An abdominal mass in the newborn is most frequently due to:
Correct Answer B:
The discovery of an abdominal mass on physical examination in the newborn period causes concern and the need for a rapid diagnosis. The incidence of an abdominal mass is 1/1000 live births.
The majority of masses are of benign origin and greater than 50% are of renal origin. Examples include multicystic dysplastic kidney, posterior urethral valves and mesoblastic nephromas.
The most likely diagnosis in a 3-year-old with a abdominal mass, found to be of renal origin, is:
Wilms tumor (WT) is the fifth most common pediatric malignancy and the most common type of renal tumor in children. This neoplasm may present with renal signs and symptoms, such as hypertension, hematuria and abdominal pain. Wilms' tumor should be considered in the differential diagnosis of an abdominal mass in a child. The mean age at diagnosis is 41.5 months for males and 46.9 months for females. Wilms' tumor can present as an abdominal mass in newborns, and it occasionally develops in adolescents.
When an abdominal mass is detected in a child, ultrasound examination of the abdomen should be performed within 24 hours by a radiologist with pediatric experience. If the ultrasound examination does not clearly identify the origin of the mass, abdominal CT scanning should be performed. If the mass is confirmed to be of renal origin, immediate referral to a pediatric oncologist and a pediatric surgeon is indicated.
Differential Diagnosis of Abdominal Mass in Children
⇒ Neonates
-Renal
-Pelvic
⇒ Infants and children
-Retroperitoneal
-Liver
-Gastrointestinal
-Other
*Common. †Rare.
A 10-year-old white male presents to the emergency department with a 24-hour history of painful lower extremities and severe abdominal pain. On physical exam, you note a temperature of 37.4°C and severe arthritis of both knees along with a purpuric rash located on the lower extremities and buttocks. The stool guaiac is positive, as is a urine dipstick for protein and blood.
Which of the following is the most likely diagnosis?
Correct Answer C:
Henoch-Schönlein purpura is a vasculitis affecting primarily small vessels that occurs most often in children. Common manifestations include palpable purpura, arthralgias, GI symptoms and signs, and glomerulonephritis. Diagnosis is clinical. Disease is usually self limited. Corticosteroids can relieve arthralgias and GI symptoms but do not alter the course of the disease.
The disease begins with a sudden palpable purpuric rash that typically involves the extensor surfaces of the feet, legs, and arms and a strip across the buttocks. The purpura may start as small areas of urticaria that become indurated and palpable. Crops of new lesions may appear over days to several weeks. Many patients also have fever and polyarthralgia with associated periarticular tenderness and swelling of the ankles, knees, hips, wrists, and elbows.
A 6-year-old white male visits your office with chief complaints of a recent onset of fever, bilateral knee and ankle pain, colicky abdominal pain, and rash. On examination, his temperature is 38.3°C (101.0°F), and there is a prominent palpable reddish-brown rash on the buttocks and thighs. There is pain on motion of his knees and ankles, and mild diffuse abdominal tenderness. The stool is positive for occult blood.
Laboratory findings reveal the following:
Which one of the following is the most likely diagnosis?
Henoch-Schönlein purpura (choice C) typically follows an upper respiratory tract infection, and presents with low-grade fever, fatigue, arthralgia, and colicky abdominal pain. The hallmark of the disease is the rash which begins as pink maculopapules, progresses to petechiae or purpura, which are clinically palpable, and changes in color from red to dusty brown before fading. Arthritis, usually involving the knees and ankles, is present in two thirds of cases, and gastrointestinal tract involvement results in heme-positive stools in 50% of cases. Laboratory findings are not specific or diagnostic, and include indications of mild to moderate thrombocytosis, leukocytosis, and anemia, and an elevated erythrocyte sedimentation rate. Treatment is typically symptomatic and supportive, although corticosteroids are indicated in the rare patient with life-threatening gastrointestinal or central nervous system manifestations.
→ Systemic juvenile-onset rheumatoid arthritis (choice A) usually presents with an evanescent salmon-pink rash.
→ Rocky Mountain spotted fever (choice B) does not present with arthritis and the rash begins distally on the legs.
→ Iron ingestion (choice D) does not typically cause a rash, fever, or arthritis.
→ Disseminated anthrax (choice E) does not present with a rash or joint symptoms.
You are caring for a 4-year-old child with Henoch-Schönlein purpura.
Which one of the following is the most common serious complication of this illness?
The most serious complication of Henoch-Schönlein purpura is renal involvement, which occurs in 50% of older children but is serious in only 10% of these patients. The spectrum of renal disease varies from microscopic hematuria to a nephritis or nephritic syndrome with renal failure. Overall, 2%-5% progress to end-stage renal failure. Gastrointestinal tract disease occurs in approximately two-thirds of children, varying from colicky pain to intestinal hemorrhage and intussusception. Subarachnoid hemorrhage is not a recognized complication of the disease, although both seizures and coma are rare CNS complications. Pancreatitis and cardiac involvement are also rare complications. Joint involvement occurs in 60%-84% of children, but is transient and leaves no permanent deformity.
Click to expand