 300 words of the full text of this article appear below.

	Case 1 Presentation

 
A 14-year-old boy who has Down syndrome comes to the ED after feeling dizzy and experiencing a "fainting spell." While waiting to be evaluated, he rapidly develops respiratory distress. He has a 2-day history of conjunctivitis and coldlike symptoms but no other complaints.

No cardiac problems are reported. He is in remission from acute lymphocytic leukemia and has been off chemotherapy, which included doxorubicin, for more than 4 years. He lives near a small town in west Texas. There is no history of recent travel or contact with sick people.

On physical examination, the boy is leaning forward and cannot speak. He is afebrile, his respiratory rate is 60 breaths/min, and his blood pressure is 124/84 mm Hg initially but soon drops to 80/40 mm Hg. Lung examination reveals rhonchi and rales bilaterally. Cardiac and abdominal findings are normal. A chest radiograph reveals severe pulmonary edema. His condition worsens within 2 hours of arrival.

He is intubated, and copious secretions are encountered. Arterial blood gas results are: pH, 7.21; PCO₂, 30.6 torr; PO₂, 47.3 torr; and HCO₃, 9.3 mEq/L (9.3 mmol/L). His WBC count is 45x10³/mcL (45x10⁹/L) with a left shift, Hgb is 19.7 g/dL (197 g/L), Hct is 57.2% (0.58), and platelet count is 16x13⁹/mcL (16x10⁹/L). His prothrombin time is 14 seconds, partial thromboplastin time is 78.8 seconds, and fibrinogen concentration is 246.7 mg/dL (normal). Echocardiography yields normal findings.

The boy's hypotension and hypoxemia continue despite administration of intravenous boluses of fluid, fresh frozen plasma, diuretics, vasopressors, and oscillator support. He dies 14 hours after presentation. An additional test reveals the diagnosis.

	Case 2 Presentation

 
An 11-month-old boy is evaluated in late winter for elevated transaminase values noted on testing performed prior to scheduled surgery . . . [Full Text of this Article]

David Zlotkin, MD
Amanda Hudgins, MD
Amy Thompson, MD
Christine E Waasdorp, MD
James R. Kerrigan, MD
Shashi K. Nagaraj, MD
Robert P. Schwartz, MD
Texas Tech University Health Sciences Center, Lubbock, Tex
121^st General Army Hospital, Seoul, South Korea
Wake Forest University Health Sciences, Winston-Salem, NC

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