with Thuy Ngo, Johns Hopkins on the Hot Seat
The Case
3 month-old FT girl p/w fever, vomiting and loose stools for the past 2 days. Patient started to have fever (Tmax 102F) 1 day ago with loose stools (5-6 total) and one episode of vomiting (NB/NB). Pt also had slightly decreased PO intake (2 oz formula q3h with baseline being 4-5 oz q3h), no change in wet diapers.
Given persistent loose stools and questionable abdominal pain that mother states she noticed at times, pt was taken to PCP’s office in AM and thought to have abdominal tenderness.
Pt then transferred to OSH with limited work-up done including CBC (WBC 11/Hgb 9/Hct 28/Plt 200), UA showing no WBCs, LE neg, nitrites neg, urine culture and blood culture pending. Pt was then transferred to you for further management.
PMH: Birth weight: 3 kg. At birth, patient had decreased activity and poor PO intake. Patient blood culture showed E.coli and placental pathology consistent with chorioamnionitis. Pt was treated for sepsis w/o complication and discharged at 3 weeks of life. Pt also noted to have intermittent tachycardia (HR 240s) with cardiology consult. Initially, etiology was suspected to be SVT but given a working diagnosis of sinus tachycardia with outpatient f/u scheduled at 4-5 months of life.
ROS: All otherwise negative
Vital signs: T38.9C // HR 185 // RR 68 // BP 77/49 // 100% O2 sat on RA // Wt 5.9kg
Gen: Alert, crying yet consolable
Skin: warm, dry, pink. No rashes.
HEENT: AFOF/PFOF; Eye: EOMI, normal conjunctivae; TMs clear; no pharyngeal erythema or exudates. No nasal congestion.
CVS: RRR, no murmurs or gallop appreciated, 2+ pulses in 4 extremities.
Resp: CTAB, non-labored respirations
GI: soft, slightly distended, ?TTP (difficult to assess given pt crying intermittently throughout exam)
Neurologic: +Moro reflex, palmar and plantar grasp.
Your initial workup includes sending the pt for a chest radiograph showing no consolidation and an abdominal radiograph (shown here), preliminary read as normal:
Questions for you (click on "vote" to record your vote and see what others said):
Your lab test is pending. On re-examination, the baby is less generally fussy and calmer with exam. However, on abdominal exam she clearly has generalized TTP over entire abdomen. Organomegaly is not appreciated.
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Hey, does anybody else think that abdominal radiograph looks abnormal? The resolution on the screen is not great, but I think there is pneumotosis in the RLQ, and the small bowel appears to be tied up in the LUQ. Fever, tender belly, vomiting and the X-ray with ? pneumatosis in a 3 month old deserves a CT abdomen to assess for NEC, volvulus or other surgical badness. Don't waste time with US or UGI, in my opinion, especially if the lytes/I-Stat demonstrates an acidosis.
ReplyDeleteI was looking at this x-ray also, wondering how it was normal. As Dewesh mentioned, and without having evidence on a different view of abdomen, showing that the right side is filling nicely with bowel gas, there is a clear absence of adequate bowel outline on the right. I also wondered about whether I am actually seeing pneumatosis, or bowel wall on bowel wall (showing as bowel wall thickening). The more I look, the more I am worried about intramural colonic air. If the belly is tender all over, then one would have to think about an obstructive etiology such as volvulus.
ReplyDeleteI would keep malrotation on my differential (age), but I would do lytes, but not wait until they are back before I do the CT. I will keep the upper GI in my pocket to use, because depending on the CT, I might have to look for a dynamic study to look for malrotation. But I will do the CT first.
Sounds like CBC and UA are okay. Not sure if the birth history of decreased activity is significant, as it is not clear what this means. the non-bloody, non-bilious emesis potentially goes against a mid-gut volvulus, and the presence of loose stools suggests that there is some passage of material through the entire GI system.
But, I am with Dewesh on the BMP --> CT First.
I agree with Dewesh and Moh here. The KUB does not look normal to me. The loops of bowel look like SB and are moderately dilated and the gaseous loops seem to be more prominent on the left side. That strip of lucency on the RLQ is a weird location for free air on a flat plate. I've seen lucencies like that that radiology calls a 'fat strip' (a layer of fat lining the peritoneum, but usually would be seen bilaterally and symmetrical, not the case here). Can't really assess the bowel wall on my computer screen. NEC is a great thought, though I have never seen it this late in life. In short, febrile, vomiting with diarrhea and dilated loops of bowel collecting on the left side, I'd be concerned about malrotation +/- intermittent midgut volvulus resulting in bowel ischemia. Not sure I would jump to CT, it would probably require sedation for this little tot. Probably would discuss with radiology given my concern for malrotation but also possible NEC, what imaging they would recommend. Probably UGI, keep NPO, IVF hydrate.
ReplyDeleteThank you for an interesting case, Fareed. How often do we see an infant with loose stools and emesis in the PED? Our patient has a history of E.coli bacteremia during the neonatal period, treated presumably without incident and this history of intermittent (impressive) tachycardia. It’s unclear what the work-up for this tachycardia was but I’m assuming an EKG was done which showed upright p-waves thus the diagnosis of sinus tachycardia. Today, she presents with labs and we have a CBC which shows anemia with a hemoglobin of 9, low for 3-month old. We would expect the physiologic nadir around 6-8 weeks of life. The remainder of the labs appear to be within normal limits. She is febrile, tachycardic, tachypneic, and slightly hypotensive, with a distended and possibly tender abdomen to palpation. The 1-view abdominal x-ray shows distension within the small bowel and a linear lucency extending from the RUQ to the RLQ concerning for free air. I would repeat this study and obtain a 2-view study: flat view in addition to an upright/cross-table lateral view to discern if this is free air or a trick played on my aging eyes. Given her current symptomatology, I would double check that there are blood and urine cultures pending at the other facility, or send them now and I would also want a venous/arterial blood gas with electrolytes and a lactate to see if she is acidotic and if imminent doom is on the horizon. I would also guaiac the stools to see if it’s positive as we do not have an explanation for why she is anemic.
