I'd consider methemoglobinemia although it doesn't fit all the criteria.
A level would be nice to know in this case.

Peter Antevy MD
Joe DiMaggio Children's Hospital
Attending Physician

On Nov 8, 2011, at 10:03 AM, Trey Katzenbach wrote:

> I am interested in your thoughts on a case that I recently saw.
> Pt is a 7 mo who p/w vomiting about 20 times over the 90 minutes prior
> to arrival, going from clear to yellow; + watery diarrhea x1 tonight;
> pt looks pale; pt was in usual good state of health until sxs started
> tonight; no fever; ate cinammon for first time today; uri sxs last
> week that resolved; no rash; no sob; pt looks lethargic.
> PMHx was unremarkable. FHx was unremarkable.
> Vitals in triage: 108/75, HR=161, RR=28, Pox=98%ra, Temp=96.9 rectal, 8.8kg
> I was called to triage by the nurse because the patient was pale and
> actively vomiting.  I brought the pt right back to a room and got a
> dextrose-stick of 132. When placed on the stretcher she was somnolent
> with occasional vomiting and I was struck by her relative bradycardia
> of 125 with a normal appearing heart rhythm on the monitor.  She began
> to fall asleep and her pulse ox dropped to 90%ra.
> Relevant P/E showed the patient to be afebrile, lethargic, pale,
> vomiting yellow emesis, not crying. Atraumatic, Normocephalic. Sclera
> are normal, Ears and nose normal to inspection, Oropharynx normal,
> Mucous membranes pink and moist, No stridor. Breath sounds clear and
> equal bilaterally, No respiratory distress, No accessory muscle use,
> No retractions. Heart sounds normal, Pulses 2+, equal bilaterally, No
> murmurs, Rate is bradycardic, Rhythm is normal. Abdomen is soft, No
> distension, No masses, Bowel sounds normal, Liver and spleen normal,
> heme negative stool. Neuro exam shows no focal motor deficits but pt
> is lethargic. Skin is warm and dry. Pt is pale.
> I placed an IV, got a chest and belly x-ray, and did an ECG.  The
> xrays were unremarkable. The ECG was read as normal but the HR was 122
> and I think bradycardic for this age.  Even during stimulation for her
> IV and D-stick she did not have an active cry and her HR did not rise.
> Her pulse ox became normal with stimulation up to 98% with blow-by
> O2.  I gave her 1.35 mg IV zofran and 250cc NS bolus and the vomiting
> stopped after about 5 minutes.  She became more alert and active with
> a HR into the 180's after about 20 minutes.  She looked well enough
> after about an hour to tolerate a bottle of pedialyte with no issues.
> A blood cx was sent and the following labs were obtained.  CBC with
> wbc count of 26.5 (40%N, 51%L, 4%B), hgb=11.4, plt=529; u/a negative
> except for trace ketones; LFT's and BMP were all within normal limits;
> UDS was negative.  Given the elevated wbc count, I treated her with
> 75mg/kg of IV ceftriaxone to cover for possible bacteremia but I
> really think the elevation was due to a stress response.
> What are you thoughts on the differential here given the most
> impressive things about her were the lethargy, bradycardia and
> hypoxia?  We entertained intussusception and other mechanical bowel
> issues, sepsis, meningitis/encephalitis, drug ingestion, and
> gastroenteritis among others. Ultimately she was back to her baseline
> within 30 minutes of interventions.  She was admitted to the hospital
> and discharged after >24 hours of negative blood culture and normal
> exam with good PO's.  I think all of her sx's may be related to
> vasovagal issues related to continuous vomiting and hypoventilation
> from lethargy.  Have any of you ever seen this in this age group?
> - Trey Katzenbach, Pediatric attending
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