INDEX

OF
SUSPICION
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.

Case 1 Presentation urine, and pleural fluid cultures show Case 3 Presentation
no growth. Further testing reveals the
A 5-year-old girl is seen because of A 3-year-old boy is brought to the
diagnosis.
5 days of fever and worsening cough emergency department because of the
accompanied by nausea, poor appetite, sudden onset of left-sided weakness.
and decreased fluid intake. She com- Case 2 Presentation On waking him this morning, his
plains of right-sided back and shoulder A previously healthy 9-month-old girl parents noticed that he could not
pain and has difficulty walking. She comes to the urgent care center with stand or move his left arm or leg.
has had no contact with ill persons. a 5-day history of diarrhea and 1 day There is no history of trauma nor
On physical examination, her rectal of nonbilious vomiting. She vomited any suspicion of abuse. The child
temperature is 38.9˚C (102˚F), pulse eight times this afternoon and gradu- has had a recent cough and nasal con-
is 151 beats/min, respirations are ally has become lethargic. She is ad- gestion that were treated with a syrup
52 breaths/min, and oxygen saturation mitted for intravenous (IV) rehydration. containing pseudoephedrine and
by pulse oximetry is 95% on room air. On physical examination, the infant dextromethorphan, but he has not
Her respirations are labored, rapid, is sleepy but arousable. Her blood appeared ill. He has developed nor-
and shallow, with nasal flaring, retrac- pressure is 111/53 mm Hg, pulse is mally and always has been healthy.
tions, and occasional grunting. Inspira- 120 beats/min, respiratory rate is Physical examination reveals an
tory crackles are heard over the right 48 breaths/min, and temperature is afebrile, fearful boy who does not
lung base. Scattered palatal petechiae 38˚C (100.4˚F). She is mildly dehy- appear toxic and who shows no signs
are present. Her abdomen is diffusely drated. Results of cardiopulmonary of trauma. Neurologic evaluation
tender, without guarding or rebound examination are normal. Her abdomen reveals decreased strength (grade
tenderness. is soft, and no organs or masses are I-II/IV) in his left arm and leg. Deep
Her leukocyte count is 7,900/mm3, felt; distinct bowel sounds are heard. tendon reflexes are brisker on the
with 76% band forms, 5% metamyelo- Initial blood chemistries are: sodium, left side. No sensory loss is demon-
cytes, and 2% myelocytes. Chest radi- 146 mmol/L; potassium, 2.4 mmol/L; strable. No signs of increased intra-
ographs demonstrate complete opacifi- chloride, 114 mmol/L; bicarbonate, cranial pressure or meningeal irritation
cation of the right middle lobe with a 19 mmol/L; urea nitrogen, 18 mg/dL; are present. The remainder of the
small right pleural effusion. The child creatinine, 0.2 mg/dL; and glucose, physical examination is normal.
is admitted for intravenous rehydration 110 mg/dL. Her stool is guaiac- Results of the following studies
and broad-spectrum antibiotic therapy. negative. are normal: complete blood count;
Despite therapy, she develops mod- Twelve hours later, the child’s levels of electrolytes, blood urea
erate respiratory distress, vomiting, urinary output has decreased despite nitrogen, creatinine, and glucose;
and oliguria. Computed tomography IV rehydration. She has become very liver function tests; prothrombin
of the chest demonstrates a large right irritable, her abdomen is rigidly dis- time; partial thromboplastin time;
pleural effusion with early left medi- tended, and no bowel sounds are and bleeding time. A lumbar puncture
astinal shift. A right thoracostomy heard. A rectal examination is normal. yields normal cerebrospinal fluid.
tube is placed and 400 mL of fluid is An abdominal radiograph reveals an Results of computed tomography
evacuated. air-fluid level in the left upper quad- of the head are normal.
Despite these measures, the child’s rant, with the left diaphragm partially The boy is admitted to the hospital.
condition continues to deteriorate. obscured by a round soft-tissue mass That evening he is much improved
Her platelet count is 18,000/mm3; superimposed on the heart shadow. and the next day is running about
hematocrit, 15%; direct bilirubin level, A gastrografin enema is normal. An normally. One week later, he is read-
22 mg/dL; aspartate aminotransferase attempt to place a nasogastric (NG) mitted for a different disorder that
level, 200 U/L; prothrombin time, tube during fluoroscopy is unsuccess- explains his previous episode of
15 sec; and serum creatinine level, ful. The child is taken to surgery, transient weakness.
1.5 mg/dL. Blood, cerebrospinal fluid, where the diagnosis is made.

