# Quiz Time!



## amlove21 (Oct 7, 2012)

So, just for giggles, I want all your medical geek opinions on a pt I saw recently.

You are conducting a MEDCAP in the Horn of Africa. A mother of three brings in her 20 month old African son. The mother states (through an interpreter) that about a month ago, the child "stopped wanting to eat. Even his favorite foods are left alone." As you talk to the mother, the child becomes agitated and scared, and crying. Produces tears and snot (cear) as he cries. In the course of the interview, child falls asleep. When asked if that is normal, the mother replies "He just does that. He gets exhausted from crying or playing, and just runs out of energy and goes to sleep." Mother reports he has some intermittent loose bowel/diarrhea, but is unable to say how many times a day he makes urine/fecal matter. She also states that he sleeps very well at night. 

Upon inspection, the child seems to be undersized and slightly malnourished, but if you saw this child up and walking around, it would not "jump out" that he is malnourished. No signs of trauma, no significant med history because no doctors live where he does. Pt tracks personnel in the room prior to going to sleep, and interacted normally with the mother. HEENT intact and unremarkable. Intact brachial and pedal pulse, HR 110, cap refil -1, no turger, abdomen slightly distended, soft, and reveals no guarding, and the examination did not wake the patient. Lungs are equal and bilateral, with non labored breathing WNL. NSTR for the rest of the head to toe/interview. Reflexes normal. O2 sat normal (98 on ambient air). BGL is WNL. Temp is WNL.

You don't have access to a lab, so you're unable to draw/test labs. You don't have a CT scan or ultrasound because it's a field hospital. 

Let's talk differential diagnosis and treatment.

Discuss!


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## Polar Bear (Oct 7, 2012)

Cool post. I am way off but I am thinking tapeworm


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## LimaOscarSierraTango (Oct 7, 2012)

Great post!  Non-medical opinion: Rotavirus?  I don't know how long it lasts.  A month seems like a long time, and temp seems normal, so I am probably wrong.  But that's my final answer.


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## amlove21 (Oct 7, 2012)

LimaOscarSierraTango said:


> Great post! Non-medical opinion: Rotavirus? I don't know how long it lasts. A month seems like a long time, and temp seems normal, so I am probably wrong. But that's my final answer.


 

Well, there is no "answer", just probability. I like where your head's at- most common cause of diarrhea in kids worldwide, developing country, fecal/oral transmissions (dirty hands touching food). PT was asymptomatic- no fever, vomiting, severe diarrhea, and definitely no pain in the abdomen. Usually the diarrhea and fever are intense in the first week. The maxim "The patient doesn't read the books and won't present how the books teach you" plays here, but gastroenteritis status post 1 month would be more pronounced, I think. Rota usually has an expiration date. I think I'd be pretty comfortable ruling it out.



Polar Bear said:


> Cool post. I am way off but I am thinking tapeworm


 
Parasitic infection made our top 3. While the child was asymptomatic, tapeworms and other worms of that family sometimes produce no symptoms. We couldn't rule it out completely, but if it was tapeworms I would assume his malnourishment would have been much more acute, especially after a month.


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## TLDR20 (Oct 7, 2012)

Mono?


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## 0699 (Oct 7, 2012)

African sleeping sickness.


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## Mac_NZ (Oct 7, 2012)

Its Africa dude, I'm going with AIDs sadly.


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## Diamondback 2/2 (Oct 7, 2012)

Wow that could be a hundred different things here in the USA, much less Africa. I don’t know my ass from a hole in the ground medically speaking, but I am trying to learn… Maybe look at the diet and see if any known food/water contaminations have taken place in the area. Possibly some form of a parasite? Are any other children having the same problems, any other patients with the same symptoms in the last 30+ days? And if so, what have they been eating, drinking, messing with...


