Hematochezia and Cold Symptoms in an Infant
Radiology Cases in Pediatric Emergency Medicine
Volume 2, Case 15
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
A 7-month old male infant arrived in the E.D. at 7:45
a.m. after passing a dark maroon colored stool with
clots at 7:00 a.m. He has passed small amounts of
blood in his stools intermittently since 4 months of age,
but this current episode is the worst it has ever been.
He has been taking amoxicillin-clavulinic acid for the
past 7 days for otitis media. He also has some nasal
congestion and coughing. He passed a normal stool at
4:00 a.m. earlier.
His past medical history is unremarkable except for
the intermittent blood in his stool (small amounts).
Stool cultures and examinations for ova and parasites
done in the past as an outpatient were negative. His
growth has been good. His development has been
normal. His diet consists of soy formula, baby foods,
and table foods.
Exam VS T37.0 (tympanic), P192, R40, BP
154/128, oxygen saturation 94-95% in room air. Alert,
crying, in no distress. Skin warm and dry. Color pink.
Anterior fontanelle soft and flat. Pupils reactive. TM's
normal. Oral mucosa moist. Throat clear. Neck
supple. Heart tachycardic, regular, without murmurs.
Lungs good aeration, clear. Abdomen soft, slightly
distended, non-tender, bowel sounds active, no
masses, no hepatosplenomegaly. Peripheral pulses
good. Capillary refill time 2 seconds. Excoriation noted
over the perianal region. Muscle tone good. Moves all
extremities well. Stool is guaiac positive.
Laboratory studies: CBC WBC 10,900, 11 bands,
32 segs, 51 lymphs, 2 monos, 3 eos, Hgb 11.4, Hct
34.6, platelet count 176,000. Prothrombin time and
partial thromboplastin times are normal. Urinalysis
specific gravity 1.020, pH 6, 3-5 WBC's and 3-5 RBC's
per high power field. An IV is started and a clot tube for
blood type and screening for possible transfusion is
sent to the lab. An abdominal series is ordered.
View Abdominal Series: Flat (supine) view.
View Abdominal Series: Upright view.
His repeat vital signs at 8:35 a.m. show P172, R40,
BP 141/100. He passes two more bloody stools in the
E.D. which appear to resemble currant jelly (blood
mixed with mucus somewhat resembling strawberry
jelly without the seeds). A nasogastric tube is placed.
An aspirate of his gastric contents is guaiac negative.
At 9:40 a.m. his blood pressure falls. He passes more
blood per rectum. He is transfused with packed RBC's.
After stabilization, a water soluble contrast enema is
performed to rule out intussusception. This study is
In reviewing his abdominal series, the abdomen
portion of the study is non specific. However, the chest
portion of the upright abdomen is positive for interstitial
infiltrates. In retrospectively reviewing his vital signs,
his oxygen saturation of 94-95% in room air before he
developed hemodynamic decompensation is suggestive
of a significant ventilation perfusion mismatch
suggesting some type of pulmonary condition. Reactive
airway disease is the most common cause of this, but
since wheezing was not noted on examination, an
occult pneumonia should be suspected. Most infants
with normal lungs should have an oxygen saturation of
98-100% in room air. This is especially true of young
infants less than 3 months of age who almost always
have an oxygen saturation of 100% in room air.
Anything less than 98% should be viewed with some
suspicion in this age group.
This interstitial pneumonia was appreciated in the
E.D., however, the oxygen saturation rose to 100% with
some blowby oxygen. The hemodynamic stabilization
seemed to have a greater priority at the time.
After stabilization in the intensive care unit, he was
placed on cimetadine and IV fluids. A Meckel's
diverticulum was suspected. His pneumonia was felt to
be viral in etiology and he was not placed on any
antibiotics. His oxygen saturation stabilized at 99% with
1 liter per minute of oxygen by nasal cannula.
After multiple consultants became involved in his
care, he was started on antibiotics. A nuclear medicine
Meckel's scan was negative. Endoscopy and
colonoscopy were both negative. He continued to
bleed intermittently, requiring additional transfusions of
RBC's and platelets. Stool, blood, and urine cultures
were negative. He underwent an exploratory
laparotomy. Frozen section examination of intestinal
biopsies were positive for viral inclusion bodies,
suggesting cytomegalovirus enteritis.
Probable severe CMV infection and the interstitial
pneumonia raised the possibility of HIV infection. His
mother was not known to be HIV positive nor at high
risk for HIV. An HIV ELISA study was positive and an
HIV p24 antigen assay was also positive. He
underwent extensive treatment with gamma globulin,
anti-viral agents, antibiotics, and intensive care support.
He eventually developed respiratory insufficiency and
expired 15 days after presenting to the E.D.
The classification of HIV is very detailed ranging
from asymptomatic HIV infection to AIDS associated
manifestations including specific secondary infections,
recurrent serious bacterial infections, progressive
neurologic disease, lymphoid interstitial pneumonitis,
specific secondary malignancies (lymphomas and
Kaposi sarcoma), and HIV wasting syndrome. The
details of this classification are beyond the scope of this
Manifestations of HIV infection in children are
extensive. They are summarized here briefly by organ
system. Systemic manifestations include failure to
thrive and recurrent or chronic fever. The failure to
thrive is usually due to reduced caloric intake secondary
to anorexia and acclerated energy expended in fighting
chronic infection. Examination findings include
hepatosplenomegaly, lymphadenopathy, and dermatitis.
