8yo F w/ PMH of chronic active EBV (CAEBV) complicated by HLH, s/p BMT complicated by EBV-related relapse and GVHD, now presenting with acute on chronic abdominal pain. Mom says patient has had waxing and waning abdominal pain for years since BMT, but it has acutely worsened this week, currently rated as 8/10 in severity. Reported a fever (100.8) 6 days ago which resolved with Tylenol, and one episode of NBNB emesis yesterday. Mom notes her face looks more yellow than normal. Also reports a dry cough for 1 week with intermittent chest pain. Denies sick contacts at home or known sick contacts at school. No recent travel, no new foods, but endorses decreased appetite yesterday. BMs have been normal, brown in appearance, no diarrhea. Mom has given Tylenol for pain and fever, denies any daily medications (off immunosuppression x1 year). 

No known allergies, no daily medications (history of prior iron supplementation), IUTD 

Physical Exam:  

VS: T 36.8 HR 102 RR 24 BP 111/70 SpO2: 100% 

General: Sitting up, cooperative, smiling, no acute distress 

Skin: Scattered areas of hyperpigmentation from healed rash and lesions. No erythematous or new rash. Mild facial jaundice  

HEENT: Normocephalic, atraumatic, no scleral icterus  

Neck: Supple 

CV: Regular rate and rhythm. Normal peripheral perfusion, distal pulses intact  

Resp: Intermittent cough, no wheezing, lungs clear to auscultation, no crackles 

GI: Epigastric and periumbilical tenderness to palpation. No hepatosplenomegaly  

MSK: Moves all extremities, no joint swelling 

Neuro: No focal deficits  

Lab results:  

WBC 8.9, Hgb 8.3 (baseline 11), Hct 23.7 Platelets 254  

RVP: R/E+ 

Creatinine 0.97 (baseline 0.3), BUN 19 

Normal AST/ALT 

Lipase 53 

Awaiting patient to urinate  

Chest XR obtained

CXR: Streaky middle lobe airspace opacity with partial silhouetting right heart border may represent mild atelectatic changes but superimposed infection cannot be excluded in appropriate clinical setting.  

Renal Ultrasound:  

Bilateral echogenic kidneys concerning for medical renal disease. No hydronephrosis  

Urine obtained  

UA: 1+ glucose, 3+ blood, 2+ protein, Trace LE, WBC 4, RBC 230