Rose C. Graham-Maar, MD; Pierre Russo, MD; Ann M. Johnson, MD; Robert Baldassano, MD; Petar Mamula, MD Series Editors: David A. Piccoli, MD; Petar Mamula, MD


June 15, 2006

Case Presentation

A 2-year-old boy presented with an 8-day history of emesis and a 1-day history of facial edema. The emesis, which was clear or white, nonbloody, and nonbilious, occurred multiple times per day, both day and night. He tolerated only small sips of liquids and did not tolerate food at all. He complained of periumbilical abdominal pain intermittently throughout the illness. One day before presentation, the patient's mother noticed periorbital and bilateral pedal swelling that was not warm or red and did not seem painful. He had been fatigued and had rhinorrhea for the previous 3 weeks. He has had no fever, headache, diarrhea, or neurologic symptoms.

Medical history was significant for Kawasaki's disease 10 months ago, which was treated with intravenous immune globulin and did not result in any sequelae. He has infrequent upper respiratory infections and occasional self-limited episodes of acute gastroenteritis accompanied by both diarrhea and vomiting. His last episode of acute gastroenteritis occurred more than 6 months ago. He has had normal growth and development. There is no history of surgery. The patient is taking no medications and has no known drug or food allergies. His diet typically consists of table foods and he drinks approximately 500 mL of juice and 240 mL of milk per day. Family and social histories are noncontributory.

On physical examination, the patient's weight was 12.5 kg (50th percentile) and height, 88 cm (50th percentile). Vital signs were normal. He was awake, alert, and nontoxic appearing. There was mild periorbital edema without erythema or warmth. Sclerae were anicteric and conjunctiva noninjected. Lung and heart examinations were normal. The abdomen was mildly distended but very soft and nontender without palpable hepatosplenomegaly, masses, or ascites. There was mild edema of hands and feet bilaterally. There was no skin rash. The neurologic examination was normal.

Erythrocyte sedimentation rate, amylase and lipase levels, and comprehensive metabolic panel including electrolytes and liver function tests were all normal, except for a low total protein of 2.5 g/dL and low serum albumin of 1.6 g/dL. Complete blood count with differential was within normal limits, except for 6% eosinophils and 14% atypical lymphocytes.

What is the differential diagnosis?

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