Index of Suspicion

A baby boy is born by vaginal delivery after a 35-week gestation. During the week prior to delivery, his mother experienced low-grade fever, coryza, diarrhea, abdominal cramping, and mild vaginal bleeding. A small placental abruption was diagnosed, and labor was induced. In the first few hours after birth, the baby develops poor perfusion and tachypnea. Blood cultures are drawn, and he is treated with ampicillin and gentamicin for 5 days and improves. The cultures show no growth.On the fifth day of life, just prior to discharge, the infant suddenly becomes apneic and again demonstrates poor perfusion. He is intubated, stabilized, and again evaluated for sepsis, including lumbar puncture. Antibiotics are changed to vancomycin and cefotaxime. Acyclovir is added.His white blood cell (WBC) count is 14.1×103/mcL (14.1×109/L), with an absolute neutrophil count of 13.1×103/mcL (13.1×109/L) and bands noted on smear. Cerebrospinal fluid (CSF) results reveal 15×103/mcL (15×109/L) WBC, 3,920×103/mcL (3,920×109/L) erythrocytes (believed to be due to a traumatic puncture), a normal glucose level, and an elevated protein level. Bacterial cultures of CSF, blood, and urine are negative. Polymerase chain reaction (PCR) testing of CSF also is negative for herpes simplex.For 24 hours the baby is stable, then quickly deteriorates. He rapidly develops hypotension, severe coagulopathy (with an international normalized ratio [INR] of 10 and partial thromboplastin time [PTT] of >150 sec), renal failure, liver failure, and acute respiratory distress syndrome.Supportive care is initiated, including intravenous fluid, inotropic drugs, fresh frozen plasma, platelet transfusions, and eventually peritoneal dialysis. He develops a massive left intracerebral hemorrhage, resulting in brainstem herniation, with loss of brainstem reflexes. With parental approval, support is withdrawn on the eighth day after birth.A test result reported after death confirms the diagnosis.An 8-year-old boy is brought to the hospital having a 3-month history of cough and occasional fever. The cough is intermittent, is nonproductive, and lacks diurnal fluctuation. He has had no chest pain, hemoptysis, anorexia, weight loss, or headache, nor any history of asthma, allergy, sinusitis, or exposure to tuberculosis. His initial chest radiograph shows normal findings, and results of a tuberculin test with purified protein derivative are negative.On physical examination, the boy’s weight is 55 lb (25 kg) (50th percentile), temperature is 99.2°F (37.3°C), pulse is 86 beats/min, respiratory rate is 20 breaths/min, and oxygen saturation is 97% in room air. He has no pallor, lymphadenopathy, clubbing, or sinus tenderness. Ear, nose, and throat findings are normal. His trachea is midline, and the apex beat is in the left fifth intercostal space at the midclavicular line. The chest is symmetric with normal movement. Percussion reveals normal resonant notes bilaterally. Breath sounds and vocal resonance are completely absent in the entire left hemithorax. Breath sounds in the right hemithorax are normal. Cardiovascular and abdominal findings are normal. Complete blood count, repeat chest radiographs (inspiratory and expiratory), and sinus radiographs show normal findings. A diagnostic intervention is performed.A 2-month-old infant is brought to the emergency department because of progressive respiratory distress. Cough, rhinorrhea, and fever started 1 week ago. As the respiratory distress has worsened, she has displayed acute episodes of agitation with feedings and has had decreased oral intake over the preceding 24 hours. A term infant, she has been well previously.Physical examination reveals a lethargic, pale infant in moderate respiratory distress. Her rectal temperature is 99°F (37.2°C), blood pressure is 83/44 mm Hg, pulse is 190 beats/min, respiratory rate is 60 breaths/min, pulse oximetry saturation is 100%, height is 56 cm (25th percentile), weight is 4 kg (45th percentile), and head circumference is 38 cm (40th percentile). She is breathing with nasal flaring and subcostal and suprasternal retractions. Mild expiratory wheezing is audible. The cardiac examination reveals no murmurs, but a laterally displaced cardiac point of maximal impulse, thready pulses, cool extremities, and a capillary refill of 4 sec are noted. The liver edge is measured 3 to 4 cm below the costal margin.A rapid antigen test for respiratory syncytial virus (RSV) is positive. A radiograph of the chest shows a large cardiac silhouette with streaky perihilar markings. A 12-lead electrocardiogram (ECG) shows deep Q waves in leads 1, aVL, and V6 and ST segment elevation in leads V4 to V6. Further testing confirms the diagnosis.A 16-year-old African-American girl comes to the emergency department because of 1 week of painless, intermittent vaginal spotting without nausea, vomiting, vaginal discharge, or previous bleeding. The patient is sexually active, has multiple sexual partners, and uses condoms occasionally. Her last menstrual period was 3 months ago, and a urine