7. Grann V, Pool JL, Klaus M: Comparative study of bone marrow aspiration and biopsy in patients with neoplastic disease. Cancer 19:1898\x=req-\
1900, 1966.
Singh G, Krause JR, Breitfeld
V: Bone examination for metastatic tumors. Cancer 40:2317-2321, 1977. 9. Triche TJ, Ross WE: Glycogen-containing neuroblastoma with clinical and histopathologic features of Ewing's sarcoma. Cancer 41:1425\x=req-\ 8.
marrow
1432, 1978. 10. tron
Greenberg R, Rosenthal I, Falk GS: Elecmicroscopy of human tumors secreting cate-
cholamines: Correlation with biochemical data. J Neuropathol Exp Neurol 28:475-500, 1969. 11. Horvat BL, Caines M, Fisher ER: The ultrastructure of rhabdomyosarcoma. Am J Clin Path 53:555-564, 1970. 12. Mackay B, Masse SR, King OY, et al: Diagnosis of neuroblastoma by electron microscopy of bone marrow aspirates. Pediatrics 56:1045-1049. 1975. 13. Delta BG, Pinkel D: Bone marrow aspiration in children with malignant tumors. J Pediatr 64:542-546, 1964. 14. Finklestein JZ, Ekert H, Isaacs H, et al: Bone marrow metastasis in. children with solid tumors. Am J Dis Child 119:49-52, 1970. 15. O'Neill P, Pinkel D: Wilms' tumor in bone marrow aspirate. J Pediatr 72:396-398, 1968.
Idiopathic Linear Calcification the Ascending Aorta in an
evidence of calcification of the ascending aorta, but a subsequent roentgenogram, one month later, showed for the first time a linear calcification of the aorta (Fig 1, top). The roentgenologic evidence of linear calcification of the aorta has persisted since then with no further extension of the lesion. Her most recent physical examination showed an active, alert, acyanotic girl with normal vital signs. Blood pressures were as follows: right arm, 90/68 mm Hg; left arm, 92/70 mm Hg; and leg, 106/70 mm Hg. White, scaly, cutaneous lesions involved both the upper and lower extremities, both ears, and the oral mucous membrane. The fingernails and toenails were dystrophic. Examination of the heart disclosed no abnormalities; there was no thrill, parasternal heave, heart murmur, or ejection click. The hemoglobin level was 10.8 g/dL and the hematocrit reading was 32%. Total and differential WBC counts, urine analysis, serum electrolytes, total protein and albu¬ min-globulin ratio, and serum chemistry
levels, including serum bilirubin, fasting blood glucose, SGOT, SGPT, calcium, phos¬ phorus, and alkaline phosphatase values, were
of
all within normal limits. Immuno-
globulin electrophoresis, repeated twice, showed a normal profile. The results of
Adolescent
cated pregnancy and a full-term spontaneous delivery. Her birth weight was 3.4 kg. There was no family history of congenital heart disease, vascular disease, or candidiasis. She remained perfectly well until 9 months of age when, after an upper respiratory tract infection, oral thrush developed. Candida albicans grew from cultures of material obtained from the oral
VDRL and FTA-ABS tests, as well as fluorescent antinuclear antibody and skin tuberculin tests, were ngative. Laboratory values were as follows: total serum choles¬ terol, 176 mg/dL; triglycérides, 121 mg/dL; free fatty acids, 0.57 mEq/L; total serum lipids, 530 mg/dL; phospholipids, 57 mg/ dL; protein-bound serum iodine, 8.3 mg/ dL; T„ 22.5%; T4, 10.9 mg/dL; parathyroid hormone, 338 pg/mL; and serum cortisol, 6 pg/dL. The results of glucose tolerance tests were normal. Chromatographie anal¬ ysis of urine and serum amino acids disclosed a normal profile. Repeated 12-lead ECGs indicated no abnormalities. Retrograde aortography showed calcification involving the outer wall of the ascending aorta (Fig 1, bottom). There was no evidence of aneurysm of the aorta or sinuses of Valsalva. An echocardiogram was entirely within normal limits for the patient's age and weight, with no evidence of vegetations involving aortic valves, supravalvular aortic root, or left ventricular outflow tract.
lesions. Despite antifungal treatment\p=m-\ first with nystatin (Mycostatin) and later with amphotericin B\p=m-\themucocutaneous lesions spread and, during the next four years, involved the arms, legs, both ears, and all fingernails and toenails, which became dystrophic. At the age of 5 years, staphylococcal pneumonia developed from which she made a complete recovery with no adverse seque¬ lae. Cutaneous candidiasis persisted, how¬ ever. Three years later, the patient had another episode of severe upper respirato¬ ry tract infection. A chest roentgenogram obtained at that time did not show any
Com ment.—Linear calcification of the ascending aorta is extremely uncommon in infants or older chil¬ dren. Singleton and Merten- recently described two children with an unusu¬ al syndrome that was characterized by dental dysplasia, cardiomegaly, sub¬ stantial heart murmur, osteoporosis, marked widening of the medullary cavities of the metacarpale and pha¬ langes of both hands, and linear calci¬ fication of the ascending aorta. Car-
Although a frequent roentgenographic observation in elderly persons,1
linear
calcification
of
the
ascending aorta is extremely rare in infancy and childhood. Our purpose is to
report linear calcification of the
aorta in an adolescent in whom extensive investigations failed to establish causal basis for the lesion.