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Case 1 Discussion known as Weil syndrome, which of jaundice, azotemia, and oliguria.
is characterized by a hemorrhagic In severe cases, a hemorrhagic diath-
As the child’s clinical course
diathesis, renal failure, and jaundice esis and shock may ensue. Chest
evolved, the constellation of jaun-
(5% to 10% of cases). radiographs usually are abnormal
dice, renal compromise, anemia,
The onset of the self-limited form and may show evidence of large
and thrombocytopenia raised con-
cern about leptospirosis. Serologic of leptospirosis usually is abrupt and confluent areas of consolidation, as
titers for antibodies to Leptospira involves nonspecific flu-like symp- in this case. More commonly, how-
interrogans were obtained and toms, including high fever, chills, ever, there is evidence of bilateral
were positive. Further investigation headache, severe myalgia, and parenchymal disease.
revealed that she lives downhill malaise. Gastrointestinal symptoms The diagnosis of leptospirosis
from a pig slaughterhouse and that are common. Conjunctival suffusion frequently is missed and should be
water seeps into the yard, especially is a characteristic physical finding, considered in the differential diag-
after rainstorms. In addition, a dead but is present in fewer than 50% of nosis of patients who have severe
rat had been found near the house the cases. Physical examination also headache, myalgia, and fever and
prior to the girl’s becoming ill. may reveal the presence of a macu- whose occupational, recreational,
Leptospirosis is a zoonotic lopapular rash, pharyngeal injection, or household activities suggest risk
disease caused by the spirochete hepatosplenomegaly, lymphadenop- factors for exposure. Leptospirosis
L interrogans. The true incidence of athy, and myositis. These signs and may account for as many as 10%
the disease in the United States is symptoms are prominent for 4 to of cases of aseptic meningitis and,
unknown, although it has been noted 7 days during this septicemic stage. therefore, should be considered in
to occur most commonly in the sum- The organism may be isolated from these cases as well. Blood and CSF
mer months. The highest reported both blood and cerebrospinal fluid should be cultured on special media
incidence is in the south Atlantic, (CSF) during this stage. in the first 7 to 10 days of illness, as
Gulf, and Pacific coastal states. After the initial septicemic stage, should urine after the first week and
Sources for infection include the patient defervesces and may during convalescence.
both wild and domestic mammalian show signs of clinical improvement. Serologic tests for the detection
species, especially dogs, rats, and Following an asymptomatic period of leptospiral antibodies are avail-
livestock, who excrete the organism of 1 to 3 days, the patient enters the able, and the diagnosis can be
in their urine. Human transmission immune stage of illness (notable for made by documenting a fourfold
occurs through direct contact of the appearance of immunoglobulin or greater rise in titers of antibody
mucosal surfaces and cut or abraded M [IgM] antibodies). Aseptic menin- in acute- and convalescent-phase
skin with the urine or carcass of gitis, characterized by fever, head- sera taken from a patient who has
infected animals. In addition, trans- ache, and vomiting, is the hallmark a clinical presentation compatible
mission may occur indirectly from of this stage. The CSF cell count is with leptospirosis.
swimming or wading in streams greater than 500 cells/mm3 in most Supportive care and close moni-
or puddles that have been contami- cases, with a predominance of poly- toring of these patients is essential.
nated by the urine of infected morphonuclear cells early in the ill- The hepatic dysfunction in Weil
animals. Persons at risk include ness, followed later by a predomi- syndrome usually resolves and
individuals engaging in outdoor nance of mononuclear cells. Blood rarely is the cause of death. Renal
recreational activities such as and CSF cultures usually are nega- failure may require temporary
freshwater swimming, canoeing, tive during this stage, which lasts hemodialysis, but it also usually
kayaking, fishing, and hunting. from 4 to 30 days. Leptospiruria resolves spontaneously. Penicillin is
Furthermore, certain individuals develops and typically persists for the drug of choice for patients who
are predisposed by occupation, 1 to 6 weeks. have severe illness (1.5 million units
including farmers, ranchers, trap- In approximately 5% to 10% of administered intravenously every
pers, veterinarians, loggers, sewer cases, as in this child, leptospirosis 6 hours for 7 days). In patients who
workers, rice-field workers, and follows a more severe clinical course have mild illness, oral doxycycline
military personnel. Infected people that may be characterized by hepatic or amoxicillin may be effective in
usually excrete the organism in their involvement (jaundice, abnormal shortening the course of the illness.
urine for several weeks, but person- liver function tests, hepatomegaly, The child in this case responded to
to-person transmission is rare. and liver failure) and renal dysfunc- a 7-day course of high-dose intra-
The incubation period for lepto- tion (proteinuria, pyuria, azotemia, venous penicillin. Her renal and
spirosis usually is 7 to 12 days. oliguria, and anuria). This form, hepatic dysfunction resolved with
Following penetration of skin or called Weil syndrome, has a mortal- supportive care, and she had no
mucosal surfaces, the organism ity of 5% to 10% and also involves further complications.
invades the bloodstream and spreads anemia, thrombocytopenia, and Vaccination of dogs and livestock
throughout the body. The spectrum leukocytosis with neutrophilia. prevents disease, but not infection.
of clinical illness includes subclini- Initially, the patient presents with Furthermore, vaccination programs
cal infection, a self-limited anicteric nonspecific, flu-like symptoms, but have not been shown to prevent
febrile illness with or without between the third and seventh day of transmission to humans. For this
meningitis (85% to 90% of cases), illness, the clinical course becomes reason, protective clothing, boots,
and a severe, potentially fatal illness more severe, with the development and gloves should be worn to reduce

