case 7 Toddler With Fever and Abdominal Tenderness

Toddler With Fever and Abdominal Tenderness

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BACKGROUND
A 14-month-old boy is brought to the emergency
department by his parents for an evaluation of
persistent fever, vomiting, and diarrhea that has
lasted for 3 days. The mother states that her
son's pediatrician examined him 2 days ago for a
"viral illness." However, the child has appeared
increasingly ill since then. He has become
irritable, and he has been minimally active and
feeding poorly. He has had normal stool output
and appearance and his normal number of wet
diapers. The parents deny observing a runny nose,
cough, and wheezing or stridor. The child lives
at home with his parents, he is not in day care,
and he has had no contacts with people who are sick.

On physical examination, the boy is crying,
fussy, and poorly consoled. His vital signs
include a rectal temperature of 101°F, a
respiratory rate of 32 breaths per minute, a
blood pressure of 98/56 mm Hg, and a heart rate
of 168 beats per minute. His oxygen saturation is
100% while he is breathing room air. The
patient's weight is 10 kg. Palpation reveals
diffuse abdominal tenderness without rigidity or
guarding. The patient has diffusely hypoactive
bowel sounds. His stool is negative for occult
blood. The rest of the physical findings are otherwise unremarkable.

Abdominal conventional radiography and CT are
performed (see Images). Laboratory investigation
reveals the following results: WBC count 19.4 X
109/L with a predominance of neutrophils,
hemoglobin 8.4 g/dL, hematocrit 26.6%, platelets
310 X 109/L, Na 136 mmol/L, K 3.8 mmol/L, Cl 105
mmol/L, CO2 20 mmol/L, BUN 6 mmol/L, creatinine
17.7 µmol/L (0.2 mg/dL), and glucose 4.1 mmol/L
(73 mg/dL). Urinalysis shows trace ketones, but
the results are otherwise normal.

What is the diagnosis?
Hint
The patient's symptoms developed approximately 2
days after the mother dropped a box of pins on the carpet at home.
Author: Anusuya Mokashi, Medical Student, New York Medical College, Valhalla

Justin Weir, Medical Student, New York Medical College, Valhalla

Margaret D. Smith, MD, Program Director,
Department of Medicine, St. Vincent Catholic
Medical Centers (SVCMC) St. Vincent's Hospital
Manhattan, Senior Associate Dean and Associate
Professor of Clinical Medicine, New York Medical
College, St. Vincent's Hospital Manhattan
eMedicine Editor: Erik Schraga, MD, UCLA - Olive
View Medical Center Residency, Department of
Emergency Medicine, Olive View - UCLA Medical Center

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