Differential Diagnosis in Pediatrics: A Compendium of Symptoms and Findings

464 Pages·1980·7.822 MB·English

by  Hans Ewerbeck M.D (auth.)

Hans Ewerbeck
Differential Diagnosis
in Pediatrics
A Compendium of Symptoms and Findings
Translated and Revised by
Judith Remischovsky
With 28 Tables
Springer-Verlag New York Heidelberg Berlin
HANS EWERBECK, M.D., Professor of Pediatrics, University of
Cologne, Children's Hospital, D-5000 Koln, Fed. Rep. of Germany
JUDITH REMISCHOVSKY, M.D., Assistant Professor of Pediatrics,
College of Medicine, Rockford School, University of Illinois, Rock
ford, Illinois, USA
First published in 1976: Differentialdiagnose von Krankheiten im Kindesalter
Library of Congress Cataloging in Publication Data
Ewerbeck, Hans.
Differential diagnosis in pediatrics.
Translation of Differentialdiagnose von Krankheiten im Kindesalter.
Bibliography: p.
Includes index.
I. Children-Diseases-Diagnosis. 2. Diagnosis, Differential.
I. Remischovsky, Judith. II. Title. [DNLM: I. Diagnosis, Differential-In
infancy and childhood-Handbooks. 2. Pediatrics-Handbooks. WSI41
E94d]
RJ50.E913 1980 618.92'0075 80-11721
All rights reserved.
No part of this book may be translated or reproduced in any form without
written permission from Springer-Verlag.
The use of general descriptive names, trade names, trademarks, etc. in this
publication, even ifthe former are not especially identified, is not to be taken as
a sign that such names, as understood by the Trade Marks and Merchandise
Marks Act, may accordingly be used freely by anyone.
© 1976 by Springer-Verlag Berlin Heidelberg
© 1980 by Springer-Verlag New York Inc.
Softcover reprint of the hardcover I st edition 1976
987654321
ISBN-13: 978-0-387-90474-0 e-ISBN-13: 978-1-4612-6074-5
001: 10.1007/978-1-4612-6074-5
Preface
The continuing development of sub specialties in pediatrics may be
justifiably considered to be progress. Due to this fact, complex syn
dromes can be analyzed today in their pathogenesis, are better under
stood in their symptomatology, and can be therapeutically controlled.
Therapy has reached an unexpectedly high level of effectiveness
through this specialization, never dreamed of even a few years ago. No
pediatrician can afford to do without it.
However, this gain in knowledge inevitably places new burdens
on the individual physician because of the confusing diversity of the
diseases under consideration. The colleague in private practice who is
called upon to treat an acutely ill child is all too likely to have the
patient admitted to the hospital without necessity or without the de
sired diagnostic insight. The hospital-based physician, confronted with
the same situation, tends to rely more on a haphazard utilization of the
laboratory facilities or the specialists. Should an illness not present
itself strictly according to the textbook, the wide range of biochemical
investigations and "tolerance tests" to which the patient is subjected
offers the physician, made insecure by the diversity of the diagnostic
possibilities, an opportunity for thinking and reading on the problem.
Medical literature, however, has reached such enormous proportions
that many physicians give up trying to keep abreast of it. Be it for lack
of time or some other reason, they may consult pediatric literature only
superficially or not at all-to the harm of the sick child.
This book on differential diagnosis is offered as an aid in such
situations. In obscure cases it uses a conspicuous symptom as a pointer
in the direction of a possible diagnosis, shortens the path to it, and
helps the physician avoid diagnostic errors or a mUltiplication of un
necessary examinations. The required investigations for the differential
diagnosis of a condition are listed and rare diseases are described. The
boundaries between subspecialties are defined in such a way as to help
the pediatrician understand additional diagnostic means, for which the
v
Preface
pediatric radiologist, the cardiologist, the neurologist, the endo
crinologist, and others are responsible.
