Quiz Time!

[x SF med]

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.

 

[HoosierAnnie]

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

 

[x SF med]

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.

 

[NeverSayDie]

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

 

[amlove21]

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.

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.

 

[x SF med]

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.

 

[Polar Bear]

Maybe it is a tumor

 

[amlove21]

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.

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.

 

[x SF med]

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?

 

[amlove21]

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.

 

[HoosierAnnie]

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

 

[DoctorDoom]

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.

 

[AF_MD]

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.

 

[AWP]

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

 

[SPLAT]

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...

 

[Blizzard]

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...