In the next in our series, Dr David Capehorn asks what might be the underlying cause in a child who is withdrawn and lethargic several weeks after apparent gastroenteritis. Put your suggestions in the comments below – answer to be revealed soon!
Note details of the case have been changed to protect individuals’ identities
A pale-looking five-year-old is brought into a busy morning clinic by his mother. ‘He’s just not himself,’ she says. ‘He’s been a bit off for a couple of weeks – eating less, seems more tired than usual.
‘He’s had a couple of bugs. Nothing major though – just loose stools, mild tummy pain and a low fever. But no vomiting.’
On examination, his abdomen is soft and non-tender. No red flags jump out.
Judging that recent viral gastroenteritis seems likely, and that it could be post-viral fatigue, the GP offers reassurance and advises fluids and rest.
Two weeks later, the child is back at the GP clinic. He’s still not himself. His mother says he now naps during the day – something he hasn’t done since he was three. He’s eating poorly and hasn’t bounced back. The loose stools continue, but aren’t frequent or severe.
Again, the GP is not overly concerned, so offers reassurance and safety-netting advice: ‘It’s probably just lingering viral effects, but come back if he worsens or in 2 weeks if still no better.’
At a third visit 2 weeks later, a different GP sees the child.
This GP enquires: ‘Are the loose stools happening at night too?’
The mother pauses, then says: ‘Yes, sometimes he wakes us up needing the toilet. I thought that was just part of the bug.’
That detail changes the picture. The GP checks his growth and notes there’s been no weight gain for 12 months. In fact, the boy has dropped a centile on the growth chart.
His abdomen is still soft. No guarding or organomegaly. But now, the pattern feels wrong.
Investigations are arranged, with blood tests showing:
- CRP: raised
- ESR: raised
- Coeliac screen: negative
What further investigation might you like to do? What’s the likely diagnosis?
Put your suggestions in the comments below. Answer to be revealed in the coming weeks!
For more diagnostic puzzles, see previous articles in our Case of the month series:
- Case of the month answers: What was causing this patient’s nausea and tingling fingers? – Pulse Today
- Case of the month answers – what was causing this patient’s panic episodes? – Pulse Today
- Case of the month – answers: Did you get the cause of the patient’s sudden memory loss? – Pulse Today
- Case of the month answers: Did you get what caused this man’s pityriasis rosea? – Pulse Today
- Case of the month answers – what was the cause of this young worker’s abdominal pain? – Pulse Today
Have you handled a case which had a slightly surprising outcome? Perhaps an elderly man with non-vertigo dizziness? Or an unexpected cause of bradycardia? Would you like to share your case studies with us to help support and inform GPs? Please get in touch if you would like to contribute! [email protected]
In need of a chest Xray for possible pneumonia.
And a stool sample for OCP too.
UTI is also possible, but usually has other symptoms in a boy too.
Although not the ones the microbiologists require in order to get an MSU done.
Crohn’s/ IBD – if has an iron deficiency anaemia
Likely IBD. Check faecal calprotectin.