A 2-year-old boy is brought to the office by his father because of a 3-month history of decreased activity, poor appetite, sporadic vomiting, clumsiness and speech regression. Since his birth his family has lived in an old area of the city where there is demolition of old buildings.
Examination of a peripheral blood smear is likely to show which of the following?
Correct Answer A: This child suffers from lead poisoning. Prior to the 1970s, lead was used in paint, gasoline, water pipes, and many other products. During the demolition of older structures, lead is released and can become ingested by humans, primarily children. Exposure to excessive levels of lead can cause brain damage; affect a child’s growth; damage kidneys; impair hearing; cause vomiting, headaches, and appetite loss; and cause learning and behavioral problems. Lead eventually becomes associated with mitochondria in red blood cells and appears as basophilic granules via H & E staining. This is a form of sideroblastic anemia.
A 12-month-old girl presents to your office for a well-child examination. She has been growing and developing well. She is taking solids well and has not had any gastrointestinal problems. She is happy and playful, and there are no abnormalities on physical examination. Routine screening reveals a lead level of 50 μg/dl. The child lives in a home built in 1980 and there is no peeling paint.
The most appropriate initial management is:
Correct Answer D:
For lead levels over 45 μg/dl, chelation treatment is usually needed (choice D). No treatment is recommended for blood lead levels below this threshold. This child's lead level is 50 microgram/dl which is higher than the threshold for treatment. If oral chelation with succimer is used as an outpatient, there must be assurance that the home environment is free of lead.
→ A repeat lead level (choice A) within 3 months is acceptable for children with lead levels between 10 and 14 μg/dl, but is not adequate management for a lead level this high. Action should be taken within 48 hours.
→ A complete investigation must be done to identify whether or not the home is actually the source of lead. It is less common for a house built as late as 1980 to contain lead paint (choice B). Lead can also come from pottery, soil, home remedies, plumbing, automobile repair supplies, batteries, and various solvents.
→ Any patient who has a blood lead level over 20 μg/dl needs careful evaluation and repeated blood lead levels (choice C).
→ Emergency hospitalization (choice E) and intravenous chelation is usually reserved for children with lead levels over 70 μg/dl.
A father brings in his 5-year-old boy who complains of fatigue, terrible stomach aches and weakness in his right hand (wrist drop).
His blood results will likely reveal:
Correct Answer A:
Lead poisoning.
High levels of lead in the body are toxic to bone marrow, the central and peripheral nervous system, the kidneys, heart, intestinal tissue, and reproductive system. Symptoms can include abdominal pain, headaches, vomiting, confusion, muscle weakness, seizures, hair loss and anemia.
A particularly vulnerable patient population are children younger than 6 years of age. Canadian homes, in particular those built prior to 1960, do contain lead paint so it is conceivable that lead dust from paint poses an on-going risk to children. The CDC recommends: 1) screening virtually all children for lead exposure at 12 and 24 months; 2) screening children at high risk every 6 months beginning at 6 months of age; and 3) using direct measurement of BPb (annual blood lead levels) rather than erythrocyte protoporphyrin (EP) to screen.
PEARL:
A 3.5-year-old girl is admitted to the Children's Hospital after swallowing an undisclosed number of her mother's ASA (aspirin) tablets. She is hypotensive, flushed, and tachypneic.
Which of the following acid-base disturbances would be most likely?
Salicylate poisoning can cause vomiting, tinnitus, confusion, hyperthermia, respiratory alkalosis, metabolic acidosis, and multiple organ failure in adults and children > 4 years old. Diagnosis is clinical, supplemented by measurement of the anion gap, ABGs, and serum salicylate levels. Treatment is with activated charcoal and alkaline diuresis or hemodialysis. ABGs suggest primary respiratory alkalosis during the 1st few hours after ingestion, later, they suggest compensated metabolic acidosis. Respiratory alkalosis occurs in this age group because aspirin stimulates the respiratory center.
ASA toxicity in children < 4 years of age leads to high anion gap metabolic acidosis with compensation (due to tachypnea). Therefore, the pH will be low or normal (due to compensation). The HCO3 will be low (due to metabolic acidosis) and the pCO2 will be low (due to respiratory compensation).
→ High HCO3-2 (choice B) is seen in metabolic alkalosis. Aspirin toxicity primarily causes metabolic acidosis in children < 4 years old.
→ pH low; HCO3 low; pCO2 high (choice C) shows metabolic acidosis compounded with respiratory acidosis.
→ pH low; HCO3 high; pCO2 low (choice D) is not a feature of any known acid-base disturbance because pH low signifies acidosis, this should be accompanied by either low HCO3 to suggest metabolic acidosis or high pCO2 to suggest respiratory acidosis; it is very unlikely to see an acidic pH, while both the HCO3 and pCO2 point to alkalosis.
→ pH high; HCO3 high; pCO2 high (choice E) shows a metabolic alkalosis compounded with respiratory compensation.
A previously well 8-month-old infant is admitted to hospital following a 12-hour history of intermittent periods of screaming and vomiting. On physical examination, he appears quite ill, he is pale and slightly dehydrated. There is a questionable palpable mass in right hypochondrium.
The most likely diagnosis is:
Correct Answer B:
Intussusception is telescoping of one portion of the intestine into an adjacent segment, causing intestinal obstruction and sometimes intestinal ischemia.
The initial symptoms are recurrent colicky abdominal pain that occurs q 15 to 20 min, often with vomiting. The child appears relatively well between episodes. Later, as intestinal ischemia develops, pain becomes steady, the child becomes lethargic, and mucosal hemorrhage causes heme-positive stool on rectal examination and sometimes spontaneous passage of a “currant jelly” stool. The hallmark physical findings in intussusception are a right hypochondrium sausage-shaped mass and emptiness in the right lower quadrant (Dance sign).
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