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occupational exposure. In adults, displacement of the pyloric region recurrences, the stomach is fixed in
doxycycline 200 mg orally once a anteriorly, in front of the esophagus. position with anterior gastropexy
week is an effective prophylaxis Other factors that can contribute and, if necessary, gastrostomy. Any
and should be considered for high- to the development of gastric volvu- associated intra-abdominal abdomi-
risk groups who have short-term lus include diaphragmatic hernia or nal abnormalities are corrected at
exposure. However, tetracycline eventration, esophageal hiatal hernia, this time.
drugs should not be administered and pronounced distention of the This child did well postopera-
to children younger than 8 years stomach or adjacent intestines. In tively. She was given total parenteral
of age. (Stephanie R. Starr, MD, this case, an attenuated gastrosplenic nutrition and broad-spectrum anti-
Derek S. Wheeler, MD, United ligament, a left hemidiaphragmatic biotics for 8 days. By her ninth
States Naval Hospital, Guam) eventration, and a massively dis- postoperative day, she could tolerate
tended stomach predisposed this G-tube and oral feedings. She was
Case 2 Discussion child to gastric volvulus. sent home 12 days after surgery.
Prompt recognition of gastric Her diet has been supplemented
During laparotomy, a gastric volvu- volvulus is required to prevent with vitamin B12 and iron.
lus was found and derotated. Cloudy infarction. In adults, the Borchardt Although gastric volvulus is
fluid was present in the peritoneal triad of unproductive retching, acute rare, this case reminds the clinician
cavity. The stomach was massively localized epigastric distention, and of the wide spectrum of disorders
distended and infarcted irreversibly. inability to pass a NG tube is patho- that can obstruct the intestinal
A subtotal gastrectomy was per- gnomonic for gastric volvulus. How- tract and of the necessity to keep
formed, sparing a section of the ever, these clinical features are not obstruction in mind when children
gastric cardia and antrum. A par- present in all children who have manifest repeated vomiting or per-
tially infarcted spleen, which was gastric volvulus. Children usually sistent abdominal pain. Nonbilious
attached to an eventrated left hemi- present with a subset of the follow- vomiting, as experienced by this
diaphragm, was separated from the ing symptoms: colicky abdominal patient, suggests obstruction of
eventration. A splenectomy was pain, upper abdominal distention, the gastrointestinal tract proximal
believed to be unnecessary. The vomiting, regurgitation, hemateme- to the ampulla of Vater. Plain ab-
anterior gastric wall was anchored sis, and failure to thrive. This child dominal radiographs may provide
to the peritoneum. A gastrostomy presented with vomiting and later significant clues about the specific
tube (G-tube) was placed. The developed abdominal distention. diagnosis, but often contrast radiog-
patient was admitted to the pediatric The inability to place a NG tube,
intensive care unit for continued raphy is required for definitive
