index of suspicion sylvia yoo, senthilkumar … · drs yoo, sankararaman, wells, vanchiere, baker,...

DOI: 10.1542/pir.33-5-2332012;33;233Pediatrics in Review

Vanchiere, Scott D. Dickson and Michael S. TankersleySylvia Yoo, Senthilkumar Sankararaman, Troy W. Baker, Wanda Wells, John

Index of Suspicion

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Case 1: Lower Extremity Weakness 2 Years AfterScoliosis Surgery in a Teenager

Case 2: Fever, Cough, Shortness of Breath, Jaundice,and Hepatomegaly in a Teenager

Case 3: Recurrent Infections in a Teenager

Case 1 PresentationA 14-year-old girl presents with 10days of progressive lower extremityweakness together with numbnessfrom her umbilicus to her feet. Shedenies incontinence but notes diffi-culty starting her urinary stream aswell as constipation. She has no feversor headaches. There is no recent his-tory of trauma, illness, travel, camping,or insect bites. Two years before pre-sentation, she underwent a posteriorspinal fusion for idiopathic scoliosiswithout complications. She has donewell, andher progress ismonitored reg-ularly by her orthopedic surgeon, whonotes that she has complained inter-mittently of mild back discomfortbut has had no back pain in the pastfew weeks. There is no family historyof tumors, neurologic disorders, orautoimmune diseases.

On physical examination, the girlis afebrile and has stable vital signs.She is alert and in no distress. Herskin is free of rashes and acne. Hercranial nerves are intact, and her neckis supple. There is no spine tender-ness or erythema on her back. Herupper extremity strength is normal.Lower extremity strength is decreasedto 2–3/5 on the left and 4/5 on theright, with normal tone, bilateral 4þhyperreflexia, and 3 beats of clonus.She has normal rectal tone and de-creased sensation to touch, pinprick,and vibration in her legs. Proprioceptionis difficult to elicit. She walks with sup-port and without ataxia.

Laboratory evaluation shows whiteblood cell (WBC) count of 10.7 �103/mL and hemoglobin concentra-tion of 10.2 g/dL. Her cerebrospinal

fluid WBC count is 13/mL, her glu-cose level is 63 mg/dL, and the pro-tein concentration is 225 mg/dL.Her erythrocyte sedimentation rateis 27 mm/h, and her C-reactive pro-tein level is 4.6 mg/L. An imagingstudy reveals the diagnosis.

Case 2 PresentationA 13-year-old boy presents with fe-ver, cough, breathing difficulty, andreduced oral intake for 6 days. Hewas seen by his pediatrician 4 daysago for the same complaints and wasstarted on treatment with amoxicillin/clavulanic acid and azithromycin forpneumonia. Because the symptomshave not improved, he is referredfor further evaluation. He has beendiagnosed as having severe develop-mental delay, a seizure disorder, autismspectrum disorder, and scoliosis. Hetakes carbamazepine. He has no his-tory of allergies, exposure to pets, sickcontacts, or recent travel.

Physical examination findings reveala malnourished, ill-appearing boywith a temperature of 40°C. Hisrespiratory rate is 30 breaths per min-ute, his pulse oximetry saturation is95% in room air, his heart rate is120 beats per minute, and his bloodpressure is 100/70 mmHg. Heweighs 26 kg, which is well belowthe 5th percentile for his age. Heis icteric, and his liver is enlarged(4 cm below the right costal marginwith a span of 14 cm) and tender. Ex-amination of his chest reveals de-creased breath sounds at the rightbase. The rest of his physical findingsare within his baseline limits.

Pediatrics in Review Vol.33 No.5 May 2012 233

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Laboratory results are as follows:WBC count is 43 � 103/mL (43 �109/L), with 98% neutrophils and2% bands; platelet count is 642 �103/mL (642 � 109/L); erythrocytesedimentation rate is 82 mm/h; pro-thrombin time is 12 seconds;C-reactiveprotein is 19.5 mg/dL, with a serumalbumin level of 1.2 g/dL; direct bil-irubin level is 5.2 mg/dL; aspartateaminotransferase level is 140 U/L;and alanine aminotransferase levelis 132 U/L. Imaging studies revealthe diagnosis.

