A 4-year-old boy with vomiting and abdominal pain. In ED, his vital signs were as follows: T 102.8 0F, respiratory rate of 34. His abdomen was soft and non-tender. Chest was clear. CBC showed WBC of 29.5 with 90% neutrophils.

What is your diagnosis?

The answer and explanation to Mystery Case 17 will not be revealed until a reader posts a correct answer to the case.

A 4-year-old boy was brought to the emergency department with abdominal pain. He has a prior history of constipation and was taking stool softener. His vital signs were stable. The abdominal examination revealed a large mass in the left side of his abdomen. The mass was firm and slightly tender. A CT scan of abdomen was obtained.

What is your diagnosis?

The answer and explanation to Mystery Case 16 will not be revealed until a reader posts a correct answer to the case.

This boy visited the Emergency Department with this rash. He has been in a family picnic trip over the weekend. In the ED, he was scratching over his forearms. His parents gave him diphenhydramine, which offered no relief.

What is your diagnosis?

View the answer to Mystery Case #15.

Poison ivy causing contact dermatitis.

Acute onset of pruritis, inflammation, and grouped or linear papulovesicles or bullae usually indicates the presence of contact dermatitis.

Go to Mystery Case 15…

A 2-year-old African American boy was brought to the Emergency Department because of dark colored urine and vomiting. He had fever, cough and runny nose for 2 days. In the ED he was pale and jaundiced. Spleen was palpable. Hemoglobin was 4.6 gm/dL and hematocrit 12.7% with reticulocyte count of 7.84%. His urine was dark and cloudy with +3 blood on urinalysis.

What is your diagnosis?

View the answer to Mystery Case 14.

The presence of hematuria, jaundice and anemia suggests hemolysis. Among the causes of hemolysis in a previously healthy child, Glucose-6-phosphate dehydrogenase deficiency is one of the common. It is an X-linked recessive disease affecting exclusively males. The hemolysis is usually triggered by an infection or a medication.

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05.15.09

A 16-year-old male presented with blistering rash in sites of sun exposure. Rash occurred the day following sun expsoure. The patient had a history of chronic granulomatous disease and was being treated with levofloxacin and voriconazole for lung infection. On examination, confluent erythematous papules were present in the sun exposed sites of the face, dorsum of hands, and forearms. There was sparing of the forehead under a lock of hair and the neck in the shade of the chin. Bullous lesions were present on the neck. Both lips were eroded.

What is the diagnosis?

From Fitzpatrick Color Atlas Case of the Week Archive: November 26, 2006. AccessMedicine Web site. Available at http://www.accessmedicine.com. Accessed May 15, 2009.

Go to the answer for Mystery Case 13…

Bullous phototoxic drug reaction, secondary to voriconazole.
Voriconazole is a new triazole antifungal agent approved for oral treatment of invasive fungal infections. It has been reported to cause severe phototoxic reactions (Vandecasteele SJ et al: Two cases of severe phototoxic reactions related to long-term outpatient treatment with voriconazole. Eur J Clin Microbiol Infect Dis 23(8):646-657, 2004.)

Management
Voriconazole was discontinued. Clobetasol ointment was applied BID. There was marked resolution of the rash in one week.

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A 48-year-old woman presented to the Emergency Department with lower abdominal pain and 3 days of vaginal bleeding. She reported that her last menstrual period was two and a half months prior to ED presentation. Physical examination revealed suprapubic abdominal tenderness without rebound or guarding, as well as a 14- to 16-week-sized uterus on bimanual examination. Quantitative serum β-human chorionic gonadotropin level was 321541 mIU/ml.

What is your diagnosis?

Go to the answer for Mystery Case 12…

Ultrasound revealed substantially enlarged uterus with a large coarse echogenic mass occupying the endometrial canal with suggestion of multiple cysts and poor differentiation between the mass and myometrium. Surgical pathology specimens revealed chorionic villi with histologic features consistent with molar pregnancy. The diagnosis of molar pregnancy is usually made by a markedly elevated quantitative serum β-hCG level and a typical snowstorm appearance on ultrasound.

Go to Mystery Case 12…