especially during fluoroscopy, treatment. (Mary E. Rimsza, MD,
intubation and further management. should alert the physician to the
Gastric volvulus is a rare dis- John Pohl, MD, Cindy Duke, MD,
possibility of a gastric volvulus. Maricopa Medical Center, Univer-
order in childhood. It is caused by
Abdominal radiography is essen- sity of Arizona College of Medicine,
an abnormal rotation of one part of
tial for diagnosing children who Phoenix, AZ)
the stomach around another along its
have gastric volvulus because the
coronal or sagittal axis. Normally,
the esophageal hiatus, the pylorus, clinical presentation is nonspecific.
On an erect abdominal plain radio- Case 3 Discussion
and four gastric ligaments hold the
stomach in position. The ligamen- graph, a mesentricoaxial volvulus The boy was readmitted to the
tous attachments are gastrophrenic, demonstrates a large gastric shadow hospital after developing complex
gastrohepatic, gastrosplenic, and with double air-fluid levels in the partial seizures with secondary gen-
gastrocolic. The stomach loses its fundus and antrum. A barium study eralization that involved the left
anchoring when the ligaments are shows an inverted stomach and pos- side of his body. Interictal electro-
absent or become attenuated, which sibly an obstruction. An organoaxial encephalography revealed multifocal
allows abnormal mobility of the volvulus demonstrates a large hori- spikes in the right temporal lobe. A
stomach. Gastric volvulus usually is zontal stomach with a single air- detailed family history obtained at
classified as organoaxial or mesen- fluid level. The gastroesophageal this stage revealed a positive family
tricoaxial. Rarely, combinations of junction lies lower than the normal history of seizures on both sides of
these two anatomies may be encoun- position, and the antrum and duode- the family, although neither parent
tered. Organoaxial gastric volvulus num might be distorted. In addition had experienced seizures.
is the most common form and to the volvulus, signs of diaphrag- In retrospect, the weakness re-
accounts for two thirds of the cases. matic hernia or eventration also sponsible for his previous admission
In these patients, absence or laxity might be noted on an abdominal was designated as Todd paralysis
of the gastrohepatic and gastro- radiograph. This child’s radiographic following an unobserved seizure that
splenic ligaments allows the stom- findings were suggestive of an had occurred during sleep. The par-
ach to rotate along its longitudinal organoaxial gastric volvulus with ents had observed only the residual
axis. In patients who have mesentri- a left diaphragmatic eventration. paralysis, which characteristically
coaxial volvulus, laxity of the gas- Treatment of gastric volvulus is resolved completely in 24 hours.
trophrenic ligament and duodenal surgical. After derotation, the stom- Todd paralysis typically occurs in
attachments allows rotation around ach is decompressed with NG suc- a patient who has nonprogressive
the stomach’s transverse axis, with tion or gastrostomy. To prevent neurologic disease that involves