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## x SF med (Oct 7, 2012)

Has the kid been eating any domestic animal fecal matter?  What animals live in the hovel with the family?
What are the normal water sources?  How fouled are they?
What are the locally endemic diseases besides AIDS? (trying to make the unicorns go away)

Just getting the better Hx to think


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## HoosierAnnie (Oct 7, 2012)

I'm gonna vere off from any infectious/parasitic cause and head down the gastric tract itself road. A otherwise apparently non-ill toddler that doesn't eat isn't hungry; likely from decreased gastric emptying so what little he does eat keeps him full longer. Now when you combo this with the lower GI intermittent diarrhea, I'm thinking either decreased intentinal motility or obstruction. I'd lean to some sort of obstruction (small bowel), causing a sort of "dam" effect upstream and the diarrhea is leaking around the obstruction. This will also have a negative effect on nutrient absorbtion causing the relatively (for the area) malnutrition hence the easy tiring.


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## policemedic (Oct 8, 2012)

Tagged for later.

I see some folks showing some solid critical thinking and epidemiology skills...more when I have a few minutes.


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## Rangermom (Oct 8, 2012)

H.Pyllori? Just a guess since I had an episode that went undiagnosed for a very long time and presented similarly.


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## amlove21 (Oct 8, 2012)

0699 said:


> African sleeping sickness.


I'll cosign on this one, although 1- the child has never traveled, and we didn't see any other cases of African Sleeping Sickness (ASS?! ). No period of fever, no joint pain, no swollen nodes or "Winterbottom's Sign" (characteristic swelling of the lymph nodes in the back of the neck).  



cback0220 said:


> Mono?


Interesting, and I like it. The spleen didn't feel enlarged, and neither did the lymph nodes, but that's not a solid rule out. It would explain the lethargy and the delayed/non-acute symptoms. 



Mac_NZ said:


> Its Africa dude, I'm going with AIDs sadly.


 
 Where we were had a very large (over 40%) AIDS rate, so it bears some thought. Although, usually full blown AIDS kills from infections (e.g- pneumonia) and HIV has very little discernable symptoms. A lab and a white cell count would be awesome, but no dice. Without those, it's very hard to diagnose HIV. 



x SF med said:


> Has the kid been eating any domestic animal fecal matter? What animals live in the hovel with the family?
> What are the normal water sources? How fouled are they?
> What are the locally endemic diseases besides AIDS? (trying to make the unicorns go away)
> 
> Just getting the better Hx to think


 
In order- EVERYONE here has been eating domestic animal fecal matter, since the beginning of time. We considered Rota and Hanta (mice). Didn't scream "that's it", but cant rule it completely out. Mostly goats (sidebar- I saw a picture perfect ORF case. The lady was astounded I knew she lived with goats). Normal water source is the one and only well in town. CA tested their water a while back, and is was JUUUUUUST this side of potable. The villagers had some pretty good instruction on boiling water before drinking it, but again, we are getting information from the parent, so consider your source. Handwashing is simply not done. Local endemic diseases besides AIDS? It's a veritable "who's who". The main culprits- Unchecked TB, fungal infections, pink eye, everything/anything you can think of being bad. Here is a very long read, for starters (http://www.who.int/diseasecontrol_emergencies/toolkits/Hoa2.pdf).



HoosierAnnie said:


> I'm gonna vere off from any infectious/parasitic cause and head down the gastric tract itself road.


 
BANG! This is what I would diagnose with a gun to my head. Some sort of impaction (mechanical or otherwise) in the bowel, slowly building over time, and that's where we are now. This is what I personally concluded. I don't know if it's _the_ answer, but it's the one I felt most comfortable with, even though the abdominal exam didn't seem to lead that way. CT would be awesome here, and I was dying for a closer look, but alas, no dice. 



Rangermom said:


> H.Pyllori? Just a guess since I had an episode that went undiagnosed for a very long time and presented similarly.


 

We had not thought of this one, but it is HAYOOG in Africa, especially in east Africa. Great catch, Rangermom! That's good work right there.


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## x SF med (Oct 8, 2012)

Wow, the domino effect of multiple low level endemics is astounding, coupled with the in utero infection/antibody array this is very interesting - and without the ability to perform the labs, makes it very difficult to hazard a Dx... the differential algorythym is mind boggling.

Has the kid eaten a stick/rock/piece of cloth and caused a physical blockage in the GI tract?


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## amlove21 (Oct 8, 2012)

x SF med said:


> ... Dx... the differential algorythym is mind boggling....
> 
> Has the kid eaten a stick/rock/piece of cloth and caused a physical blockage in the GI tract?