This diagnostic directory intentionally restricts itself to the symp
toms and signs of illnesses and does not attempt to make a systematic
presentation of them, especially if the diseases can be diagnosed at first
sight and differential diagnostic alternatives do not exist.
Sufficient numbers of outstanding textbooks, handbooks, and
special works are available to the interested reader as soon as a correct
diagnosis is within reach.
The differential diagnosis at hand saves time for the physician
who works in pediatrics and in this way serves the patient as well. The
pragmatic shortness of the text, numerous tables, and a detailed table
of contents should help to achieve this goal, and provide stimulation
and information for the diagnostic workup.
The author's thanks is extended primarily to Dr. D. EBEL who
was kind enough to take upon himself the chapter on pediatric radiol
ogy and also to edit critically those parts of the book that pertain to his
field. Thanks is also expressed to Dr. G. SCHMITZ (pediatric cardiol
ogy) and Dr. K. KELLERMANN (pediatric neurology), who likewise
have critically reviewed and supplemented the chapters relating to the
areas of their expertise. All have substantially contributed to the suc
cess of this diagnostic tool.
HANS EWERBECK
vi
Acknowledgments
The translator-editor wishes to thank Professor HANS EWERBECK,
M.D., author of this book, for giving her the opportunity to translate
this work into English and for replying so promptly, lucidly, and
precisely to communications addressed to him in the course of the
project.
Thanks is due to Springer-Verlag for inviting the translator to
assume this exciting task and for answering questions about it.
Deepest gratitude must be expressed to Sister M. PHILIPPA
COOGAN, Ph.D., Professor of English at Niles College of Loyola Uni
versity for her untiring efforts in reviewing the manuscript and in
helping to make it idiomatically acceptable. She has remained a source
of humor and support throughout the trials of completing the transla
tion.
The translator thanks sincerely DOUGLAS L. SMITH, M.D., for
verification of many references and for a careful and critical reading of
the entire text.
SACHIDANANDA SHASTRI, M.D., has generously shared with the
translator the expertise derived out of his profound theoretical and
clinical knowledge.
Thanks is expressed for the assistance provided by HERBERT H.
GU)BL, M.D., in the translation of parts of the radiology sections and
by Mr. GREGORY P. TRAUTH in the translation of the preface.
Heartfelt thanks is offered to members of the teaching staff of the
following hospitals and medical schools, listed in alphabetical order
according to institutions. These staff members have supplied reference
material or have been helpful in answering questions that arose in
connection with revising some sections of the book.
JAY BERNSTEIN, M.D., William Beaumont Hospital, Royal Oak,
Michigan; NASROLLAH T. SHAHIDI, M.D., The University of Wiscon
sin, Madison, Wisconsin; DONALD P. PINKEL, M.D., City of Hope
National Medical Center, Duarte, California; ANGELO M. DIGEORGE,
vii
Acknowledgments
M.D., St. Christopher's Hospital for Children, Philadelphia, Pennsyl
vania; SUSAN KIENAST-PORTER, M.D., St. Mary's Hospital Medical
Center, Madison, Wisconsin.
A. TODD DAVIS, M.D., ORVILLE C. GREEN, M.D., GEORGE R.
HONIG, M.D., Ph.D., JOHN D. LLOYD-STILL, M.D., HENRY L. NAD
LER, M.D., and LAWRENCE G. TOMASI, M.D., Ph.D., The Children's
Memorial Hospital, Chicago, Illinois.
RORY W. CHILDERS, M.D., PETER R. HUTTENLOCHER, M.D.,
JANET D. ROWLEY, M.D., RAMESH C. TRIPATHI, M.D., Ph.D., and
JAMES H. TONSGARD, M.D., The University of Chicago, Pritzker
School of Medicine.
