Index of suspicion.

Abstract

We invite readers to contribute case presentations and discussions. Please use the Submit and Track My Manuscript link on the Pediatrics in Review homepage: http://pedsinreview.aappublications.org . An 11-month-old previously healthy girl is admitted for persistent fevers and loose watery stools of 2 weeks’ duration. She continues to have normal oral intake and urine output. She was evaluated in the emergency department a week earlier for generalized maculopapular rash. A urinalysis revealed 2 to 5 white blood cells (WBCs) per high-power field with few bacteria, and she was treated for a presumed urinary tract infection (her urine culture result was negative for infection after 72 hours). Later, she was seen by her pediatrician, who was concerned about an atypical presentation of Kawasaki disease. She was therefore treated with one dose of intravenous immunoglobulin (IVIG), however, required a second dose due to ongoing fevers and irritability. She has had no conjunctivitis, oral ulcers, or swelling of the palms or soles and moves all her joints. Her vaccines are up to date, and there has been no recent travel or exposure to unusual animals. Her birth history is unremarkable, and she is developmentally appropriate. On examination, her weight is 10.17 kg (75th to 90th percentile), height is 77 cm (90th percentile), and head circumference is 47 cm (95th percentile). Her temperature is 98.2oF (36.8oC), heart rate is 127 beats per minute, respiratory rate is 32 breaths per minute, and blood pressure is 121/75 mm Hg, which decreases to 104/65 mm Hg when not agitated. She has hepatosplenomegaly without any evidence of lymphadenopathy. Her lungs are clear, and she has no murmur. Laboratory results reveal the following: WBC count, 28,800/μL (28.8 ×109/L), with 54% neutrophils, 12% bands, 24% lymphocytes, 7% monocytes, 1% eosinophils, and 1% basophils; hemoglobin, 5.9 …