ReplyDeleteIf the repeat abdominal x-rays come back and show free air, I would be concerned about:
• NEC - she’s is a bit old for this
• Malrotation/volvulus – the presence of loose stools makes a complete obstruction unlikely.
• Intussusception with bowel necrosis – this is highest on my differential at this time given the intermittent fussiness, abdominal tenderenss, and emesis/diarrhea. Bowel necrosis can lead to bowel ischemia and then bacterial translocation. A plausible explanation for our patient presenting with fever, tachycardia, hypotension, anemia, abdominal pain, and fussiness.
• I always like to add a “miscellaneous” category to my differential to cover any and all other bases.
In addition to antipyretics and IV fluids and possibly broad spectrum antibiotics, I would start with an abdominal ultrasound, especially if I’m able to get it in a timely fashion and if I’m confident in my sonographer. If not, then I would consider an IV/PO contrast abdominal CT but that will also take some time.
Now, if the repeat x-rays come back negative, I would want to increase my differential and take a look at this history of tachycardia. I would wonder if this is an odd presentation of heart failure with a patient’s heart beating at 240 and getting tired of doing so for prolonged periods of time. Also, given her current symptoms and her history of E.coli bacteremia, I would keep galactosemia in the back of my mind although there is no mention of a non-routine birth, abnormal newborn screen in the history, and no evidence of the patient failing to thrive, making this unlikely.
Always interesting cases!
ReplyDeleteA lot has already been discussed above.
About the Xray: Agree that the bowel loops look dilated, I couldn't identify free air in the walls though. The lack of air in the RLQ bowels is tricky on 1 view, so yes, we need more views. Note, most of the time a KUB is ordered, especially in this age group, 2 views or more are recommended.
I would personally start with an U/S as intussusception will be highest on my differential at this point. I have seen it in this age group, actually in a very similar presentation.
The other thing not mentioned would be appendicitis. It presents atypically in this age group (well, we think it is atypical!) and it's very easily missed. I'm not sure how sensitive an U/S for appy is at this age. But a CT would be a next step to consider.
not many comments on the fact the kid is febrile. history of gram negative bactermia and now a febrile illness with diarrhea makes me think the kid has something like a salmonella enteritis/bacteremia and an underlying immunodeficiency. good to at least consider things like galactosemia here, or an underlying gut problem. but 5.9kg is pretty reassuring for a 3mo old.
ReplyDeleteI'm not in a rush to CT the abdomen here, but agree the XR is not normal. I learned that intussusception was a diagnosis of 2mo-2yo. But anectdotally, i've never seen one in less than 6mo and i've seen a ton of ileo-colic ones in the 2-3yo age group. But definitely needs to be considered here.
My approach would be: VBG, 2-view abdomen, blood/urine/stool cx, amp/gent/flagyl, re-evaluation after XR. The XR is going to guide this case. Pneumatosis or free air takes us down a different path than "air not filling in RLQ". US is good for more than just intussusception, remember. a good ultrasonographer can see the position of the SMA to assess for malrotation. So not an unreasonable adjunct here. I vote no CT until there is more information. even pneumatosis (full term NEC) without perforation doesn't always need advanced imaging.
DDx: appy, stones, UPJ obstruction, malro, intussusception (tho xrays not hugely suggestive of the last two, tho remember intermittent malro can present with diarrhea).
ReplyDeleteMy brazen-anecdotal-non-ebm-supported experience:
3 wk old with colicocolic intussusception.
6 wk old with NEC.
6 wk old with appendicitis.
4 wk old with internal hernia (exploding baby belly appearance)
So, in addition to fluid resuscitation and maybe antibiotics, an ultrasound would be a good first test: look for appy, stones, hydro, SMV/SMA orientation AND intussusception. If unrevealing, baby needs a scan, and if looks sick, a bona fide surgery consult.
Thanks for another head-scratchin' brain-teaser. Maybelle
Fareed - great case. And to Thuy - my 2nd year fellow when I was a lowly 1st year fellow, who transitioned me from 30 minute to 5 minute splinting of broken bones - an awesome review of most likely diagnoses. Not much else to add to the extensive ddx thrown out already.
ReplyDeleteStepping back, this kid has had a rough start in life. Not every FT kid spends their first 3 weeks in the NICU and then lands in the ER again with persistent fever and a tender belly. That's either bad luck or bad protoplasm. On the latter end, coming off the recent PEM boards, when I read "E.coli in a neonate", the neuron that fired "galactosemia" was thankfully still working. It would explain the (?hemolytic) anemia, the v/d, and e.coli; some kids have other classic signs early (eg cataracts) but there is clinical heterogeneity with delayed presentations as well. For those of us who can't afford Isabel, I did an OMIM search for "e. coli sepsis" and a short list of syndromes came up, mostly dysmorphic ones and galactosemia was the only one relatively "normal" looking.
All that said about Zebras... most likely diagnoses in the "real world" would be gastroenteritis (bacterial or viral), intuss, malro, appy.