Index of Suspicion

Abstract

1. Debbie West, MD* 2. Harry J. Shaia† 3. William E. Wear, MD‡ 1. 2. *Medical Center of Central Georgia, Macon, GA 3. 4. †Medical College of Virginia, Richmond, VA, and Frederick Rahal, MD, Richmond, VA 5. Staunton, VA This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page. We invite readers to contribute case presentations and discussions. A 4-month-old girl is seen in clinic because of fever as high as 102°F (38.8°C) for 4 days and an anterior cervical mass. She appears only mildly ill. The mass measures 4 cm by 2 cm and is firm and very tender. No erythema or warmth is noted. Lymphadenitis is diagnosed and she is given an oral cephalosporin. Two days later, because she has not improved, she is admitted to the hospital, where a computed tomographic (CT) scan reveals a cluster of large lymph nodes without evidence of abscess. Intravenous nafcillin is administered and she is discharged 4 days later on oral medication when her temperature is close to normal. The baby is readmitted less than 1 week later because the mass has enlarged and fever has returned. Her liver edge is palpable 2 cm below the right costal margin. There is an erythematous, scaling rash on her scalp that is thought to be seborrhea. Testing for human immunodeficiency virus is negative, but serology for Epstein-Barr virus is positive. She is sent home on an oral cephalosporin; when seen 2 weeks later, her adenopathy has regressed markedly. She still has low-grade fever, and her mother reports that she has decreased appetite and activity, but she does not look ill. One week later the baby is brought to …