Case by Alicia Rolin MD, CNH PEM Fellow

10-year-old previously healthy male presenting with 10 days of non-bloody, non-bilious emesis. Reports 7-10 episodes of emesis per day. Initially only after eating, but now spontaneously throughout the day. Not worse in the AM. No diarrhea. Intermittent 8/10 dull non-radiating epigastric abdominal pain. No identifiable trigger. Does not improve with Tylenol. Additionally reports intermittent headaches. Not worse in the AM. Does not change with positioning. No vision changes. No change in color saturation.

Denies any ingestions including substance use or non-edible objects. No fevers, respiratory distress, weakness, gait abnormalities, scrotal pain, urinary symptoms, excess urination, night sweats, or weight loss (prior to these 10 days). No one else is sick at home. No recent travel outside of DC area. Born in the US. No new stressors. Doing well at school. No family history of migraines or cyclic vomiting. Up to date on vaccinations.

He has been to 3 different emergency departments over the past week, most recently yesterday. He has had an extensive work-up including a negative US appendix yesterday, multiple negative urinalysis, normal CMP, and POC glucose. He has been discharged home with famotidine and ondansetron. They have taken the ondansetron twice this week with no improvement in his vomiting.

T 36.2 HR 58 RR 20 BP 141/80

General:  Alert.  appropriate for age.  cooperative.  smiling.  tired-appearing.  
Skin:  Warm.  dry.  no pallor.  no rash.  normal for ethnicity.  
Head:  Normocephalic.  atraumatic.  
Neck:  No tenderness.  no lymphadenopathy.  
Eye:  Pupils are equal, round and reactive to light.  extraocular movements are intact.  normal conjunctiva.  no discharge.  no jaundice.  No nystagmus.  
Ears, nose, mouth and throat:  No pharyngeal erythema or exudate.  Lips chapped.  
Cardiovascular:  No murmur.  No gallop.  Normal peripheral perfusion.  Extremity pulses equal.  Bradycardic rate (mid 50s, sustained), normal rhythm.  
Respiratory:  Lungs are clear to auscultation.  respirations are non-labored.  breath sounds are equal.  Symmetrical chest wall expansion.  
Gastrointestinal:  Soft.  Non distended.  Normal bowel sounds.  No organomegaly.  tenderness to palpation in all quadrants. No guarding.  
Genitourinary:  Normal genitalia for age.  Normal cremaster reflex bilaterally. Testicles in normal position. No testicular tenderness.  
Musculoskeletal:  Normal ROM.  moves all extremities.  
Neurological:  Alert.  No focal neurological deficit observed.  Cranial nerves II – XII: intact.  Coordination: bilateral, normal, finger(s) to nose, negative Romberg test: , normal Pronator drift and rapid alternating movements.  Speech: normal.  Gait: normal.  Motor function: no active tremor, no resting tremor.  strength 3/5 in bilateral grip strength and leg raise, although unclear if this is volitional. Coordinated alternating movements, finger to nose, and heel to shin. Able to ambulate normally as well as on heels and toes. Normal straight leg raise and straight arm raise.
Psychiatric:  Cooperative.  appropriate mood & affect.  

Initial labs with normal CBC, electrolytes within normal limits, normal glucose. UA not concerning for UTI or nephrolithiasis. No glucosuria. Lipase normal.

Obtained head CT given persistent vomiting, bradycardia, and mild hypertension on arrival. No intracranial mass or evidence of increased ICP. AXR with no radiopaque foreign body, signs of obstruction, no significant stool burden.

EKG shows sinus bradycardia (52 bpm), prolonged QTc (450-490s), and T wave inversion in inferolateral leads.

Consulted cardiology. Concern for myocarditis despite presenting with bradycardia. Obtained troponin and BNP which were negative. CXR showed no cardiomegaly. Bedside ECHO was overall reassuring. Good function.

Patient continues to have multiple episodes of emesis.