by Evan Sherman, Children’s National
with Pavan Zaveri, Children’s National

The Case
The case is of an 8wo otherwise healthy M presenting to the ED as a bounceback with URI sx, vomiting, and “fussiness” for the past few days. The challenge of this case was what to do with a found Hgb of 7.1.

Reminder CBC showed:
WBC 14.4 (with a benign diff), Hgb 7.1, Plt 607
MCV 91, MCH 29.9, MCHC 32.9, RDW 17.1

Here’s How You Answered Our Questions

“Other”: with another caregiver during the time in question
partial SBI, in that likely bld, urine, no abx, observe +/- admit

Providers were worried about the vomiting, fussiness and limited history.  If possible, obtain a more detailed history (e.g. make a call to the grandma).  Several providers stated that they would pay special attention to the HPI/PE for signs/symptoms of NAT given the potentially concerning social situation.  Providers felt a that a Hgb of 7.1 is too low to be explained by a physiologic nadir (see UpToDate graph below) or viral suppression.  It was noted that a reticulocyte would help to further determine the cause of anemia (an inability to adequately produce RBCs vs rapid destruction or loss of RBCs).  The majority felt that an admission for further work-up and management is warranted.

Denouement
Given the history of vomiting, anemia, and multiple caregivers, the ED provider was concerned for increased ICP, possibly secondary to NAT, and decided to obtain a head CT. While awaiting the CT, the patient’s grandmother arrived and provided a more thorough history, including the fact that the patient had been febrile to 101F rectal that morning. CT showed no acute bleed, ventriculomegaly, or fracture. Given the new history of true fever, a full r/o SBI workup was performed, with a negative LP but a UA with 2+ LE and 42 WBCs. After the LP, the patient developed worsening respiratory distress and was placed on HFNC. CXR appeared “viral,” without focal consolidation (or rib fractures, for that matter). The patient was admitted to the PICU.

RVPCR revealed both rhino/entero and RSV, and the urine culture grew out E. coli. Hemoglobin remained low during hospitalization, with retic fraction of ~4%. Coags and DAT were normal, and the anemia was ultimately felt to be secondary to a combination of viral suppression and physiologic nadir. SW was consulted in-house and found the parents to be appropriate, albeit young and inexperienced, with no concern for NAT. Renal US performed during admission was normal. The patient was weaned off HFNC and discharged home on amoxicillin to treat his UTI.

Teaching Points
Don’t forget birth history – maternal anemia, placental rupture, twin to twin transfusion syndrome, prematurity, jaundice, prolonged newborn hospitalization requiring multiple blood draws

Normal values for Hct and Hgb during the first year of life in healthy term infants

Normal values for MCV are high at birth and decrease with age (2 mos = MCV 77 to 115)