Case 3 PresentationA 17-year-old boy presents to the pe-diatric clinic for follow-upof a pneumo-nia diagnosed in the local emergencydepartment. It is his second occur-rence of pneumonia in the past6 months, documented as lobar con-solidation on chest radiograph. Hehas experienced recurrent episodesof acute otitis media as a young child,requiring bilateral myringotomy withtube placement. He also reports re-current sinusitis over the past severalyears, requiring frequent courses ofantibiotic treatment. In addition, hehas a recent history of intermittentdiarrhea and subsequently was diag-nosed as having giardiasis and wastreated. He denies any daily medica-tion use and travel outside the UnitedStates, and his immunizations are upto date.

Physical examination reveals a well-developed, well-appearing boy witha temperature of 99.1°F (37.3°C),a heart rate of 89 beats per minute, arespiratory rate of 18 breaths perminute, blood pressure of 96/64mmHg, and an oxygen saturationof 98% in room air. Both tympanicmembranes show tympanosclerosis,his throat is clear, and tonsillar tissueis present without exudate. Findingsfrom the rest of the examination areunremarkable.

Laboratory analysis reveals a WBCcount of 6.1 � 103/mL (6.1 � 109/L; 62.5% neutrophils, 28.6% lympho-cytes, 7.5% monocytes, and 1.1%eosinophils), with an absolute neu-trophil count of 3,813 and an abso-lute lymphocyte count of 1,745.Hemoglobin level is 14.5 g/dL(121 g/L), hematocrit level is 43%,and platelet count is 296 � 103/mL(296 � 109/L). Values for aspartateaminotransferase, alanine aminotrans-ferase, plasma protein, and albuminare normal.

On review of his medical history,additional laboratory evaluation is per-formed, which reveals the diagnosis.

Case 1 DiscussionOwing to the girl’s neurologic find-ings, spinal cord compression wasan immediate concern. MRI of thethoracic spine was nondiagnostic be-cause of metallic artifact from thespinal rods. Computed tomographic(CT) scan of the spine with myelo-gram showed fusion of the thoracicspine from T4 to T12, with the leftT4 pedicle screw traversing the leftparacentral spinal canal, causing com-pression of the spinal cord (Fig 1).There was a bony lucency lateral tothe left T4 pedicle screw and in thevertebral body (Fig 1). The prevertebralsoft tissues were unremarkable.

The patient was taken urgently tothe operating room for removal of allspinal hardware and irrigation anddebridement of the posterior spine,which appeared infected with puru-lent fluid around the pedicle screws.Cerebrospinal fluid leaks were notnoted. Treatment with vancomycinand piperacillin-tazobactamwas startedpostoperatively. Anaerobic wound cul-ture samples grew Propionibacteriumacnes at day 7 (the culture speci-men was requested to be held for 2weeks).

Background and DifferentialDiagnosis

There is limited literature on late-presenting infections after scoliosissurgery, with several case reports anda few retrospective studies that reportan incidence of 0.3% to 8.3%. The im-portance of awareness of this possiblecomplication can be drawn from theprevalence of adolescent idiopathicscoliosis at 3% of the population, with10% of those affected requiring treat-ment, and the potentially devastatingneurologic outcome of complicationsthat can occur if infection is not recog-nized and treated promptly.

Spinal cord neoplasm and epiduralabscess were high on the differential,given her indolent presentation andabsence of systemic symptoms. Otherpossibilities were transverse myelitisand multiple sclerosis, which can pres-ent with weakness but are unlikely tohave upper motor neuron signs.Guillain-Barré syndrome and tickparalysis can present with ascending pa-resis, but these patients also are usuallyhyporeflexic.

Clinical and DiagnosticFeatures

The organism that grew in this pa-tient’s wound culture sample has beenreported commonly to cause late-presenting infection after scoliosissurgery. P acnes is a Gram-positive ba-cillus found in hair follicles. It isanaerobic but tolerates limited amountsof oxygen. The bacterium can estab-lish chronic infections without provok-ing a host immune response becauseof its cell wall structure, which mayprevent degradation from neutrophilsand macrophages, and it may be ablealso to suppress T-cell activation. Inaddition to requiring anaerobic condi-tions for optimal growth, this microbegrows slowly, making it difficult togrow in a culture sample, unless it issuspected. Culture samples usually arepositive by 8 to 10 days.

