Hot Seat #19 Denouement: Abdominal Pain, Fever, and Fatigue

by Amy Boutsikaris, Inova Fairfax
with Christina Johns, Children's National, on the Hot Seat

The Case This is a case of an 11 year-old boy with crampy abdominal pain, fatigue, and anemia presenting in shock. For the complete case presentation, click here.

Thank you to Dave and Dewesh for your comments. Click here to read them. Some clinical pearls include recognizing abnormal labs, synthesizing the clinical picture with the labs, work up of potential hemolysis, the importance of dietary history, and not to automatically think infectious just because there is a fever:

• "If I was bold-facing what is "abnormal", I'd probably bold face the MCV=112. A macrocytic anemia is pretty uncommon and it points you in a very different direction from other anemias." -Dave (CNMC)
• "Remember, B12 is only found in animal products (eggs, meat, milk), which his diet seems to lack for years. I'd like to see a lower extremity neurological examination and one focusing on the dorsal columns (if his mental status allows it). I'd empirically give vitamin B12 replacement while awaiting levels." -Dewesh (CNMC)
• "I'm not sure this isn't something acute on chronic." -Dave (CNMC)
• "Folate deficiency can classically present with depressed mental status and weight loss and other nonspecific symptoms (such as this child) with macrocytic anemia." -Dewesh (CNMC)
• "In an autistic kid with food issues to begin with, pica is not uncommon and could explain several symptoms—the hemolysis, decrease in appetite, the abdominal cramping and “gastroenteritis” symptoms (although I know constipation is also commonly described), and the fatigue/mental status changes." -Christina (CNMC, the Hot Seat)

Here's how you answered our questions:
The nurse was only to obtain 1cc of blood with their multiple sticks to obtain an IV, which test would you prioritize? 

More history reveals that the patient has had weight loss and a severely restricted diet. Labs show a macrocytic anemia and mildly elevated INR. The patient remains tachycardic with prolonged capillary refill time after a normal saline bolus.

What is your next intervention?

From the Hot Seat
by Christina Johns, CNMC

Thanks to Dewesh and Dave for getting the ball rolling with the anemia discussion. I think B12/Folate deficiency has to be considered given the history and CBC result, but another thought that entered my mind in the first paragraph was acute and/or chronic lead poisoning. In an autistic kid with food issues to begin with, pica is not uncommon and could explain several symptoms—the hemolysis, decrease in appetite, the abdominal cramping and “gastroenteritis” symptoms (although I know constipation is also commonly described), and the fatigue/mental status changes. He could be shocky if he ingested a large amount of lead over a short period of time due to fluid shift in the GI tract. I can’t really explain the fever, however. In any event, a more thorough history looking for lead exposure would be important.

So in addition to resuscitating this shocky patient the usual ABC way, I’d be tempted to send lead levels and FEP- free erythrocyte protoporphyrin as well as all those other Heme labs Dave mentioned above. Basophilic stippling in the blood cells shows up in lead poisoning as well as Folate and B12 deficiencies so really aren’t too helpful in sorting those 3 out, but I’d like to hear what the blood smear shows anyway. Before I get on fire ordering a bunch of complicated Hematology tests, I tend to consult them relatively early so that I don’t wind up over-ordering and end up with results I don’t know how to interpret.

Lead levels seem to take forever to come back, so Radiology may have to be considered? AXR to look in the GI tract?—to help you decide whether or not you need to start chelation therapy and/or whole bowel irrigation. I’d probably send a type & hold, too.

I love the Poison Control folks, so I’d probably check in with them as well as I started down the road of lead poisoning. These days we don’t think of it very often, especially acutely.

The Denouement
by Amy Boutsikaris, Inova Fairfax

This patient was resuscitated with a repeated bolus of IV fluids, given the undisputed picture of shock. Even prior to lab confirmation of the underlying diagnosis, the chronic nature of the anemia was a clear possibility, so a conscious effort was made to not transfuse too hastily. The child was given 5cc/kg PRBCs immediately and another after monitoring for signs of failure.

A diagnosis of severe anemia was clear, but clinically what seemed to fit was an acute febrile illness acting as a tipping point for more chronic issues of:

malnutrition due to extremely restricted diet (low albumin, low total protein)

B12 deficiency (megaloblastic anemia)

Vitamin K deficiency (elevated PT/INR)

His subsequent clinical course included:

Bone marrow biopsy: "8% myeloblasts (non-leukemic) and no malignant clone; disordered hematopoiesis "classic" for B12 deficiency including hyper segmented neutrophils, very large white cells, disordered erythroblast maturation, and hypercellularity."

Supplementation with B12, folate, Vit K, multivitamin

NG feeds to gingerly improve nutrition for eventual gtube placement for baseline nutrition needs

Enrollment in a feeding program

He did not require more than 10cc/kg PRBC, and it took nearly 1-2 weeks for all of his labs to normalize and his surprisingly, his sallow appearance took nearly 3 weeks to completely resolve.

The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA. Emily Willner is the faculty advisor on case presentations. We welcome your commentary.