Berkowitz’s – Section V: Hematologic Disorders

Anemia

Joseph L. Lasky III, MD, and Eduard H. Panosyan, MD
CASE STUDY
An 18-month-old girl is brought to the office with a 3-day history of cough, rhinorrhea, low-grade fever, mild scleral icterus, and pallor. During her first week of life, the girl had hyperbilirubinemia of unknown etiology that required phototherapy. Her family history is significant for mild anemia in her father; the cause of his condition is unknown. A paternal aunt and grandfather had cholecystectomies while in their 30s. On physical examination, the girl is tachycardic and tachypneic (no respiratory distress) with scleral icterus and pallor. Her spleen is palpable 3 cm below the midcostal margin. The remainder of her examination is normal.
Questions
1. What hemoglobin/hematocrit values are associated with anemia?
2. What is the appropriate initial evaluation of children with anemia?
3. What emergency situations in children who present with anemia should be recognized by the primary pediatrician?
4. When should a child with anemia be referred to a hematologist?
5. How is the family history relevant in the evaluation of anemia?

Bleeding Disorders

Joseph L. Lasky III, MD, and Eduard H. Panosyan, MD
CASE STUDY
A 6-year-old girl presents with a several-month history of recurrent epistaxis. Episodes occur every 2 to 3 weeks and last 15 to 20 minutes at a time. Both nares are affected. Her mother also notes that the girl has always bruised easily. On physical examination, several 2- to 3-cm ecchymoses are noted on her lower extremities. Initial laboratory evaluation includes a complete blood cell count, which is normal (platelet count 300,000/mL); a normal partial thromboplastin time of 30 seconds; and a normal prothrombin time of 12.5 seconds, with international normalized ratio 1:1.
Questions
1. What conditions should be considered when easy bruising is the chief complaint?
2. What is the appropriate laboratory evaluation for children with clinical signs of bleeding?
3. What management is appropriate for the most common pediatric bleeding disorders?
4. What are the common medical complications that children with bleeding disorders face?
5. When is consultation with a hematologist

Lymphadenopathy

Eduard H. Panosyan, MD, and Joseph L. Lasky III, MD
CASE STUDY
A 12-year-old girl is brought to the office with swelling of the anterior cervical nodes, which she has had for 2 weeks. Intermittent fever with temperatures as high as 101°F (38.3°C) and decreased appetite have been associated with the condition. On examination, her temperature is 100.4°F (38.0°C) and her other vital signs are normal. Three to 4 non-tender nodes 1 to 2 cm in diameter are present bilaterally. The remainder of the examination is normal.
Questions
1. When is lymphadenopathy of medical concern?
2. What are the clinical features of childhood diseases that present as cervical lymphadenopathy?
3. What are the diagnostic approaches to the evaluation of children with lymphadenopathy?
4. What is an appropriate therapeutic approach to cervical lymphadenopathy in children?