Case 6: An Infant Presenting with Hematuria and Pallor

1. Lauren C. Riney, DO* 2. Jennifer D. Treasure, MD* 3. Charles D. Varnell Jr, MD† 4. Holly Depinet, MD, MPH* 1. *Division of Emergency Medicine and 2. †Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH A 5-month-old healthy boy presents to our pediatric emergency department with parental concerns of blood in the urine and yellow appearance of the skin. His medical history and birth history are normal. The patient has had nonbloody diarrhea for the past 2 weeks that resolved 2 days ago. He has had 1 episode of nonbilious nonbloody emesis the previous day. In addition, he has had decreased oral intake and increased fussiness for the previous 2 days. His mother noticed a red-brown discoloration in the front of the diaper yesterday and yellow discoloration of the skin, prompting her to present to the pediatric emergency department. Vital signs at presentation are heart rate, 157 beats/min; respiratory rate, 42 breaths/min; blood pressure, 127/70 mm Hg; and rectal temperature, 97.9°F (36.6°C). On initial examination in the emergency department, the patient is pale but alert, active, in no apparent distress, and playful. His mucous membranes are moist, and his oropharynx is normal, without lesions. The cardiovascular examination reveals a regular rate and rhythm, without murmurs, rubs, or gallops. He has strong peripheral pulses and good distal perfusion. His pulmonary examination findings are normal. His abdomen is soft, nondistended, and nontender, with normal bowel sounds. Neurologic examination shows symmetric normal strength and tone with grossly intact cranial nerves and no deficits. Skin examination shows generalized pallor but no rash or petechiae. Both feet seem to be mildly edematous. Pertinent laboratory studies in the emergency department show a white blood cell count of 27,200/μL (27.2×109/L) (reference range, 6,000–17,500/μL [6.0–17.5×109/L]), with 38% segmented neutrophils and 2% bands; a hemoglobin level of 3.7 …