Contemporary Pediatrics Puzzler

Infant with failure to thrive and hypotoniaA 4-month-old girl arrives at the clinic for a well-child visit. Her mother voices concerns about the infant’s poor weight gain, slow feeding habits, and physical delays such as head lag, poor grasp reflex, and rolling over.
Tight, shiny membrane encases newborn’s skinAfter a cesarean delivery at 30 weeks, a 1430-gram premature female neonate was noted to have generalized thick, dark brown scale forming a tight membrane over her entire skin surface. Her mother was a healthy 19-year-old gravida 1 with normal prenatal screening ultrasound and laboratory studies. Family history did not reveal any congenital malformations or genetic disorders.
Small-for-age toddler is unable to walkA 22-month-old African American boy born at 38 weeks by normal vaginal delivery presents to a local hospital from a private pediatric office for failure to thrive. He was seen by his pediatrician until aged 1 month but was lost to follow-up. His delay in walking prompted his mother to reestablish care at age 22 months.
Newborn with persistent hypoglycemiaA full-term male infant was born to a 33-year-old gravida 3, para 3 mother. The prenatal course was uncomplicated, without gestational diabetes; the mother received prenatal care at an out-of-state institution. At the delivery, however, the baby was notably macrosomic, with shoulder dystocia and perinatal distress requiring positive pressure ventilation.
Infant with facial lesions and respiratory distressA 2-month-old Hispanic girl is transferred by her pediatrician to the emergency department (ED) for evaluation of decreased oral intake, failure to thrive, and large bleeding facial hemangiomas.
Treat plays trick on a 3-year-old boyA 3-year-old boy presents to the emergency department (ED) with a 1-day history of irritability and listlessness. According to his parents, he was well until the night before when he began to behave abnormally, becoming excessively tired approximately 2 hours after eating dinner. During the night, the boy slept poorly, sporadically awakening with crying followed by brief periods of calmness. The morning of presentation, he was difficult to arouse with intermittent fussiness and reluctance to ambulate.
Peeling rash in a 4-year-old boyThe mother of a 4-year-old boy, whose family recently emigrated from Haiti, brings him to the pediatric mobile clinic for evaluation of a rash that had begun 11 days earlier as an eruption of vesicular, pruritic papules on the bilateral lower extremities and had spread to the buttocks and medial thighs with sparing of the face. The skin eruption was followed by desquamation of the skin on his palms and soles.
Pearl-like mass on a girl’s tympanic membraneDuring a routine office visit for mild acute nasal congestion and possible diminished hearing, an isolated, small, pearl-like mass was noted just posterior to the umbo of the left tympanic membrane of a 5-year-old girl.
Boy with fever, cough, and oral lesionsA previously healthy, 16-year-old Hispanic boy initially presents to the clinic with a 5-day history of tactile fevers, achy malaise, congestion, and a dry cough. He was afebrile with negative rapid strep and monospot tests, but was prescribed fluticasone, benzonatate, and ibuprofen for a presumed upper respiratory infection. He was encouraged to return if symptoms did not improve.
Hypothermia and emesis in a newbornThe patient, a 7-day-old, small-for-gestational-age female (birth weight, 2.21 kg), born by vaginal delivery at 37 weeks to a G1P0 mother, presented to the pediatric emergency department for hypothermia and emesis at the recommendation of her pediatrician.