I am sharing this story of a patient we saw today, mostly for those who might be interested by the case. Sorry that it's more of a medical one.
My first patient of the day was a 9 year old girl, who presented with a 2 day history of vomiting and diarrhea, 8-10 times a day. No visible blood in the diarrhea. Some stomach pain. No fever. 2 days ago she was diagnosed with a UTI and an intestinal infection by another clinic, and was given Bactrim and Metronidazole, but was still sick. They didn't do a stool sample. One day ago she developed petechiae on her trunk, shoulders, and legs.
On exam she had scattered petechiae, and some lower left quadrant tenderness. She also had a very unusual sounding heart. She had a grade III/VI murmur on expiration, heard best at the aortic, pulmonic, and tricuspid areas. The murmur was heart best while sitting. The Doc at the clinic said he heart a gallop, and Cody said he heard clicks. Peripheral pulses equal, BP 90/62, no cyanosis, cap refill <3 sec. Throat, ears, nose, lungs normal. No meningeal signs, sitting there smiling and even laughing a couple of times. And temp of 98 degrees F.
She had a history of being hospitalized for "purpura" but the family didn't know why. She was hospitalized 3 times in the past. This was her first time coming into our clinic. Apparently she had been given some sort of diagnosis in the past, but the parents couldn't remember what it was. Consistency in primary care and follow-up here are seriously lacking. There seems to have been some sort of other illness ("fever" according to the dad), at each of these times. No history of cardiac issues in the family. She has never been diagnosed with a murmur of a heart problem in the past, according to the parents. Parents deny any history of cyanosis, fainting, or weakness/tiring easily.
We did an ECG and a urinalysis on site at the clinic (tried to do a stool analysis, but didn't happen). The urinalysis showed slightly dark yellow urine with 4+ blood and 4+ protein, some casts in the urine, 1+ leukocytes, no nitrates, 1+ ketones, no glucose, bili neg. I didn't analyze it carefully, for lack of ECG experience, but she had "rabbit ears" on the ECG, which is a bad sign. We're asking her to come back tomorrow with the lab results (coag studies, platelets, CBC with diff, and BUN/creatinine). We have to choose labs here carefully and then explain the costs to the families. We may also repeat the ECG. We will determine the rest of our course of action then.
We're considering hemolytic uremic syndrome, idiopathic thrombocytopenic purpura, coagulation disorder, glomeronephritis, and/or a reaction to the Bactrim. And of course an intestinal infection, and other types of infections. We asked her to stop taking Metro and Bactrim, and explained that she should avoid Bactrim in the future. It is unclear if she had been taking Bactrim in the past when her petechiae/purpura showed up. She basically went home with a lab slip, a prescription for oral rehydration solution dosed by her weight, and instructions to come back.
If anyone has any thoughts, pass them along. This family seems concerned (I reassured the mother a lot throughout the cardiac exam, especially when 3 men came into the room to listen to her heart when I went for another opinion!). I am believing that this concern means that we will actually get to do some short-term follow-up. But even all that aside, this has been an interesting case to think through.
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