A Case of a 15-Month-Old With Periorbital Edema and Severe Anemia Audrey D. Kamzan, MD, Charles A. Newcomer, MD, Laura J. Wozniak, MD, MSHS, Noah C. Federman, MD, Lydia S. Kim, MD, MPH This is the case of a previously healthy 15-month-old girl who initially abstract presented to her primary pediatrician with a 2-week history of intermittent periorbital edema. The edema had improved by the time of the visit, and a urine specimen was unable to be obtained in the clinic. A routine fingerstick demonstrated anemia to 8.8 mg/dL, so the patient was started on ferrous sulfate. She then returned to the emergency department 1 month later with severe periorbital edema and pallor but no other significant symptoms. On physical examination, she was tachycardic with striking periorbital edema and an otherwise normal physical examination. She was noted to have a severe microcytic anemia (hemoglobin of 3.9 mg/dL and mean corpuscular Mattel Children’s Hospital and University of California, Los Angeles, Los Angeles, California volume of 53.1 fL) and hypoalbuminemia (albumin of 1.9 g/dL and total protein of 3.3 g/dL). The remainder of her electrolytes and liver function test Drs Kamzan, Newcomer, and Kim conceptualized this diagnostic dilemma and drafted the initial results were within normal limits. A urinalysis was sent, which was negative manuscript; Drs Wozniak and Federman contributed for protein. Our panel of experts reviews her case to determine a unifying to drafting the initial manuscript; and all authors diagnosis for both her severe anemia and her hypoalbuminemia. reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work. Dr Kim’s current affiliation is Northern Navajo CASE HISTORY WITH SUBSPECIALTY At this visit, it was also noted that Medical Center, Indian Health Service, Shiprock, NM. INPUT a screening hemoglobin had not yet DOI: https://doi.org/10.1542/peds.2019-0391 fi Accepted for publication May 22, 2019 Dr Audrey Kamzan (Pediatric been done; a ngerstick hemoglobin Hospitalist Medicine, Moderator) was performed and was 8.8 mg/dL. Address correspondence to Audrey D. Kamzan, MD, Department of Pediatrics, Mattel Children’s Hospital, A 15-month-old girl presented to her Dr Lydia Kim, what were your initial 10833 Le Conte Ave, A2-383 MDCC, Los Angeles, CA primary pediatrician’soffice with a 2- concerns as an outpatient pediatrician? 90095. E-mail: [email protected] week history of intermittent unilateral What is on the differential for this PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, periorbital edema. She had not had any patient with periorbital edema and 1098-4275). recent illness, fever, or changes in urine anemia? Copyright © 2020 by the American Academy of Pediatrics output. Her physical examination in the Dr Lydia Kim (General Pediatrics) clinic was normal with no evidence of FINANCIAL DISCLOSURE: Dr Federman has served edema at the time. Her past medical The mother describes intermittent as a scientific advisory board member for Loxo history and birth history were swelling around 1 eye. With no other Oncology and Bayer; the other authors have symptoms, and given the intermittent indicated they have no financial relationships unremarkable; she was born term relevant to this article to disclose. without any complications. Both of the nature of the swelling, I might explore ’ any atopic history the child might have. FUNDING: Dr Federman is supported by the National patient s parents were born in Croatia, Institutes of Health National Center for Advancing She also fits into the classic age range but the patient was born in the United Translational Sciences (grant UL1TR001881). for nephrotic syndrome, so I would States, and there was no history of POTENTIAL CONFLICT OF INTEREST: The authors have want to check a urinalysis for protein. consanguinity. Two months ago, she indicated they have no potential conflicts of interest traveled with her parents to Croatia. The patient also had anemia on her to disclose. There was no significant family history. screening hemoglobin test. Iron On review of systems, she had no deficiency anemia (IDA) is the most To cite: Kamzan AD, Newcomer CA, Wozniak LJ, history of fever, weight change, recent common cause of anemia in her age et al. A Case of a 15-Month-Old With Periorbital illness, diarrhea, bloody or melanotic group and is most frequently Edema and Severe Anemia. Pediatrics. 