pregnancy test was positive 2 months ago. She underwent an abortion at age 14 years and a miscarriage at age 15 years. Her menarche was at age 11 years, and her menstrual pattern has been regular. There have been no prior medical problems, including sexually transmitted diseases.Physical examination reveals an obese girl in no distress. Her pulse is 83 beats/min, blood pressure is 100/70 mm Hg, respiratory rate is 16 breaths/min, and temperature is 98.7°F (36.7°C). The abdomen is soft, nonrigid, nontender, and free of palpable masses. The vagina shows no discharge or bleeding. A speculum examination reveals some bloody discharge, but no clots or fetal parts. The cervix is closed and has no erosions. A bimanual examination shows no cervical or adnexal tenderness or fullness in the adnexal area. The uterus is large; the examiner could not get around it with his fingers. Laboratory tests lead to the diagnosis.The CSF viral culture grew echovirus type 11, the infectious agent that caused this baby’s illness and deathEnteroviruses are members of a large group of viruses that includes polioviruses, coxsackieviruses, and echoviruses. Enteroviral infections occur worldwide and have a seasonal peak from May through September in Canada and the United States. Transmission occurs through fecal-oral or respiratory routes. The incubation period is 2 to 6 days. Viral replication occurs initially in the pharynx and gastrointestinal tract. Subsequently, viremia and dissemination of the virus occur. Most infections are asymptomatic or cause a nonspecific febrile illness.Hematogenous dissemination across the placenta or perinatal ingestion or aspiration of infectious vaginal or fecal matter can result in infection in the first week after birth.Neonates are very susceptible to enteroviral disease. Many serotypes cause self-limited syndromes in newborns similar to those in adults. However, some serotypes can cause fulminant disease that often is fatal.In general, signs develop between 3 and 7 days after birth. Early in the course, the manifestations are mild and nonspecific and include poor feeding, lethargy, transient respiratory distress, and increasing jaundice. About 30% of infants have a biphasic illness, with a period of 1 to 7 days of well-being between the initial phase of mild signs and the development of a more severe illness.Serious neonatal disease often manifests as myocarditis, fulminant hepatitis, or meningoencephalitis. Myocarditis usually is due to coxsackie group B viral infections.Fulminant hepatitis is characterized by hypotension, disseminated intravascular coagulation, jaundice, and multisystem failure. Echovirus 11 is the most common isolate from cases of fulminant hepatitis. In the second phase of the illness, significant jaundice, bleeding from puncture sites, and petechiae often are seen. The disease progresses rapidly to severe hemorrhage, liver failure, renal failure, and shock. Laboratory investigation often reveals a metabolic acidosis, severe thrombocytopenia, and markedly prolonged INR and PTT.Most infants who have fulminant hepatitis die within a few days of presentation, despite intensive supportive therapy.The initial presentation of infants who have enteroviral infections is indistinguishable from that of infants who have bacterial, fungal, or herpes simplex sepsis. Therefore, management in the early stages should include consideration of these infections. A sample of CSF should be sent for viral culture and PCR analysis. In this case, the WBC count of 15×103/mcL (15×109/L) was within the normal range for the child’s age, but culture proved the presence of infection. It is worth sending CSF for viral culture or PCR because during enteroviral season one of those tests will be positive in 10% to 15% of CSF specimens, even if the WBC count is not elevated.PCR has revolutionized the ability to determine the presence of enteroviruses quickly from oropharyngeal secretions, stool, blood, CSF, and tissues obtained at autopsy. Serologic testing is impractical because of the existence of many viral subtypes and the delay in obtaining results of testing acute and convalescent specimens for many weeks.Unfortunately, there is no definitive treatment for enteroviral infections of the newborn. Supportive care should be undertaken, including management of respiratory failure, coagulopathy, and shock. Intravenous immune globulin never has been proven to be effective, but has been thought to be useful in case reports. Therefore, its administration should be considered. Pleconaril is an oral antiviral drug currently undergoing investigation for treatment of severe enteroviral infections, but it is available only on compassionate grounds from the manufacturer. (Elaine Gilfoyle, MD, Marina Salvadori, MD, Ram Singh, MD, Children’s Hospital of Western Ontario, London, Ontario, Canada)The association of chronic cough and absent breath sounds in the presence of normal percussion suggests the possibilities of foreign body (FB) aspiration, bronchial compression by lymph nodes, or congenital lobar emphysema. A