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234 Pediatrics in Review Vol.33 No.5 May 2012



Other implant-related infectionshave been associated with P acnes,including endophthalmitis after in-traocular lens placement, ventricu-loperitoneal shunt infection, andprosthetic joint infections. Otherorganisms implicated in late-presentinginfections after scoliosis surgery areStaphylococcus epidermidis, S aureus,andMicrococcus varians. Culture sam-ples may be negative despite a puru-lent appearance of the site, possiblybecause of aseptic inflammation re-sulting from corrosion of the im-planted metal or inadequate cultureconditions. P acnes typically is sensitiveto penicillin and clindamycin, but sen-sitivities should be obtained on all cul-ture samples because resistance toantibiotics has developed.

The first scoliosis surgery was per-formed in 1930, and since the 1970s,

there have been advances in the im-plants used, with modular systemsthat provide more versatility in surgi-cal correction. The bulk of thesemodular systems has been implicatedas a possible contributing factor to theincidence of late-presenting infections.It has been thought that the delayedinfection is caused by intraoperativeinoculation, despite sterile techniqueand antibiotic prophylaxis, followedby an indolent period. Hematoge-nous seeding is another possibility.It also has been suggested that anaseptic process caused by metal cor-rosion leads to irritation and inflam-mation resembling infection.

The most common presentingsymptoms are back pain after a pain-free interval and swelling with or with-out fluctuance and drainage. Fever isuncommon. This infection presents

an average of 2 to 3 years after theprocedure and was described in onecase report to present after 14 years.Lower extremity weakness similar tothis patient’s was described in one casereport but is not reported as a frequentpresenting symptom in retrospectivestudies. Laboratory evaluation resultsusually are normal. Most patientshave elevated levels of inflammatorymarkers, but normal levels do notrule out this infection.

Management and PrognosisThe recommended treatment in-cludes removal of instrumentation,irrigation, debridement, and a courseof antibiotic treatment. Naturallythere is concern for loss of correctionor pseudoarthrosis if instrumentationis removed, but these complicationsappear to be significant only if the im-plants are removed earlier than 18months after surgery. No significantdifference in pain, function, self-image,or satisfaction was observed betweenthose who had late-presenting infec-tion and those who did not. This pa-tient received 1 week of treatmentwith intravenous vancomycin andpiperacillin-tazobactam until culturesample and sensitivity results wereavailable; she was then dischargedfrom the hospital on a regimen of oralclindamycin for 6 weeks. She recov-ered well and has full function ofher lower extremities. Although wetreated the patient for osteomyelitis,shorter antibiotic durations havebeen effective in some reported cases,a finding that leads some to considerthat this infection involves only softtissues.

Lessons for the Clinician

• Patients can develop postsurgicalcomplications, including infection,years after successful scoliosis sur-gery; such patients may presentwith neurologic symptoms andmin-imal pain.

Figure 1. CT scan of the spine with myelogram showing a left pedicle screw traversingthe left paracentral spinal canal causing compression of the spinal cord (red arrow)and a bony lucency lateral to the pedicle screw and in the vertebral body (bluearrows).

index of suspicion




• In such cases, the surgical serviceshould be consulted urgently.

• In a patient having a persistent lo-calized infection, a foreign bodyshould be suspected and, con-versely, infection should be sus-pected in a patient who has newsymptoms at a site where thereis a known implant.

• If a fastidious organism is sus-pected, the microbiology labora-tory staff should be notified ofthe need for optimal culture con-ditions and extended observationof the culture sample.

(Sylvia Yoo, MD, Department of Pedi-atrics, Lucile Packard Children’s Hos-pital, Palo Alto, CA)

Case 2 DiscussionTwo important diagnostic clues werethe presence of high fever and tenderhepatomegaly. These findings, alongwith leukocytosis, abnormal liverstudy results, and elevation of righthemidiaphragm seen on chest radio-graph, were suggestive of liver abscess.Ultrasonography showed two hetero-geneous masses in the liver measur-ing 9 � 13 cm and 7 � 8 cm indiameter, located predominantly inthe right lobe. Both masses had mul-tiple small cystic spaces separated byseptae with a larger central hypoe-choic cystic component, which fa-vored the diagnosis of liver abscess.The remaining findings from abdom-inal ultrasonographic examinationwerewithin normal limits. CT scan re-sults confirmed the above findings(Fig 2). The presence of an aggrega-tion of small abscesses with the for-mation of a larger abscess cavity isan important clue to the diagnosisof pyogenic liver abscess (PLA).The absence of significant travel his-tory to an endemic area for amebiasisfurther strengthened the clinical sus-picion of PLA.