Tell me about it. The even worse part? I don't know when we are going back, and I wanted to come up with SOMETHING so I could get ABX, some sort of treatment for this kid. It's very likely this child is not going to be seen if he does have a serious problem. But I don't think you can just throw this kid some INANZ or Moxy or cipro and call it good. 

We asked if he could have eaten rocks, something man made, all that stuff. Mother never saw that, but consider the source.


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## LimaOscarSierraTango (Oct 8, 2012)

No signs of scratching or funny taste in his mouth (like metal)?  What color is his urine?  What's his mother's medical history?  Anything she may have passed on?

Just reaching out there a little.

Do you think it could be something as "simple" as anemia?  Then again, out in the Horn of Africa, how many people probably don't have anemia?


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## amlove21 (Oct 8, 2012)

LimaOscarSierraTango said:


> No signs of scratching or funny taste in his mouth (like metal)? What color is his urine? What's his mother's medical history? Anything she may have passed on?
> 
> Just reaching out there a little.
> 
> Do you think it could be something as "simple" as anemia? Then again, out in the Horn of Africa, how many people probably don't have anemia?


Mother didn't report any color for the urine. Mother has no idea what she has/doesn't have, as the only times she's ever seen a doctor had been because she was giving birth. Can't know what the kid was "tasting", he couldn't speak English (or Somali, or Arabic, or French), so dead end there.


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## amlove21 (Oct 8, 2012)

And his skin was warm, lacking of any profound issues, save the scars from "coining", which was very popular where we were.


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## pardus (Oct 8, 2012)

Cholera?


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## amlove21 (Oct 8, 2012)

pardus said:


> Cholera?


Another one we thought through and it just wasn't adding up. We did talk about it, though, so you can pat yourself on the back for that one. 
We thought maybe it was one of those things American kids get shots to prevent, like MMR, and moved past those in short order also.


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## x SF med (Oct 8, 2012)

He could have been invaded by evil spirits...  did exorcism work?

Actually with the multiple endemics, long term malnourishment and tainted water a systemic shut down in an infant is not unheard of, the constant multiple stresses on all systems can cause the individual sytems to systematically shut down.  The sleeping/loss of weight could be from the adrenal/endocrine shutdown, esp. thyroid malfunction and related pituitary malfunction as a secondary to the thyroid issue.  I'm almost positive that there is little if no iodine in the diet to include the mother's diet while nursing.  Did you check for scurvy and rickets...  I would go for the more nutirtive based disease states at this point - they mimic infectious diseases, esp. when there are combinatory deficiencies in play.


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## HoosierAnnie (Oct 8, 2012)

x SF med said:


> Did you check for scurvy and rickets... .


I might agree with ya there but A) AM made no mention of bleeding gums or deformed bones and 2) the relative short onset


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## x SF med (Oct 8, 2012)

HoosierAnnie said:


> I might agree with ya there but A) AM made no mention of bleeding gums or deformed bones and 2) the relative short onset


 
Not key symptomatic indicators when dealing with pts under 4 y/o  at 20 mo, the pt is probably still intermittently breastfeeding so mother's health and symptoms may play a bigger role in dx than we are all giving room for.


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## NeverSayDie (Oct 9, 2012)

How well nourished are the child's peers? The slight malnourishment could be purely environmental and unrelated.


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## amlove21 (Oct 9, 2012)

x SF med said:


> Not key symptomatic indicators when dealing with pts under 4 y/o at 20 mo, the pt is probably still intermittently breastfeeding so mother's health and symptoms may play a bigger role in dx than we are all giving room for.


 Nope, solid food. Stopped nursing at 1 year.



NeverSayDie said:


> How well nourished are the child's peers? The slight malnourishment could be purely environmental and unrelated.


 Well, it's Africa, so just about everyone is malnourished. However, the appearance of peers doesnt discoun't the pt's symptoms. Just because everyone is doesn't mean his malnutrition is unrelated.


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## x SF med (Oct 9, 2012)

I still think that nutritional deficiencies are at least an exacerbating item in the health of the pt.......  most assuredly there are key minerals and vitamins missing from the diet that are masking or inflating symptomology and severity.


