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A Young Infant From New Hampshire With Fever, Splenomegaly, Anemia and Thrombocytopenia

Heyne, Thomas F. MD, MSt*; Tsurutis, Andrea D. MSN-CPNP†,‡; Herzberg, Emily M. MD§; El Saleeby, Chadi M. MD†,‡,¶

The Pediatric Infectious Disease Journal: July 2019 - Volume 38 - Issue 7 - p 765
doi: 10.1097/INF.0000000000002262
Your Diagnosis, Please

From the *Department of Medicine, Massachusetts General Hospital

Department of Pediatrics, Massachusetts General Hospital for Children

Division of Pediatric Hospital Medicine, Massachusetts General Hospital for Children

§Department of Newborn Medicine, Boston Children’s Hospital

Division of Pediatric Infectious Disease, Massachusetts General Hospital for Children, Boston, Massachusetts.

Accepted for publication November 6, 2018.

The authors have no funding or conflicts of interest to disclose.

T.F.H. and A.D.T. are equal contributors.

T.F.H., E.M.H., A.D.T. participated in reviewing the literature and drafting and reviewing the article. C.M.E.S. supervised the project, and he participated in reviewing the literature and drafted, and revised the article. All authors reviewed and approved the final article as submitted and agree to be accountable for all aspects of the work.

This article should be attributed to the Department of Pediatrics, Harvard Medical School at the Massachusetts General Hospital for Children in Boston, Massachusetts.

Address for correspondence: Andrea D. Tsurutis, MSN-CPNP, Massachusetts General Hospital for Children, 55 Fruit Street – Ellison 17, Boston, MA 02114. E-mail:

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An 83-day-old, unvaccinated, male infant was transferred to our hospital from an outside facility in July with fever, splenomegaly, anemia and thrombocytopenia. Seven days before transfer, the patient and his twin brother developed rhinorrhea and cough. Two days later, the patient was seen by his primary care physician for fever and was diagnosed with a viral upper respiratory tract infection. Although his twin soon improved, the patient subsequently developed decreased appetite, listlessness, emesis, worsening pallor and a rectal temperature of 38.8°C, prompting evaluation at a local emergency department.

The patient was born without complications at 38 weeks of gestation with a fraternal twin. He had been healthy before the onset of this illness. His mother was healthy, and her pregnancy was uneventful. His family lived in rural New Hampshire, and his father worked as a landscaper. There was no history of foreign travel.

In the emergency department, the patient had a weight of 4.4 kg, temperature of 38°C, pulse of 162 beats/min, blood pressure of 106/72 mm Hg, respiratory rate of 64 respirations/min and oxygen saturation of 100% in ambient air. Physical examination was notable for pallor and abdominal distension. Laboratory evaluation revealed anemia (hemoglobin of 6.9 g/dL; reference range: 10–18 g/dL) and thrombocytopenia (platelet count of 43 K/µL; reference range: 150–450 K/µL) with a normal white blood cell count (8 K/µL; reference range: 5–19.5 K/µL) and differential of 25% neutrophils (reference range: 20%–46%), 1% bands (reference range: 0–10%), 71% lymphocytes (reference range: 50%–85%) and 3% monocytes (reference range: 4%–11%). His chest radiograph was normal, but abdominal radiograph revealed splenomegaly. Blood and urine cultures were obtained, intravenous ceftriaxone and a normal saline bolus were administered and the patient was transferred to our tertiary-care facility.

On arrival, the patient was pale and lethargic. His examination revealed a grade 2/6 systolic flow murmur and hepatosplenomegaly. Additional laboratory evaluations showed elevated reticulocyte count (5.3%; reference range: 1%–2%), presence of nucleated red blood cells (9.3%) in the complete blood count, normal basic metabolic panel, elevated C-reactive protein (32.2 mg/L; reference range <8.0 mg/L), elevated lactate dehydrogenase (955 U/L; reference range: 110–210 U/L) and normal total and direct bilirubin levels. Direct Coombs test was negative, G6PD activity was normal and haptoglobin level was low at <6 mg/dL (reference range: 40–165 mg/dL). Serologic testing for Lyme disease and human immunodeficiency virus and polymerase chain reaction tests for Anaplasma, Ehrlichia and HIV were all negative.

The patient received packed red blood cell transfusions for his significant anemia. An additional test confirmed the diagnosis.

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