A blood culture sample was drawn,and treatment with antibiotics (ampi-cillin, gentamicin, and metronida-zole) chosen to cover Gram-positive,Gram-negative, and anaerobic organ-isms. An interventional radiologistplaced a percutaneous pigtail catheterfor drainage, which drained frank pus(Fig 3). Gram stain and stain for acid-fast bacilli did not show any organismsin the pus. Bacterial, fungal, and my-cobacterial culture specimens fromthe pus and the blood culture sampledid not grow any organisms.

The negative culture sample forthis patient probably is due to earlierpartial treatment with antibiotics.Moreover, 20% of PLAs reported inadults are culture-negative. Multiplestool studies (microscopy and cul-ture) did not show any abnormality.Serology test results for Entamoebahistolytica, cat-scratch disease, andfungi were negative. The patientimproved clinically and follow-upultrasonography showed a decreasein the size of the abscess cavities.

A biopsy specimen taken from thewall of the abscess cavity showednormal liver cells with a prominentinflammatory response. Prolongedantibiotic therapy for 6 weeks resultedin complete resolution of the liverabscess.

The ConditionThe liver is the most common visceralorgan for the development of ab-scesses. Liver abscess may be bacte-rial, parasitic, or fungal in origin. Inthe United States, bacterial liver ab-scesses are the most common cause,whereas in the developing world, in-fection with E histolytica is the mostcommon etiology. PLAs are relativelyrare in children, and the reported in-cidence in developed countries is var-iable, ranging from 3 to 25 per100,000 pediatric hospital admis-sions. Almost one-half of cases inchildren are associated with immuno-compromised conditions, such as leu-kemia, chronic granulomatous disease,or sickle cell disease.

Figure 2. CT scan of the abdomen showing the presence of two abscess cavities(arrows) in the liver.

index of suspicion




In children, the liver is seeded byGram-negative organisms or anaerobesthrough portal circulation from intra-abdominal infections such as appendici-tis, pylephlebitis (infective suppurativethrombosis of the portal vein), and in-flammatory bowel disease, or througha hematogenous route by S aureusfrom distant primary sources of infec-tions such as endocarditis, pneumonia,or infected indwelling catheters.

In neonates, sepsis, necrotizingenterocolitis, and umbilical vein can-nulation commonly predispose to liverabscess, whereas in adults, ascendingcholangitis associated with biliary tractobstruction caused by gallstones is themost common cause of PLA. Earlysymptoms usually are minimal andnonspecific and include fever, chills,malaise, fatigue, nausea, vomiting, andabdominal pain. Physical examinationfindings may be completely normalor may reveal right upper quadranttenderness or mild hepatomegaly.Other physical signs include decreasedbreath sounds in the right base due to

pleural effusion or a fixed elevatedhemidiaphragm.

Diagnosis of PLA in the pediatricpopulation is challenging and oftendelayed. A high degree of suspicionis necessary. Serum levels of liver en-zymes and bilirubin, WBC count, sed-imentation rate, and C-reactive proteinmay be elevated but also can be nor-mal. Liver abscess should be consid-ered strongly in the evaluation offever of unknown origin, especiallyin the presence of underlying risk fac-tors such as immunosuppression.

DiagnosisBoth ultrasonography and CT scancan provide information about thepresence, number, location, and sizeof the abscesses. Ultrasonography israpid and inexpensive and lacks radi-ation exposure. CT scan is the defin-itive investigation of choice, owing tohigher sensitivity in identifying le-sions as small as 1 cm in diameter.These modalities are complementaryto each other.

Differential DiagnosisAmoebic liver abscess should be con-sidered in patients having a recent travelhistory to an endemic area; usuallythese patients have positive serologictest results for amebiasis. Abscessesdue to Candida albicans and myco-bacteria occur in individuals withreduced immunity caused by condi-tions such as hematologic malignancies,solid-organ transplants, and acquiredimmunodeficiency disorders. One alsomust consider a diagnosis of chronicgranulomatous disease in the pres-ence of liver abscess infected withS aureus. Vascular lesions and tumorsof the liver can be differentiated fromhepatic abscess by contrast-enhancedCT scan.