normal chest radiograph increases the likelihood of FB aspiration. Diagnostic bronchoscopy was performed, and a plastic pen cap (1.25 cm long) was removed from the left main bronchus. The patient could not recollect any episode consistent with aspiration.If asthma and sinusitis are excluded, FB aspiration is one of the most common causes of chronic cough in children. Most patients who have aspirated an FB have a history of an immediate episode of choking, gagging, and paroxysmal coughing, which may lead to medical consultation. However, if this acute episode does not occur or is missed, the aspiration may lead to complications ranging from occasional coughing or wheezing to recurrent lobar pneumonia, intractable asthma, or even chronic bronchopulmonary disease. Rarely, a patient who has aspirated an FB presents with hemoptysis, sometimes months or years after aspiration.Physical findings in a patient who has aspirated an FB vary and are determined by the degree of obstruction produced by the object. An FB may cause airway obstruction by one of two mechanisms. The ball-valve mechanism allows air to pass only during the inspiratory phase but not in the expiratory phase, thereby producing obstructive overinflation. In contrast, a stop-valve mechanism leads to atelectasis because no air can pass, and the air in the portion of the lung distal to the obstruction is absorbed. Physical findings associated with these types of obstruction include limited chest expansion, decreased vocal fremitus, percussion notes that are hyperresonant (due to overinflation) or impaired (due to atelectasis), and diminished breath sounds distal to the FB.Chest radiography may reveal signs of atelectasis or overinflation, depending on the type of obstructive mechanism. In obstructive atelectasis, the heart and mediastinum are drawn toward the obstructed side and remain there during both phases of respiration. In obstructive overinflation, the obstructed lung remains expanded during expiration, but the heart and mediastinum shift to the opposite side. Fluoroscopy also may be useful in certain cases. However, bronchial FB is diagnosed definitively by direct visualization with a bronchoscope. If results of the history and physical examination are equivocal, a fiberoptic instrument can be used. However, flexible bronchoscopy generally is not useful for removal of an FB because it does not permit adequate airway control or instrumentation. If the history, physical findings, and radiograph strongly suggest bronchial FB, the diagnostic instrument of choice is a rigid or open-tube bronchoscope.Endoscopic removal of the FB is the treatment of choice and should be performed as soon as possible. Chest thrusts can be applied to infants and abdominal thrusts to young children who are choking and aphonic. Chest physiotherapy and bronchodilators should not be administered because of the risk of dislodging the FB, which may lead to more severe airway obstruction. Treating complications such as infections also is important.FB aspiration in children can have myriad manifestations. This case reminds the clinician that the possibility of an FB must be considered in children who have acute or chronic pulmonary symptoms and signs, regardless of the absence of a history of aspiration.One interesting aspect of this case is the physical findings produced by the FB. Although the breath sounds were completely absent in the left hemithorax, there were no signs of obstructive overinflation or atelectasis (such as tracheal or mediastinal shift and differences in percussion note). This situation was due to the presence of a small hole in the center of the foreign body (plastic pen cap), which prevented atelectasis or overinflation but was not big enough to allow audible air entry. For the same reason, the chest radiograph did not reveal any abnormality. Even extensive radiographs may not rule out completely the presence of an airway FB. Clinicians must suspect FB aspiration when evaluating children who have pulmonary symptoms and signs that do not have a clear cause. (Ramasubramanian V. Kalpatthi, MD, Lincoln Medical and Mental MD, presentation was consistent with the of heart failure, and the findings were consistent with a presentation is of an of the left from the pulmonary If the had not been on the chest radiograph and not been performed, the patient have been diagnosed as having only an are to from on the eventually with the The cause of the of the is to occur in one of two The first that two are and that is by of the or of one of the The second that there are and that but two In this a the results in a from the pulmonary and with the left main to result in who have usually in early at 2 to 3 months of the left is to the pulmonary in the period the by the left is by blood that is but normal is transient only with or As the pulmonary and pulmonary pressure the left from the pulmonary becomes and eventually the pressure in the pulmonary is not to blood the The body to through that develop from the right to the left these have blood may be to that portion