2020;145(3): e20190391 stools, or change in activity level. attributable to poor nutritional intake, Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 145, number 3, March 2020:e20190391 DIAGNOSTIC DILEMMAS so I would be sure to obtain was 40 breaths per minute with an diagnosis at this point was broad, but a detailed dietary history.1 With an oxygen saturation of 96% on room my first concern was to stabilize this otherwise normal history and air. Her weight was 13.3 kg (.99th patient with severe anemia. She is physical examination, I would likely percentile), and her height was hemodynamically stable but certainly treat her empirically with dietary 83.8 cm (95th–98th percentile). On symptomatic from her anemia given changes and oral iron therapy then examination, the patient was well her tachycardia. My goal was to begin recheck her hemoglobin level. A rise developed and fussy but consolable. slowly correcting her anemia to avoid in hemoglobin of 1 g/dL after She was markedly pale with striking transfusion-associated circulatory 1 month of adequate iron periorbital edema. She appeared overload (TACO). TACO is an supplementation is considered well hydrated with moist mucous incompletely understood diagnostic for IDA.2 I would also send membranes. Her lungs were clear to complication of blood transfusions for a lead level test. Given the auscultation bilaterally with normal that can result in tachycardia, concurrent periorbital edema, I work of breathing. Her cardiac tachypnea, and hypoxia and is would have a low threshold for examination demonstrated associated with significant morbidity a broader workup. Renal disease can tachycardia but no murmur or gallop. and mortality. One proposed also cause anemia, again leading me Her abdominal examination was mechanism is an increase in central to pursue urine testing. normal; her abdomen was soft and venous pressure, which leads to heart nontender, and no failure and pulmonary edema.3 Dr Kamzan hepatosplenomegaly was noted. She Children ,3 years of age are at The patient’s parents mentioned that was noted to have 21 pretibial and increased risk, especially in the they have had a difficult time weaning pedal pitting edema bilaterally. setting of fluid overload, hypoalbuminemia, or cardiac or renal her off the bottle, and she was Initial bloodwork and urine were ’ impairment.4 Although slower drinking large quantities of cow s obtained by the ED physician. A transfusions and diuretics have milk. A bag was placed for urine complete blood count was significant become routine practice for severe collection, but the patient did not void for a hemoglobin of 3.9 mg/dL and anemia in many centers, the evidence spontaneously in the clinic, so urine hematocrit of 15.4 with a mean behind these interventions is weak, studies could not be performed. Given corpuscular volume of 53.1 fL. Her especially in pediatrics.5 However, in that the edema had already resolved, white blood cell count was 15.7 3 light of this patient’s risk factors a catheterized specimen was not felt 103/mL, and her platelet count was (,3 years of age and low albumin), to be necessary. A lead level was 611 000/mL. Her laboratories were , m we felt it prudent to give 2 low- obtained and was 3 g/dL. The also notable for an albumin of volume (5 mL/kg) transfusions back patient was prescribed ferrous sulfate 1.9 g/dL and a total protein of 3.3 g/dL. to back over a total of 8 hours. for treatment of her anemia, and she The remainder of her electrolytes and was scheduled for a follow-up liver function test results were within Given her hypoalbuminemia, appointment in 1 month for normal limits. A urinalysis was sent, a chest radiograph was done before a hemoglobin recheck. The patient which demonstrated a pH of 6.5, transfusion to rule out baseline was instructed to return sooner if the aspecific gravity of 1.011, 3 red blood pulmonary edema and the need for periorbital edema recurred. Three cells, and 2 white blood cells and was diuretics. The patient’s chest weeks later, the patient again otherwise negative, including for radiograph demonstrated a normal developed periorbital edema and protein. cardiac silhouette and normal lung presented to our emergency fields with no evidence of pulmonary department (ED) for evaluation. Given her severe anemia and edema or pleural effusion. The hypoalbuminemia, a pediatric patient was admitted to our pediatric In the ED, the parents noted that the hospitalist consult was obtained. Dr ward for further workup and periorbital edema was now bilateral Newcomer, as the pediatric management. and, over the last 7 days, had consultant in the ED, what were your progressively worsened. Her urine primary concerns at this point? What Dr Kamzan output was normal, and there was no additional workup did you change in her eating or drinking recommend? What did you think was causing her habits. The results of her review of microcytic anemia? What additional systems remained negative for other Dr Andy Newcomer (Pediatric workup did you recommend? symptoms. Hospitalist Medicine) On ED assessment, the patient was This patient has a chronic, severe Dr Newcomer tachycardic with a heart rate of 187 microcytic anemia as well as The most common causes of beats per minute.