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(Pediatrics in Review. 2008;29:243-248.)
© 2008 American Academy of Pediatrics

Index of Suspicion

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

	Case 1 Presentation

 
A 9-year-old girl has experienced projectile vomiting, upset stomach, and a 9-lb weight loss over a 3-week period. After GI evaluation reveals no abnormalities, her pediatrician consults a pediatric neurologist, who orders an MRI that reveals a 1.6x1.6x1.0-cm homogeneously enhancing pituitary macroadenoma. The tumor elevates the optic chiasm minimally. A neuro-ophthalmologic evaluation demonstrates no evidence of optic neuropathy, cranial nerve palsy, or chiasmal syndrome.

Physical examination reveals weight loss and decreasing height velocity (1.53 cm/y) over the preceding 3 years, resulting in a drop from the 95th percentile to the 10th percentile in height.

CBC, blood chemistries, liver function tests, insulin-like growth factor (IGF-1), and cortisol values are normal. Prolactin is elevated at 94.7 ng/mL (4,117.4 pmol/L). Pituitary macroadenoma is diagnosed, and the patient is referred to the pediatric endocrinologist for preoperative evaluation.

	Case 2 Presentation

 
A 23-month-old girl is referred to a pediatric neurologist for evaluation of generalized hypotonia and global developmental delay. She was born at term after a normal pregnancy and delivery. Breastfeeding failed because of poor latch and weak suck. Bottle feeding was possible only by widening the nipple holes. At birth, her weight was at the 25th percentile and her length and head circumference were at the 10th percentile.

At 6 months of age, the baby showed no interest in her environment, could not sit without support, was not bearing weight, and was not reaching for or holding toys. Evaluation at that time yielded normal findings on MRI of the brain and laboratory studies (creatine kinase, acylcarnitine profile, serum amino acids, urine organic acids, karyotype, fluorescence in situ hybridization for Prader-Willi syndrome).

At 23 months of age, there has been little developmental gain, with the exception of the ability to sit briefly without support and minimal babbling. There has been no regression.

On physical . . . [Full Text of this Article]

Barbara Marshall, MD
Karen Chernoff, BS
Paul Saenger, MD
Montefiore Medical Center, Bronx, NY

John R. Mytinger, MD
James A. Blackman, MD, MPH
Howard P. Goodkin, MD, PhD
University of Virginia Health Systems, Charlottesville, Va

Brian Kit, MD
Betina Franceschini, MD
Children's National Medical Center, Washington, DC, and Anne Arundel Medical Center, Annapolis, MD

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