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## Polar Bear (Oct 9, 2012)

Maybe it is a tumor


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## amlove21 (Oct 9, 2012)

Polar Bear said:


> Maybe it is a tumor


 Very well could be! And it could be any number of hereditary causes, some sort of underlying disease process, something.



x SF med said:


> I still think that nutritional deficiencies are at least an exacerbating item in the health of the pt....... most assuredly there are key minerals and vitamins missing from the diet that are masking or inflating symptomology and severity.


 Totally agree.


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## x SF med (Oct 9, 2012)

My damn Merck is in the storage unit... since we just moved, and I don't have a WHO endemics book, or the WHO Peds Manual for sub-Saharan Africa, nor the UNICEF Children's Welfare manual  (Same area focus)...   which would at least give some order to my thought processes....

Did you get to try any IV mineral/vitamin/electrolyte therapy?  As a start at least?


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## amlove21 (Oct 9, 2012)

x SF med said:


> My damn Merck is in the storage unit... since we just moved, and I don't have a WHO endemics book, or the WHO Peds Manual for sub-Saharan Africa, nor the UNICEF Children's Welfare manual (Same area focus)... which would at least give some order to my thought processes....
> 
> Did you get to try any IV mineral/vitamin/electrolyte therapy? As a start at least?


 He didn't need an IV. He was still taking in fluids and small amounts of food without any resistance, he was just eating less and less as time wore on. We gave them electrolytes and some childrens vitamins, enough on both to get him through a couple weeks until he can see a proper doctor, as opposed to some PJ's and 18D's amd CA medics coming up with tons of guesses. I'd love to follow up and see what the deal is, but alas, that's not in the cards.


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## HoosierAnnie (Oct 9, 2012)

I'm sticking with my obstruction premise, either mechanical or paralytic


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## DoctorDoom (Jan 18, 2013)

HoosierAnnie said:


> I'm sticking with my obstruction premise, either mechanical or paralytic


 
I also think it's obstructive. Paralytic or mechanical would have more intermittent pain, and occassional feculent vomiting. In a small child you may even be able to palpate the site of obstruction. I highly doubt H. pylori in a duodenal obstruction in a child this age to be the cause.

Horn of Africa, poor diet, generally minimal symptoms make me think less of an infectious cause (especially if few others in the family have similar symptoms).

Based on diet in that region, age, and the insidious onset of loss of appetite without severe malnutrition, I am suspicious of gastric obstruction from a phytobezoar.


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## AF_MD (Mar 28, 2013)

This case is classic for intussusception. Fits the age group and symptomatology. Children will have intermittent acute episodes of abdominal pain with crying followed by lethargy due to presumed natural endorphin release. The bowel will telescope in and out repeatedly and can become incarcerated leading eventually to bowel ischemia and bleeding (currant jelly) and even death. He may have a lead point leading to the intussusception caused by lymphadenopathy, helminth infection, Meckel's, etc. Ultrasound would have been nice to have to make the diagnosis.


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## AWP (Mar 28, 2013)

AF_MD, please post an Introduction in the correct subforum before posting again.


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## SPLAT (Apr 4, 2013)

I have never been to Africa but have spent a bit of time in Central America with a lot of parasitic infections and such.  I might be crazy, but I don't think that is this kid's malfunction.  Gonna go out on a limb here but it sounds like he has a Patent Ductus Arteriosus.  Symptoms match, Usually not symptomatic until 18 to 24 months of age, easily fatigued by eating or playing, falls asleep (passes out) due to hypoxia, not grossly malnurished but below the size / weight / development curve, assessment done while asleep so there would be no exertional dyspnea and the PDA murmur is very hard to detect in my experience and is easily missed in the field, harder to detect in dark complected children because cannot appreciate the circumoral cyanosis upon suckling....he may have a few other things going on as well, but my money would be on PDA as his primary issue.  Dose of Indomethacin would fix him right up.  Just my guess...


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## Blizzard (May 4, 2013)

amlove21 said:


> Nope, solid food. Stopped nursing at 1 year.


What did his diet consist of? Celiac a possibility?

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3264942/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2846249/

Undersized, distended abdomen, fatigue, irritability, diarrhea...only went to solids ~8 months earlier...now reluctant to eat...


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