Consultant for Pediatricians.

Pages: 1 2

Child Abuse—or Mimic? Retinal Hemorrhages in an Infant

By Gregory Wallace, DO | August 24, 2012

Gregory Wallace, DO, is a hospitalist at Cincinnati Children's Hospital Medical Center in Cincinnati.

retinal hemorrhages in a 4-week old girl A 4-week-old girl was brought to the emergency department while she was actively convulsing. The child was afebrile, but had repeated bouts of emesis. Her parents reported that she had been irritable and that her appetite had been diminished for several days. The baby had been breast-fed exclusively until a week before the ED visit.

Except for the fact that the family lived near an area in which western equine encephalitis was endemic, there was no other pertinent clinical history.

After seizure activity stopped with lorazepam(Drug information on lorazepam) administration, clinical evaluation was initiated. A CBC count and renal panel were ordered and the child was prepared for a lumbar puncture to rule out encephalitis.

Fundoscopy was performed before the lumbar puncture; an adult ophthalmologist confirmed the presence of retinal hemorrhages. There was no evidence of increased intracranial pressure. Findings similar to those in the Figure were noted.

CT scans of the head were normal, as were results of the lumbar puncture. The CBC count results were normal for age. Tests of renal function were as follows: sodium, 148 mmol/L (normal, 132-141); chloride, 110 mmol/L (98-107); carbon dioxide, 13 mmol/L (normal, 16-25); potassium, 3.2 mmol/L (normal, 3.3-4.7). The glucose level was 35 g/dL.

The ophthalmologist was not able to rule abuse in or out based on his examination because of the number of retinal hemorrhages seen on the exam.

Two additional lab tests were requested because of the acidosis and hypoglycemia. The lactic acid(Drug information on lactic acid) was normal; the serum ammonia was 300 mmoL/L (normal, 0-32). The hypoglycemia was treated and the child was transferred to a tertiary care center.

Do you suspect abuse—-or do the physical symptoms suggest an underlying medical explanation?

Please click here for the answer and discussion...

Pages: 1 2

by jaume querol | August 30, 2012 11:49 PM EDT

Patients with one of the five forms of urea cycle disorders are rarely acidotic(may be secondary to seizure, .... but not as essential in these enzyme defects of the urea cycle). Severe refractory acidosis suggests organic acid disorder or mitochondrial disorder.

by jaume querol | August 30, 2012 2:24 AM EDT

by jaume querol
The association of seizures and retinal hemorrhages with hypoglycemia, hyperammonemia, metabolic acidosis, normal lactate levels, suggest a biological substrate of the disease rather than a case of abuse.
Consider first glutaric aciduria. Also multiple deficiency of mitochondrial fatty acid oxidation MADD or GLUT II ,and ketogenesis disorders.
And finally, although usually present without hypoglycemia, propionic or methylmalonic organic acidemias (by increased ammonium)

by masoud sakhaei | August 28, 2012 1:20 PM EDT

with elevated ammonia, I r/o metabolic d/o first.

More Related Cases

Possible Choking Injury: Child Abuse—or Mimic?

Bite Mark on Boy’s Arm: Child Abuse—or Mimic?

Child Abuse — or Mimic? Suspicious Bruises: An Old Story with a Twist

Swollen Red Toe: Child Abuse—or Mimic?

Blister on Toddler's Foot: Burn? Blistering Disease? Abuse?

Child Abuse—or Mimic? Retinal Hemorrhages in an Infant

Retinal Hemorrhages in an Infant: Abuse—or Mimic? Quiz of the Week

Molluscum Contagiosum

Child Abuse Injuries Incidence Up or Down?

BLOG FOR CONSULTANTLIVE

Send us your blogs! Contact us for more information if you are interested in writing a post or becoming a blogger.

TOPIC INDEX

Developmental/Genetic

Nutritional/Metabolic

ABOUT OUR BLOGGERS

	On Health and Mental Health Erik R. Vanderlip, MD, is a senior fellow and acting instructor in the University of Washington Department of Psychiatry. As a dually-trained family physician and psychiatrist, Dr Vanderlip is active in national health system redesign efforts with a particular interest in newer models of the medical home. He practices family medicine in a hybrid primary care clinic within a mental health center in Seattle.
	The HIV-AIDS Observer Rodger D. MacArthur, MD, is Professor of Medicine, Wayne State University, Department of Internal Medicine, Division of Infectious Diseases and Director and Site Principal Investigator, Wayne State University HIV/AIDS Clinical Research Unit.
	Speaking of Pain Steven A. King, MD, MS, is in the private practice of pain medicine in New York, and he is Clinical Professor of Psychiatry at the New York University School of Medicine, New York.
	Tales Doctors Tell David T Nash, MD, is Clinical Professor of Medicine at Upstate Medical Center in Syracuse, New York. The author of more than 250 peer-reviewed clinical articles, Dr Nash has practiced cardiology in Syracuse for over 50 years. He is a Fellow of the National Lipid Association.
	Primary Care Matters Gregory W. Rutecki, MD, is Professor of Medicine at the University of South Alabama College of Medicine in Mobile. He is section editor of the hypertension topic center on this web site.
	Practice Makes Perfect Pamela Wible, MD, pioneered the first community-designed ideal medical clinic in America. An expert in patient-centered care, Dr Wible helps citizens design cutting-edge clinics and hospitals nationwide. Her model is taught in medical schools and featured in Harvard School of Public Health's newest edition of Renegotiating Health Care. Dr. Wible is a medical reporter for the Oregonian, has been interviewed by CNN, ABC, CBS, and is a frequent guest on NPR.

Child Abuse—or Mimic? Retinal Hemorrhages in an Infant

Join the Conversation