of the by the left The right becomes the main of blood for the because it from the the pulmonary pressure due to pulmonary through the left as the right is by the and the left and right are by blood from the right to the left and the pulmonary the of the left which has been as the usually is not a in the or in the pulmonary are However, at 6 to of age, when the pulmonary pressure below a and for oxygen have perfusion of the becomes through the and who do not will more from also can be in patients who have and of infants who are in heart is for Many types of congenital heart disease in infants can cause heart failure. may be by the age of birth, such as severe or pulmonary and large are most In the first week of life, of the small left heart pulmonary and or pulmonary can cause heart 1 to 4 after birth, of the with associated and may 4 to 6 some such as at 6 to 4 months of age, a large and such as are to be the causes of heart the congenital heart may with heart failure, few with in causes of in and include congenital congenital heart disease and and or initial symptoms of are caused by transient and of pallor, poor feeding, of and severe A in oxygen from such as a viral infection may lead to of the left free This on the leads to the development of heart failure. may with wheezing and be diagnosed as having chest radiograph usually demonstrates with of pulmonary The electrocardiogram shows Q waves in leads aVL, and V4 through V6 as well as ST segment elevation in leads V4 through consistent with an The presence of these findings in an infant the of of the left from the pulmonary with currently is the of choice to the of a blood from the the pulmonary In decreased cardiac and left can be seen. with to the and of is only when by is not definitive treatment for this is the is the of the left to its from the pulmonary was performed to from the to the pulmonary to oxygen should be administered to and should be to and the that increases oxygen and oxygen The patient should be for to pressure and should be because it also may and oxygen for patients after is The heart becomes the and heart However, the to a large on the degree and of diagnosed can and a heart may be the only MD, MD, Children’s Hospital of of was a with multiple of The day the patient underwent of the and examination of the the a of and from early tissues of are is as of that an and show of the due to of There is and loss of blood in the has two partial and are characterized by with and fetal or reveals a which most is Complete are characterized by of and of the and absence of fetal The of the is show that the of is completely from the and is not of after of the The patients develop or with as common as In contrast, patients who have a partial pregnancy are to develop with a range from to is a characterized by of the and this is characterized by of and syncytial as well as of is an of the and without the presence of and of normal tissues and to sites, the most common of which are and Most cases of to a gestation. About of are by a a a normal and About 1 of is by bleeding is the most presentation of common signs include symptoms and asymptomatic on chest can be and the those having a and those a poor is diagnosed when are elevated or there is a of in the absence of with a is associated with the last pregnancy having 4 months a in a urine or in the absence of liver or and no prior with a poor is characterized by the last pregnancy having more 4 months an elevated in a urine sample or in the liver or prior and after a term disease is an from the placental It an of syncytial to its for pregnancy is associated with significant including hemorrhage, and pregnancy in range from to cases The two risk most associated with pregnancy are at the of the years and having a history of prior The to pregnancy are not well A for the of was on on the of has the of certain and in the of this manifestations of a pregnancy are in the first or second vaginal bleeding or of abdominal pain, and The should include those that are associated with the because of and the of obtaining in the first a significant of patients who have pregnancy are diagnosed develop a has been diagnosed, of the uterus should be performed, by of the A chest radiograph should be obtained to rule out disease. the toward 10 to after of of may be 1 to 2 the is negative and then for 1 A physical examination, including a examination, is 2 then 3 months for 1 must be to for 1 and usually are treated with has been performed on the occasional patient in of is not an usually with the patient has liver in which case is and or disease of and in patients who have disease is and who have or disease and with a of and is the treatment of choice for patients who have this case, the patient that she was on a positive She had no The could have been because of mild symptoms and the at a young age is a risk for and there is a of of the of should be on including of the of that no and an with multiple the and the The for pregnancy is by MD, MD, of Hospital

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.