Index of Suspicion

Abstract

A 3-year-old, previously healthy girl presents to the emergency department (ED) with fever, increasing abdominal distension, abdominal pain, decreased oral intake, and dysuria. Three weeks ago, she had dysuria and fever (100°F [37.8°C]) and was evaluated by her primary care physician and treated with cefdinir for 7 days for cystitis. She was then taken to the ED 5 days later with increasing abdominal pain and low-grade fever. At the ED, results of her urine analysis (UA) were negative, but she was started on trimethoprim–sulfamethoxazole. Since her symptoms worsened, she was again brought to the ED. Physical examination reveals a temperature of 36.8°C, pulse rate of 148 beats/min, respiratory rate of 32 breaths/min, blood pressure 128/67 mm Hg, weight of 14.5kg (50th percentile) and height of 98 cm (75th percentile). She is sleeping but easily arousable and is non–toxic appearing. She has a firm abdomen in the periumbilical region with tenderness but without other peritoneal signs. There is a small, golf-size, nonfluctuant mass at the suprapubic area. There is no erythema or bruises in this area and no discharge from the umbilicus. Her bowel sounds are normal. Her WBC count is 13.5 × 103/μL. Levels of serum electrolytes, blood urea nitrogen, creatinine, and glucose are within normal limits for age. Repeat UA results are negative, and a bladder scan shows 416 mL of urine. Imaging studies are performed and reveal the diagnosis. She is hospitalized for further management. An 8-year-old boy with a history of behavioral changes and abnormal staring episodes of 4 weeks’ duration is hospitalized for surveillance of possible seizure-like activity. Episodes consist of sleepwalking in the evening—in which he approaches his mother and unresponsively stares for approximately 20 seconds—followed by a period of confusion. He is also noted to have episodes of repetitive kicking and trembling …