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A 6-month-old boy was hospitalized because of fever and suspected central line sepsis. He had been receiving total parenteral nutrition (TPN) since shortly after birth following a small-bowel resection, which was performed to repair a midgut volvulus. Abdominal ultrasonographic findings after the procedure were normal. The infant was born at term after an uneventful pregnancy and delivery. Alkaline phosphatase and γ-glutamyl transpeptidase levels were elevated, without hyperbilirubinemia. An ultrasonogram showed hyperhomogeneous and nonhomogeneous echogenicities of the liver, consistent with fatty changes and fibrosis.

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A 16-month-old girl was initially brought to her primary care physician because of persistent nonproductive cough of 1 to 2 weeks’ duration, with lethargy, poor feeding, and worsening cough for the past 36 hours. She had been afebrile. The patient was noted to be pale and had a decreased level of interaction. She was promptly sent to the local emergency department. Laboratory studies showed a hemoglobin level of 3.8 g/dL and hypochromic microcytic anemia. The patient was subsequently transferred to the pediatric ICU for evaluation.

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A 10-year-old boy injured his left elbow during football practice. He subsequently had pain with normal range of motion of the elbow.

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Scleroderma may present at any age and can be localized or systemic. Localized scleroderma affects the skin, subcutaneous fascia, and occasionally muscle and bone. Systemic scleroderma is characterized by chronic disease with both skin changes and visceral abnormalities. Rarely, localized scleroderma may progress to systemic disease; however, screening for this form is unnecessary in patients who have no systemic symptoms.1-5

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Match the following clinical characteristics with the photographs of Cases 1 and 2. Then read the brief descriptions that follow on pages 314 and 315 to see how well you did.

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Photoclinic: Catscratch Disease This 12-year-old girl had a persistent, nontender enlarged lymph node in the right groin. After the lymphadenopathy had failed to respond to antibiotic therapy, pathologic examination of the lymph node established the diagnosis of catscratch disease. The child remembered that she had been scratched on the right calf by a cat the month before; the scratch had already healed when the lymph node appeared. This child had no symptoms other than lymph node enlargement; however, systemic symptoms of fever, malaise, and headache may occur 2 to 3 weeks after a cat scratch. Spontaneous node regression usually occurs within 4 weeks writes Barbara Barlow, MD, of New York, NY.

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A 5-year-old girl presented with a 2-day history of a widespread pruritic rash that began while the family was on vacation. The rash appeared suddenly as small pink macules and progressed to papules and pustules. Her brother had a similar-appearing but milder rash. She denied fever, chills, or constitutional symptoms. On further questioning, her father reported that she and her brother had been in a hot tub at their vacation home.

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Twenty-two-month-old girl seen in the emergency department (ED) after several hours of abdominal pain associated with non-bloody, non-bilious emesis. Over past 2 months, has had 7 or 8 similar episodes of abdominal pain followed by emesis 1 to 2 hours later.

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The parents of this 4-month-old infant were concerned about an atrophic, 0.6-cm area on their son's parietal scalp that was surrounded by dark hair. The rest of the scalp was normal, and the child was otherwise healthy. Benjamin Barankin, MD, of Edmonton, Alberta, made the clinical diagnosis of the hair collar sign--growth of long, dark, coarse hair around a scalp lesion that may be a marker for underlying defects. The sign is sometimes found in association with aplasia cutis congenita, in which a portion of skin is absent--most commonly this manifests as a solitary round lesion on the scalp. These lesions may have healed at birth with a scar or they may remain eroded or ulcerated.

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In the aftermath of Hurricane Katrina's devastation in the Gulf Coast region, it is important for physicians in the United States to consider the infectious disease risks for children who have been displaced or who are still living in affected areas. These risks include infections acquired through ingestion of waterborne organisms; wound infections; lack of immunization continuity; and overcrowding, which increases the risk of respiratory or GI infections. In addition, problems will arise from disruption of therapy for select populations of children, such as those who are HIV-infected; those receiving immunosuppressive treatment; and those in need of continuous antibiotic prophylaxis, such as those who have sickle cell disease.

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Labor was induced at term in a 29-year-old woman who had had an uneventful pregnancy. Her baby weighed 3575 g (7 lb, 14 oz). The neonate’s left arm was internally rotated with flexion at the wrist. He had a normal grasp reflex, but Moro reflex was incomplete.