TreatmentUntreated or undiagnosed liver ab-scess is fatal. Complications ofhepatic abscess include peritonitis,subphrenic abscess, septicemia, andshock. Treatment requires ultrasono-graphic or CT-guided percutaneousneedle aspiration and empiric broad-spectrum antibiotic therapy. In thecase of small abscesses, medical man-agement alone may be tried; however,in most cases, the abscesses are multi-ple and relatively large in size, so per-cutaneous catheter placement or opensurgical drainage is required. Thesecatheters usually are removed in w2weeks, when the drainage becomesnonpurulent and scant. Most casesrequire prolonged treatment for 4to 8 weeks for complete resolutionof the abscesses.


• Symptoms and signs of PLAs usu-ally are nonspecific, so a high de-gree of suspicion is required forthe diagnosis.

• Liver abscess should be consideredin a patient experiencing fever ofunknown origin.

Figure 3. Radiograph of the abdomen showing the presence of two pigtail catheters inthe liver, draining the abscess cavities.

index of suspicion




• Although ultrasonography is thepreferred initial investigation forliver abscesses, CT scan is the de-finitive investigation of choice be-cause of its higher sensitivity.

(Senthilkumar Sankararaman, MD,Wanda Wells, MD, John Vanchiere,MD, PhD, Louisiana State UniversityHealth Sciences Center, Shreveport,LA)

Case 3 DiscussionSerum quantitative immunoglobulin(Ig) evaluation revealed low IgG(324 mg/dL), IgA (21 mg/dL),and IgM (7 mg/dL) levels. Total he-molytic complement concentrationwas within the normal age-appropriaterange. Antibodies against diphtheriaand tetanus antigens were undetect-able, and the patient also failed todevelop protective antibody titers6 weeks after vaccination. This patientwas diagnosed as having common var-iable immunodeficiency (CVID).

The history of recurrent sinopul-monary infections, low quantitative Iglevels, and a poor response to immu-nizations should raise the suspicion ofa primary immunodeficiency, but thediagnosis cannot be made withoutfirst ruling out other conditions thatmay cause secondary antibodydeficiency.Medications such as cyclophospha-mide, phenytoin, gold, penicillamine,and sulfasalzine are known causes ofhypogammaglobulinemia. HIV, cyto-megalovirus, and Epstein-Barr virusinfections as well as protein-losingstates and malignancy can lower Iglevels.

The ConditionSelective IgA deficiency is the mostcommon primary immunodeficiency,with reported incidences of 1 per 333to 1 per 700 individuals in the gen-eral population; however, most pa-tients with selective IgA deficiency

are asymptomatic. CVID is the mostcommon symptomatic antibody defi-ciency a pediatrician encounters. It isa heterogeneous disorder involvingboth B- and T-lymphocyte dysfunc-tion causing impairment of both an-tibody synthesis and response. Thetrue incidence of CVID is unknown,but it is estimated to affect between1 per 50,000 to 1 per 75,000individuals.

Symptoms may occur at any age,with a peak onset of symptoms inthe first and third decade of life. Mostcases are sporadic, but at least 10%are familial, occurring predominantlyin an autosomal-dominant inheri-tance pattern. Both genders are af-fected equally.

Laboratory evaluation results de-monstrate low serum IgG levels atleast 2 SDs below the mean. Patientstypically also have low serum IgA lev-els and frequently have low IgM lev-els. An essential part of the diagnosisalso involves confirming impairedproduction of specific antibodies,demonstrated by poor responses toprotein or polysaccharide vaccine chal-lenges. Protein vaccine responses usuallyare assessed by measuring tetanus ordiphtheria toxoids. Because of the im-maturity of the T-cell response inyoung children, polysaccharide vac-cine responses typically are expectedin individuals 2 years and older. Poly-saccharide response usually can be as-sessed with the administration ofeither pneumococcal polysaccharidevaccine or meningococcal polysac-charide vaccine.

Classically, patients who haveCVID present with recurrent otitismedia, sinusitis, bronchitis, and pneu-monia, primarily due to infections byStreptococcus pneumonia, Haemophi-lus influenzae, Moraxella catarrhalis,and S aureus. Asthma, bronchiectasis,and hearing loss because of recurrentotitis media are well described for thiscondition.