ALAN J. AXELROD, M.D., CRAIG E. BOOHER, M.D., CARL CO
HEN, Ph.D., RICHARD A. COHN, M.D., JAN A. ELLIOTT, M.D.,
CLIFFORD G. GRULEE, JR., M.D., ROBERT H. HARNER, M. D., ROGER
D. HILBERT, M.D., WILLIAM H. LANGEWISCH, M.D., PRADEEP D.
METHA, M.D., DAN G. PAVEL, M.D., FRANZ RODRIGUEZ-ERDMANN,
M.D., OSCARJ. ROSENZWEIG, M.D., KEITH M. TRUEMNER, M.D., D.
VIDYASAGAR, M.D., DONALD H. WORTMANN, M.D., and Lucy
ZABARENKO, Ph.D., The University of Illinois, College of Medicine.
Gratefully remembered for suggestions and assistance in the
preparation of the manuscript are Mr. KENNETH E. HOPPENS, director
of educational publishing, Year Book Medical Publishers, Chicago, as
well as Mr. JOHN GROSSMAN, chief manuscript editor, and Mr. BRUCE
YOUNG, managing editor, both at The University of Chicago Press.
The translator is indebted to the staff of the Woodruff L. Craw
ford Branch of the Library of the Health Sciences of the University of
Illinois in Rockford, the staff of the Library of the Health Sciences,
University of Illinois at the Medical Center, Chicago, and the staff of
the Library of the University of Illinois, Chicago Circle, for generous
help in verifying references.
A heartfelt thanks is extended to Mrs. MARILYN M. GRAHAM for
her competence, patience, and perseverance in typing the manuscript.
JUDITH REMISCHOVSKY
viii
Contents
1. Fever of Unknown Origin ............................ .
1.1 Local Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Generalized Bacterial Infections ...................... 3
1.3 Viral Infections ..................................... 5
1.4 Less Common Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.5 Chronic Inflammatory and Collagen Vascular Diseases. . 9
1.6 Tumors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1. 7 Rare Causes of Fever. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2. Vomiting (after Infancy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.1 Gastrointestinal Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.2 Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.3 Poisoning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.4 Acute Metabolic Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.5 Vomiting due to Cardiac Disorders. . . . . . . . . . . . . . . . . . . . 21
2.6 Vomiting due to Abdominal Disorders. . . . . . . . . . . . . . . . . 22
2.7 Vomiting due to Cerebral Disorders. . . . . . . . . . . . . . . . . . . 22
2.8 Rare Causes of Vomiting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2.9 Vomiting due to Psychogenic Causes. . . . . . . . . . . . . . . . . . 25
2.10 Vomiting of Blood (Hematemesis)..................... 26
3. Diarrhea (after Infancy) .............................. 27
3.1 Diarrhea due to Bacterial Infections. . . . . . . . . . . . . . . . . . . 27
3.2 Diarrhea due to Helminthic Infections. . . . . . . . . . . . . . . . . 27
3.3 Bloody Diarrhea .................................... 28
3.4 Rare Causes of Chronic Diarrhea. . . . . .. . . . . . . . . . . . . . . 29
3.5 Miscellaneous Causes of Diarrhea. . . . . . . . . . . . . . . . . . . . . 31
ix
Contents
4. Unexplained Pain. . . . . . . . . . . . .. . . . . . . . . . . .. .. . . . . .. . . 33
4.1 Headache. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
4.2 Pain in the Thoracic Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
4.3 Abdominal Pain. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.4 Unexplained Pain in the Back and Spine .............. 56
4.5 Pain in the Extremities .............................. 61
5. Somnolence, Loss of Consciousness .................... 81
5.1 Poisoning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
5.2 Disturbances of Metabolism. . . . . . . . . . . . . . . . . . . . . . . . . . 83
5.3 Altered States of Consciousness due to Cerebral Causes 88
6. Dyspnea ................... . . . . . . . . . . . . . . . . . . . . . . . . . 91
6.1 Obstructions of the Airways. . . . . . . . . . . . . . . . . . . . . . . . . . 91
6.2 Inspiratory Stridor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