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Asthma exacerbations continue to cause a significant number of emergency care visits and hospitalizations among children.1 In “Managing Asthma in Children, Part 1” (CONSULTANT FOR PEDIATRICIANS, May 2009, page 168), we reviewed the epidemiology, risk factors, and diagnosis of asthma in children. We also discussed how to make an initial assessment of asthma severity. In Part 2, we review the key components of treatment.

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The sharply demarcated, smooth red plaques on this 3-year-old's tongue had been present for several months. The child initially refused to stick out his tongue. He cooperated after he was offered a lollipop (with the stipulation that "the wider he opened his mouth, the bigger the lollipop he would receive").

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During hospitalization of a 6-month-old boy for respiratory syncytial virus infection, spiking fevers led to a bacteremia workup.

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Ill-appearing 4-year-old girl with high-grade fever, without chills or rigors, and cough of 3 days’ duration. She also had a sore throat and was unable to move her neck because of pain. No history of rhinorrhea, difficulty in breathing, vomiting, or diarrhea. She had had tonsillitis 2 weeks earlier that was treated with a 1-week course of amoxicillin. Medical history otherwise unremarkable. Immunizations up-to-date.

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The expansion of the immunization schedule for 2009 has resulted in several success stories. Two rotavirus vaccines are now available. Following the introduction of immunization against rotavirus, a sharp decline in cases of rotavirus gastroenteritis was seen.

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The imaging studies shown are from 2 children with cancer who underwent placement of 9.6 French left subclavian central venous catheters (CVCs) to facilitate treatment. Fracture of the catheters with subsequent embolization of the distal fragment to the pulmonary arteries was noted at about 18 months after placement. Findings suggestive of impending fracture were missed in previous radiographs. In both cases, an interventional radiologist removed the fragment via percutaneous catheterization of the right femoral vein.

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This palpable, nontender, nonblanching rash had developed on the elbows of an 18-year-old boy and spread to the ankles and feet. The rash was accompanied by moderate abdominal pain associated with episodes of nonbloody emesis that did not change with eating or bowel movements. Diffuse joint pain developed the day after the rash appeared.

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A 3-month-old infant presented with a 4-week history of a symmetric skin eruption on her face, axillae, distal extremities, and external genitalia. The infant was otherwise healthy, although colicky since birth. She was exclusively breast-fed and had a good appetite. Voiding and stooling patterns were normal. Her growth was appropriate for age.

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In Part 2 of this podcast series, Dr Smith continues his discussion of the practice of nonsuicidal self-injury in adolescents.

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A 4-year-old boy was referred for evaluation of refractory eczema that first appeared at 1 month of age.

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A female infant born at 29 weeks' gestation after premature membrane rupture was admitted to the neonatal ICU in respiratory distress.

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A 4-year-old boy presented for further evaluation of persistent right hip painof 2 months’ duration. Before the onset of the pain, he had been limping,favoring his right side. For several days before he was brought in forevaluation, he had had fevers and sweating in addition to the right hippain.

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In this age of evidence-based medicine and randomized clinical trials, it is easy to forget that careful clinical observation and documentation are the foundation of medical practice.

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The mother of this 11-month-old girl was concerned that her infant’s vagina was almost obscured by a membrane. This was noted incidentally a few days earlier.

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For several days, a 9-year-boy has had painful swelling on the top and left side of his forehead, bilateral eye swelling, intermittent fever, and nasal congestion. He was seen in the office 4 weeks earlier, after he had hit his left eye on a school desk. At that time, he presented with a left retro-orbital headache, nasal congestion and discharge, and intermittent fever.

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The mother of an 8-year-old boy sought medical care for her son, who had complained of a sore throat for 3 days. No fever, drooling, rash, rhinorrhea, cough, congestion, ear pain, neck stiffness, or dyspnea was reported. The boy had not been in contact with any ill persons, although his complaints coincided with a local outbreak of streptococcal pharyngitis.

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This erythematous, blanching papular rash developed on the trunk of a 20-month-old boy 3 days after he became ill with a low-grade fever (temperature of 38.3ºC [101ºF]) and mild upper respiratory tract infection symptoms.