Gastrointestinal complications af-fect 20% to 25% of individuals. Pa-tients often report mild abdominalpain, bloating, and recurrent epi-sodes of mild, watery diarrhea. Com-mon gastrointestinal tract diseasesinclude lymphonodular hyperplasia,inflammatory bowel disease, andHel-icobacter pylori–induced chronic gas-tritis. Pathogens such as Giardialamblia, Campylobacter, and Salmo-nella species are the most commonorganisms that cause enteritis.

Autoimmune disorders occur in20% to 25% of patients with CVID.The spectrum of autoimmune dis-orders varies widely: autoimmunethrombocytopenia and hemolyticanemia are the most common mani-festations. Patients who have CVIDhave a significantly higher predisposi-tion for all cancers. There is a strikinglyhigh prevalence of gastric carcinomaand non-Hodgkin’s lymphoma withCVID. Estimated relative risks are10-fold higher for developing gastriccarcinoma and an astonishing 30- to400-fold higher for non-Hodgkin’slymphoma, compared with the gen-eral population.

Classic findings on physical exam-ination and specific laboratory valuesprovide important information in dif-ferentiating CVID from other primaryimmunodeficiencies. The presence ofpalpable lymph nodes and visible tonsilsessentially rules out X-linked (Bruton)agammaglobulinemia and makes thediagnosis of severe combined immu-nodeficiency unlikely. Children whoexperience transient hypogamma-globulinemia of infancy closely re-semble patients who have CVID,and that condition should be consid-ered in patients younger than 3 yearsof age.

TreatmentIntravenous immunoglobulin or sub-cutaneous immunoglobulin replace-ment, antibiotic therapy for acute

index of suspicion




bacterial infections, and appropriatetreatments for noninfectious compli-cations are the mainstay of therapyfor CVID. Intravenous immunoglob-ulin and subcutaneous immunoglobu-lin replacement are fractionated bloodproducts made from pooled humanplasma from thousands of individuals,incorporating a mixture of antibodiesagainst a wide spectrum of infectiousdiseases. Immunoglobulin helps neu-tralize bacterial toxins, superantigens,and viruses. Immunoglobulin also ac-tivates complement and promotesphagocytosis and antibody-mediatedcytotoxicity. This therapy can be lifesaving in most individuals and im-proves their overall prognosis.

When patients who have CVIDpresent with respiratory tract infec-tions, physicians should have a lowerthreshold for starting antibiotics thathave activity against S pneumonia,H influenzae, and S aureus. Longerduration of therapy may be needed.This patient decided to undergoweekly subcutaneous immunoglobu-lin replacement therapy. His initialdoseswere given in the clinic tomonitor

for adverse reactions and thensuccessfully transitioned to homesubcutaneous immunoglobulin ther-apy. At his most recent visit, at19 years of age, all investigativestudies, including complete bloodcell count, trough immunoglobulinlevels, pulmonary function testing,and high-resolution CT scan, yieldednormal results. He has not re-quired treatment for any severe in-fections since initiating subcutaneousimmunoglobulin.


• Patients who present with infec-tions that are frequent, do notresolve with typical antibiotic ther-apy, involve unusual organisms, oraffect unusual sites should raiseconcern for a primary or secondaryimmunodeficiency.

• A general immunodeficiency eval-uation should include completeblood cell count with differential,with special attention to both theabsolute neutrophil count and ab-solute lymphocyte count, total he-molytic complement concentration,

and quantitative immunoglobu-lin levels.

• Patients suspected of having CVIDshould be referred to an immunol-ogist and require a multidisciplinaryteam approach for managementand for surveillance for autoim-mune disease, malignancies, andinfections.

• Intravenous immunoglobulin orsubcutaneous immunoglobulin re-placement is the treatment of choicein patients with CVID and can belife saving.

(Troy W. Baker, DO, Scott D. Dick-son, DO, Michael S. Tankersley, MD,Wilford Hall Ambulatory SurgicalCenter, Lackland Air Force Base, TX)

The views expressed in this article arethose of the authors and do not neces-sarily reflect the official policies or posi-tions of the U.S. Department of the AirForce, the U.S. Department of Defense,or the United States Government.

To view Suggested Reading listsfor these cases, visit http://pedsinreview.aappublications.org and click on“Index of Suspicion.”

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DOI: 10.1542/pir.33-5-2332012;33;233Pediatrics in Review

Vanchiere, Scott D. Dickson and Michael S. TankersleySylvia Yoo, Senthilkumar Sankararaman, Troy W. Baker, Wanda Wells, John

Index of Suspicion

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