6.3 Expiratory Stridor (Dyspnea) . . . . . . . . . . . . . . . . . . . . . . . . . 95
6.4 Dyspnea due to Pulmonary Causes. . . . . . . . . . . . . . . . . . . . 96
6.5 Dyspnea due to Cardiac Causes ...................... 97
6.6 Dyspnea due to Metabolic Causes .................... 98
6.7 Dyspnea due to Cerebral Causes .................. " . . 99
6.8 Dyspnea Associated with Hypoventilation ............. 99
6.9 Rare Causes of Dyspnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
7. Cough ............................................ " 103
7.1 Dry Cough ......................................... 103
7.2 Brassy Cough .................................... '" 104
7.3 Productive Cough ................................... 104
7.4 Hemoptysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .. 104
8. Cardiac Manifestations ............................... 107
8.1 Sinus Tachycardia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 107
8.2 Paroxysmal Tachycardia ............................. 108
8.3 Sinus Bradycardia. . . . . . . .. . . . . . . . . . . . . . . . . . .. . . . . . .. 109
8.4 Arrhythmias. . . . . .. . . . . . .. . . . . . .. . . . . . . . . . . . . . . . . . .. 109
9. Cyanosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 111
9.1 Poisoning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 111
9.2 Increase in Reduced Hemoglobin. . . . . . ... . . ... .. . . ... 112
10. Heart Murmurs ..................................... 117
10.1 Systolic Murmurs ................................... 119
10.2 Diastolic Murmurs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 122
x
Contents
10.3 Continuous Murmurs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 124
10.4 Pathologic Heart Sounds. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 124
11. Heart Failure ....................................... 127
12. Circulatory Manifestations . . . . . . . . . . . . . . . . . . . . . . . . . . .. 131
12.1 Hypotension ........................................ 131
12.2 Hypertension....................................... 132
13. Hematologic Manifestations ........................... 135
13.1 Anemia............................................. 135
13.2 Leukocytosis....................................... 149
13.3 Lymphocytosis...................................... 149
13.4 LeUkopenia, Agranulocytosis, Lymphopenia. . . . . . . . . .. 150
13.5 Bleeding Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 151
13.6 Leukemia........................................... 157
14. Lymph Node Enlargement. . . . . . . . . . . . . . . . . . . . . . . . . . .. 159
14.1 Malignant Lymphomas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 162
15. Splenomegaly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 165
15.1 Infections........................................... 165
15.2 Hematologic Diseases and Neoplasms. . . . . . . . . . . . . . . .. 168
15.3 Storage Diseases (Metabolic Disorders) . . . . . . . . . . . . . . .. 170
15.4 Portal Hypertension ........... " .... " . . .. . . . . . .. . .. 171
15.5 Rare Causes of Splenomegaly. .. .. . . .. . . .. . . . . . . .. . .. 172
16. Hepatomegaly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 177
16.1 Inflammation and Infections of the Liver .............. 177
16.2 Congestive Hepatomegaly. ... . .. . . .. .. . . .. . . . . .. . . . .. 178
16.3 Storage Diseases of the Liver.. ...... .. .. .. .. .. .. .... 179
16.4 Hepatic Tumors, Hepatic Infiltration by
Malignancies, and Hepatic Cysts ................... 182
17. Jaundice (Icterus) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 185
17.1 Prehepatic Jaundice due to Increased Hemolysis ....... 186
17.2 Prehepatic Jaundice due to Disturbed Transport
Mechanism (without Increased Hemolysis) .......... 186
17.3 Intrahepatic Jaundice. .. . . . . . ... . .. . .. .. . .. . . . . .. . . .. 188
17.4 Jaundice due to Defect in Hepatic Excretory
Function ......................................... 190
17.5 Obstructive Jaundice ................................ 191
xi