What is the most common cause of neonatal death in children of mothers known to have diabetes mellitus before pregnancy?
Correct Answer A:
Congenital anomalies are the most common cause of neonatal death in infants of mothers known to be diabetic prior to pregnancy. The incidence of congenital anomalies is increased threefold in infants of diabetic mothers, most notably cardiac and CNS defects. There is good evidence that tight glycemic control in early pregnancy decreases the risk of anomalies. The anomaly rate increases as the glycohemoglobin level increases. In order to improve this, preconception diabetic care must be strict.
Sepsis, hypoglycemia, birth trauma, and macrosomia are all increased in infants of diabetic mothers. However, associated congenital anomalies are more likely to cause perinatal mortality.
A 9-month-old white male is brought to your office for a well-child visit. You note that the child’s weight gain has been flat over the last several months. He has fallen from the 75th percentile to the 15th for weight, and his percentile for length is beginning to decline as well. The mother states that the child began to have diarrhea as soon as she began giving him various grain cereals and baby foods 5 months ago. The remainder of a review of systems and a social and family history is unremarkable. Physical examination reveals an undernourished infant with mild abdominal distention. A check of the infant’s hemoglobin shows a microcytic anemia with a low serum ferritin level.
Which one of the following is the most likely diagnosis?
Correct Answer B:
Celiac sprue is a condition of acquired malabsorption that resolves when the patient is exposed to a gluten-free diet. Gluten is a substance found in wheat, rye, and barley, but not in corn or rice products. Children with this sensitivity will develop inflammation and destruction of the microvilli in the small intestine as a result of an immune response to gluten. Patients with celiac sprue often present as this child has, between 4 and 24 months of age with impaired growth, diarrhea, and abdominal distention. An iron deficiency anemia can occur with impairment of iron absorption from the small intestine. Lesser cases of malabsorption are common, and this condition often goes unrecognized into adolescence or adulthood. Serologic tests, and ultimately a biopsy of the small intestine, can confirm the diagnosis.
A 15-year-old boy presents to the clinic with a 2-month-history of bulky, floating, foul smelling stools. He also complains of weight loss, fatigue and bone pain. Physical exam reveals loss of muscle bulk and pallor. The lab tests show that the patient is anemic (Hct of 30%) and the serum ferritin is 30 µg/L.
Which of the following is most likely to be associated with this condition?
Celiac disease should be suspected in any patient presenting with malabsorption and iron deficiency anemia. Our patient presents with symptoms and signs of malabsorption, which includes characteristically bulky, foul smelling, and floating stool (because of the high fat loss), loss of muscle mass or subcutaneous fat, pallor due to iron deficiency anemia and bone pain caused by osteomalacia. Celiac disease is associated with anti-endomysial antibodies.
Celiac disease is frequently tested! Know every detail about this disease! Always remember the young patient with osteomalacia and do not forget the associated pruritic rash (dermatitis herpetiformis).
A 15-year-old boy presents to the clinic complaining of an unbearable itchy rash on both legs and forearms. He recalls a 2 month history of bulky, floating, foul smelling stools. He also complains of weight loss and fatigue. Physical exam shows a vesicular eruption on the extensor surfaces of both legs and forearms as well as loss of muscle bulk and pallor. The lab tests show that the patient is anemic (Hct of 30%) and the serum ferritin is 30 µg/L.
Regarding the rash, what is the best medical treatment for it?
Celiac disease should be suspected in any patient presenting with malabsorption and iron deficiency anemia. The patient presents with symptoms and signs of malabsorption. He is also complaining of a vesicular eruption on the extensors with a severe itch, which is characteristic of dermatitis herpetiformis. It is strongly associated with Celiac disease and it is caused by the IgA antibodies deposited in the dermis. Dermatitis herpetiformis is best treated with a gluten-free diet and Dapsone.
Antihistaminics would decrease the itch to certain extent but they are not as effective as dapsone.
Antibiotics have no role in the treatment.
Fluconazole would be appropriate for an itchy fungal skin infection.
While seeing a 6-month-old infant for a well-child check, you note that his height is at the 50th percentile, and his weight is at the 5th percentile. You are concerned about the possibility of failure to thrive (FTT). Your history and physical examination reveal no obvious cause for FTT other than inadequate caloric intake due to poor parental skills.
Which one of the following would be the most likely result of laboratory evaluation of this child?
Correct Answer E:
The majority of children with failure to thrive (FTT) have no laboratory abnormalities. In a classic study of children hospitalized with FTT, only 1.4% of laboratory tests were of diagnostic significance. A practical approach is not to order any laboratory tests initially unless suggested by the history or physical examination. Screening laboratory studies can be considered in children who fail to respond to nutritional intervention.
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