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focal seizures. The seizures are fol- movement against gravity but not organ systems can lead to hemi-
lowed by a brief postictal paralysis. against resistance; III indicates plegia. Embolization of blood
Recovery is complete, with no neu- movement against partial resistance; vessels in the brain may occur in
rologic abnormalities persisting and IV designates movement against association with cardiac arrhythmias,
beyond 24 hours. full resistance. bacterial endocarditis, or cardiac
The cause of Todd paralysis is The term hemiplegia traditionally catheterization. Other cardiac disor-
not completely understood. Initially has been used to describe an upper ders, such as cyanotic heart disease
it was believed that the paralysis motor neuron type of weakness with polycythemia and hypoxia,
was due to “exhaustion” of the in- that involves both limbs on the may predispose to thrombus forma-
volved neurons, but now the paral- same side of the body. The etiology tion. Hematologic disorders such as
ysis is attributed to an inhibitory of acute hemiplegia in a child is sickle cell anemia, hemolytic-uremic
phenomenon, possibly related to diverse; no cause can be established syndrome, and polycythemia also
neurotransmitter dysfunction. The in a significant percentage of cases. can cause thrombus formation.
duration and severity of the seizure Several primary neurologic con- Lesions in the carotid artery, such
do not correlate with the degree of ditions can mimic Todd paralysis. as from accidental trauma to the
postictal paralysis. On the contrary, Hemiparetic seizures, which are neck or tonsillar area, may lead to
postictal paralysis often is more characterized by acute lateralized thrombus formation. Intracranial
pronounced after an arrested partial weakness and a normal mental hemorrhage is a rare cause of
seizure than after a complete, more state, are a type of partial epilepsy, hemiplegia and usually is seen in
severe seizure. The paralysis usually, but the paresis in this disorder is patients who have leukemia, bleed-
but not always, is noted in the ictal rather than postictal. Alternat- ing disorders, and vascular mal-
area of the focal seizure activity. ing hemiplegia of childhood may formations. The mode of onset of
A patient may experience weakness mimic Todd paralysis by causing the hemiplegia is helpful in making
in an extremity other than the one repeated episodes of hemiplegia a diagnosis. Embolic phenomena
involved in the seizure. Aphasia that last a few minutes to a few have the quickest onset, occurring
also may occur. days. A similar transient neurologic in minutes, whereas thrombus
On physical examination, patients deficit may be seen after a migraine formation usually occurs over
who experience Todd paralysis fre- attack, but the presentation usually several hours.
quently will respond to plantar re- involves the typical headache and a Experiences with patients such
flex testing during the time of weak- positive family history of migraine. as this underscore the value of a
ness with extension of the first toe. Transient ischemic attacks (TIAs) detailed history and thorough exami-
After recovery, the reflex reverts to also may present with a focal, non- nation, emphasize the need to con-
the normal plantar flexion response. convulsive neurologic deficit due sider all systems when evaluating a
It is helpful for clinicians to use to interruption of the cerebral per- child who has a puzzling condition,
a grading system to describe varia- fusion. The paralysis may occur and remind the clinician that two
tions in the strength of different abruptly, and the patient may re- quite different clinical problems
limbs or muscle groups. The grades cover completely within 24 hours. can have a common pathogenesis.
range from 0 to IV. 0 rating indi- However, recurrent TIAs can leave (Harminder S. Dhaliwal, MD,
cates that no active movement is slight residual paresis. Columbia Medical Center,
possible; I indicates movement, Embolic and thrombotic events Lewisville, TX)
but not against gravity; II denotes caused by disorders of different

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 Index of Suspicion
Harminder S. Dhaliwal
Pediatrics in Review 1998;19;385
DOI: 10.1542/pir.19-11-385

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 Index of Suspicion
Harminder S. Dhaliwal
Pediatrics in Review 1998;19;385
DOI: 10.1542/pir.19-11-385

The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://pedsinreview.aappublications.org/content/19/11/385

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly publication, it has
been published continuously since 1979. Pediatrics in Review is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright
© 1998 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0191-9601.

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