Cardiac manifestations are rarely the presenting
finding in a new patient. Cardiomyopathy, conduction
abnormalities, and congestive heart failure may result
directly from HIV or from other opportunistic viral
Pulmonary manifestations can be categorized as
infectious and non-infectious. Recurrent bacterial
pneumonia, pneumocystis carinii pneumonia (PCP),
viral pneumonia (including CMV), mycobacterium avium
complex infections, and mycobacterium tuberculosis
are some of the common pulmonary infections.
Tuberculosis infections are often highly drug-resistant.
Pneumocystis carinii pneumonia (PCP) is a diffuse,
desquamative, interstitial infection resulting in
hypoxemia, fever, productive cough, respiratory
distress, and poor exercise tolerance. PCP and
Mycobacterium avium complex disease are two of the
more severe infections affecting the later stages of HIV
Reactive airway disease is common among all
immunocompromised children, probably due to chronic
airway inflammation due to recurrent or chronic
infections. Lymphoid interstitial pneumonitis is the most
common noninfectious pulmonary condition seen in
pediatric HIV infection. This is characterized by diffuse
interstitial infiltrates. Pulmonary fibrosis is also seen
with HIV. Children with advanced HIV
encephalopathies may develop aspiration pneumonia.
GI manifestations include candida esophagitis, CMV
esophagitis, salmonellosis, shigellosis,
campylobacteriosis, rotavirus gastroenteritis, etc.
These infections are usually more severe than in
non-HIV children. Mycobacterium avium complex,
cryptosporidium, CMV, and other viruses may all induce
opportunistic enteropathies. Clostridium difficile
(pseudomembranous) colitis may develop in any patient
treated with broad spectrum antibiotics for long periods
of time. HIV children are at risk of developing chronic
hepatitis due to CMV or hepatitis B virus. CMV and
microsporidiosis have been identified as causes of
biliary tract infection. Pancreatitis may be caused by
CMV or drug toxicity (pentamidine, didanosine,
Neurological manifestations result from progressive
encephalopathy and retarded CNS development.
There is progressive motor dysfunction and loss of
developmental milestones. Exam findings include
weakness, flaccidity, hyperreflexia, spasticity, and gait
abnormalities. Seizures, cerebrovascular accidents,
CNS lymphoma, and meningitis may also develop.
Children may do well for several years. Behavioral
changes associated with chronic disease, interaction
with peers, or frequent medical visits may mimic
neurologic changes. Zoster and varicella infections can
Eye manifestions include frequent conjunctivitis and
blepharitis. Severe retinopathies are uncommon. ENT
manifestations include chronic otitis media and sinusitis.
Eradication of these infections may be difficult. These
children are at risk of developing mastoiditis. Tonsillar
and adenoidal hypertrophy may result along with
generalized lymphatic hypertrophy. Oral infections
include thrush, periodontitis, severe dental caries,
parotitis, and cervical lymphadenopathy.
Renal manifestations include nephrosis and
recurrent urinary tract infections. Children with HIV
often manifest short stature and delayed puberty.
Myopathies and non-specific rheumatologic conditions
Anemia, granulocytopenia, lymphopenia, and
thrombocytopenia all occur frequently with HIV.
Lymphopenia is a later manifestation of progressive
immune deficiency. Patients may often present with
findings similar to ITP (idiopathic thrombocytopenic
purpura) or aplastic anemia. Therapeutic agents such
as trimethoprim-sulfamethoxasole, zidovudine, and
conventional antibiotics may add to bone marrow
depression. Acquired circulating anticoagulants result
in prolonged coagulation times. Lymphomas occur in
3% of patients. Children are less susceptible to
Making the diagnosis of HIV infection in young
children can be very difficult. ELISA and Western blot
assays detecting anti-HIV IgG antibody are highly
sensitive and specific when used in adults. However,
these assays are often falsely positive in young children
due to the detection of maternal antibodies in the
infant's serum which can be detectable for as long as
18 months after birth. Only about 13% to 39% of
babies born to HIV-infected mothers will develop HIV
infection. Although overly sensitive in infants, these
commonly used tests are able to identify infants at risk
of developing HIV infection by identifying infected
More specific tests for young children include in vitro
production of HIV-specific antibodies by the child's
lymphocytes, detection of IgA anti-HIV antibodies,
detection of HIV p24 antigen (after decomplexing HIV
antigen-antibody complexes), HIV culture, and
polymerase chain reaction for detection of HIV-specific
nucleic acid sequences. However, these tests are not
as widely available.
As this case points out, any patient could be
potentially infected with HIV. Universal precautions
should be practiced routinely to prevent occupational
and nosocomial transmission. The child in this case
came from a low risk family residing in a low risk
community. In contrast to hospital personnel working in
a high risk community who routinely practice universal
precautions, hospital personnel in low risk settings may
actually be at higher risk by not practicing universal
Church JA. Clinical Aspects of HIV Infection in
Children. Pediatric Annals 1993;22(7):417-427.
Church JA. The Diagnostic Challenge of the Child
Born At Risk For HIV Infection. Pediatric Clinics of
North America 1994;41(4):715-725.
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