Case presentation
An eight-year-old child was admitted for a 5-week history of recurrent abdominal pain. The pain was reported to be present almost daily, disrupting sleep and causing episodes of agitation and restlessness, with sudden and incessant crying and increased heart rate, particularly when the child was moved from the stroller to his bed. His mother reported a partial improvement after ibuprofen administration. His previous history was remarkable for developmental delay, cerebral palsy with spastic tetraparesis, drug-refractory epilepsy treated with vigabatrin, levetiracetam, topiramate, and phenobarbital, and the placement of a percutaneous endoscopic gastrostomy 6 years earlier. The parents did not report any recent history of vomiting, diarrhea, constipation, or fever. A dental evaluation ruled out tooth decay, and an orthopedic evaluation excluded an osteoarticular issue. Laboratory tests were performed to investigate possible causes of pain, including white blood cell count, glucose, alanine aminotransferase, aspartate aminotransferase, creatinine, electrolytes, bilirubin, amylase, and lipase, and they were all in the normal range (Table 1). Physical examination was unremarkable, but brownish aggregates were noted when the diaper was removed (Fig. 1).
Table 1.
Laboratory tests
| Laboratory test | Value (reference range) |
|---|---|
| Total WBC (cells/μL) | 12110 (6000–13,000) |
| Neutrophils (cells/μL) | 7050 (1500–8500) |
| Lymphocytes (cells/μL) | 3980 (2000–8000) |
| Monocytes (cells/μL) | 730 (10–1000) |
| Eosinophils (cells/μL) | 330 (100–500) |
| Basophils (cells/μL) | 20 (0–20) |
| Creatinine (mg/dL) | 0.29 (0.2–1.15) |
| BUN (mg/dL) | 10 (6–21) |
| CRP (mg/dL) | 4.2 (< 5.0) |
| ALT (U/L) | 3 (10–25) |
| AST (U/L) | 23 (23–46) |
| Bilirubin (mg/dL) | 0.4 (0.2–1) |
| GGT (U/L) | 12 (5–14) |
| Glucose (mg/dL) | 76 (55–105) |
| Na+ (mEq/L) | 144 (135–145) |
| K+ (mEq/L) | 3.5 (3–5.5) |
| Ca2+ (mg/dL) | 9.2 (8.8–10.8) |
| Mg2+ (mg/dL) | 1.6 (1.4–1.7) |
| Amylase (U/L) | 127 (98–405) |
| Lipase (U/L) | 23 (5–160) |
WBC white blood cell, BUN blood urea nitrogen, CRP C-reactive protein, ALT alanine aminotransferase, AST aspartate aminotransferase, GGT γ-glutamyltransferase
Fig. 1.
Brownish aggregates found in the child’s diaper
Questions
1. What is the most likely cause of this child’s pain?
2. How should the diagnostic workup be completed?
3. What are the best treatment and follow-up for this patient?
Acknowledgements
The authors thank Martina Bradaschia for the English revision of the manuscript.
Author contribution
AT and SB wrote the first draft of the manuscript. EB conceived the work and substantially revised the manuscript. All authors read and approved the final version.
Funding
Open access funding provided by Università degli Studi di Trieste within the CRUI-CARE Agreement.
Data Availability
Not applicable.
Declarations
Ethics approval and consent to participate
Not applicable.
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Not applicable.
Competing interests
The authors declare that they have no competing interests.
Footnotes
The answers to these questions can be found at 10.1007/s00467-021-5156-y.
Some of this paper has been posted on the ResearchSquare preprint server. The preprint can be accessed here: https://www.researchsquare.com/article/rs-32787/v1.
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Data Availability Statement
Not applicable.