Index of Suspicion

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A 14-year-old girl has experienced vomiting, abdominal pain, and weight loss over the past 11 months. The symptoms initially were associated with consumption of dairy products, and a switch to soy-based products led to temporary improvement. However, she continues to have nonbloody, nonbilious vomiting. She has restricted her intake for fear of vomiting. Four months earlier, an evaluation that included abdominal and pelvic ultrasonography and head CT scan was performed by a gastroenterologist and yielded normal results. Trials of prochlorperazine, metoclopramide, and proton pump inhibitor were unsuccessful. She denies diarrhea, headache, fevers, chills, dysuria, dysmenorrhea, binging, purging, and dieting as well as the use of laxatives, diuretics, tobacco, alcohol, or drugs. She reports regular menstrual periods monthly. Past medical history is significant for two episodes of urinary tract infections. Family history is noncontributory. She lives with her parents and siblings. She is in the ninth grade, has a grade point average of 4.0, and remains active in dance. She denies body dissatisfaction or pressure to lose weight. On physical examination, the girl's body mass index (BMI) is 17.3 kg/m2 (10th to 25th percentile for age), temperature is 35.6°C, and heart rate is 44 beats/min. She looks tired but is not in acute distress. Cardiovascular examination reveals bradycardia. Abdominal examination findings are unremarkable. She is admitted to the hospital for bradycardia and malnutrition. Results of CBC, serum electrolyte panel, and liver and thyroid function tests are normal. An additional study reveals the cause of her vomiting. A previously healthy 9-year-old boy returns with worsening right hip pain, limp, and inability to bear weight. He was hospitalized for similar symptoms 1 week ago. He denies cough, abdominal pain, back pain, recent illnesses, or trauma. During his hospitalization, laboratory evaluation showed an ESR of 17 mm/hr, a WBC count of 10.9×103 …