The case: a 3 month old with poor feeding and otherwise normal exam, found to have transaminitis and gallstones on US.

Here’s how you answered the questions:

Discussion: While sleep is part of an infant’s job description, determining the degree of ‘sleepiness’ and degree of work up represents a clinical challenge. For this infant, with a normal exam other than sleepiness, the extent of lab work up and specific imaging differed among respondents. With the sleepiness and vomiting, many would start with an US for intussusception. Dr. Agrawal noted that the range for idiopathic intussuception is 3 mos to 2.5 years, with peak age 5-11 mos. So while this infant is on the younger age, it is still a consideration on the differential.

Respondents were split among which labs to order. Some would go down the sepsis path with CBC, urine, other would want an ammonia to evaluate for an underlying metabolic disorder. When her labs return with an elevated AST/ALT, and subsequent elevation in GGT, CK, LDH, and alk phos, the suggesting possible liver pathology. People also raised the question of NAT (which you would see on US, but important to also obtain a CT if a true concern for legalality). Given the abnormal liver tests, a RUQ was obtained which demonstrated gallstones with septations and wall thickening. The exact cause of the gallstones and the sleepiness is unclear, however Dr. Chamberlin reminded us that pain can make infants sleepy.

Denouement: MRCP done after admission and showed type IV choledochal cyst. Patient transferred to CHOP for surgery and definitive management.

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