ascending
Report of a Case.\p=m-\Thepatient, a 12\x=req-\ year-old girl, was the result of an uncompli-
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Manitoba User on 06/05/2015
Chest roentgenograms obtained at age 8 years. Top, First roentgenologic evidence of linear calcification involving aorta (arrow). Bottom, Persistence of calcifica¬ tion of lateral wall of ascending aorta as shown in retrograde aortogram; arrow shows lateral wall of ascending aorta as site involved by calcification.
diac catheterization studies showed aortic stenosis in both patients, one having a patent ductus arteriosus as well. A high prevalence of aortic stenosis has also been reported in adults with calcification of the ascend¬ ing aorta that is of nonsyphilitic origin' and it has been suggested that such calcification results from turbulent blood flow distal to the stenotic lesion. In our patient, howev¬ er, there were no clinical, ECG, or roentgenographic features suggestive of aortic valvular disease, or dissect¬ ing aneurysms, nor was there a histo'
'
ry of trauma before the detection of aortic calcification. Finally, the nor¬
mal serum lipid profile, negative sero¬ logie findings, and the young age of our patient do not favor a causal role of atherosclerosis or syphilis, the two conditions most commonly associated
with linear calcification of the ascend¬ ing aorta in adults. In recent years, the role of candidia¬ sis as a causative agent for endocardi¬ tis has become increasingly clear, especially in heroin addicts,"· immunosuppressed hosts," and patients who have a prosthetic valve.7 Furthermore, Gottlieb et als have shown that, contrary to earlier reports," candidia¬ sis can invade the normal aortic valve. In another case, reported by Gomes et al,1" fungal vegetations due to Candi¬ da infections involved ventricular as well as the aortic surface of the aortic valves. It is conceivable that distal spread of such infection could cause aortitis of the ascending aorta, deposi¬ tion of atheromatous material, and subsequent calcification. To our knowledge, however, isolated aortitis due to Candida infection has not been reported. Moreover, the patients de¬ scribed by both Gottlieb et als and Gomes et al1" had systemic candidia¬ sis, were heroin addicts, and had substantial heart murmurs indicative of aortic valvular disease. Echocardiography showed abnormal echoes pro¬ duced by fungal vegetations in the aortic root during diastole, on the aortic valve during systole and dias¬ tole and in the left ventricular outflow tract. By contrast, candidiasis in our
patient
was
of the mucocutaneous
type without any evidence of involve¬ ment of
deeper structures; clinical finding did not suggest aortic valvular disease, and echocardiography showed
normal aortic valves with no evidence of abnormal echoes either in the aortic root or in the left ventricular outflow
region. We, therefore, do
not believe that
linear calcification of the ascending aorta in our patient is related to chronic cutaneous candidiasis. In the absence of a recognizable cause, the calcification seems to be truly idio¬
pathic.
NARAYAN RANGASWAMI, MD, DCH SUBHASH CHAUDHARY, MD GEORGE FLINN, MD SHYAMAL K. SANYAL, FAAP, FACC Cardiopulmonary Disease, Infectious Disease, and Radiology Services St Jude Children's Research Hospital Memphis, TN 38101
Nonproprietary
Name and Trademark of Drug
Amphotericin B—Fungizone. 1. Lee YT, Hsu CJ: Radiologic calcification of the aorta: Its incidence and clinical significance. J Formosan Med Assoc 71:176-188, 1972. 2. Singleton EB, Merten DF: An unusual syndrome of widened medullary cavities of the metacarpals and phalanges, aortic calcification and abnormal dentition. Pediatr Radiol 1:2-7, 1973. 3. Higgins CB, Reinke RT: Nonsyphilitic etiology of linear calcification of the ascending aorta. Radiology 113:609-613, 1974. 4. Buchbinder NA, Roberts WC: Left-sided valvular active infective endocarditis: A study of 45 necropsy patients. Am J Med 53:20-35, 1972. 5. McLoughlin MJ, Pasternac A, Morch J, et al: Idiopathic calcification of the ascending aorta and aortic valve in two young women. Br Heart J 36:96-100, 1974. 6. Rosner F, Gabriel FD, Taschdjian CL, et al: Serologic diagnosis of systemic candidiasis in patients with acute leukemia. Am J Med 51:54-62, 1971. 7. Schelbert HR, Mueller OF: Detection of fungal vegetations involving a Starr-Edward mitral prosthesis by means of ultrasound. Vasc Surg 6:20-25, 1972. 8. Gottlieb S, Khuddus SA, Balooki H, et al: Echocardiographic diagnosis of aortic valve vegetations in Candida endocarditis. Circulation 50:826-830, 1974. 9. Louria DB, Hensle T, Rose J: The major medical complications of heroin addiction. Ann Intern Med 67:1-22, 1967. 10. Gomes JA, Calderon J, Lajam F, et al: Echocardiographic detection of fungal vegetations in Candida parasilopsis endocarditis. Am J Med 61:273-276, 1976.
Child Abuse: Acute Renal Failure From Ruptured Bladder In assessment of pediatric emergencies, failure to consider the possibility of child abuse may result in delayed initiation of appropriate diagnostic procedures or definitive treatment. This
report concerns a 6-year\x=req-\ boy with acute renal failure resulting from a ruptured bladder, to our knowledge a previously undescribed old
manifestation of child abuse.
Report of a Case.\p=m-\A6-year-old boy was admitted to the University of California, Davis Medical Center in Sacramento because of elevated levels of serum potassium and BUN. During the preceding five days, a complaint of abdominal pain and constipation was followed by intermittent vomiting, a noticeable decrease in urine output, several episodes of gross hematuria and hematochezia, and a progressive deterioration of mental status to the point of noticeable lethargy and confusion. Except for a fall in the shower, there was no history of trauma or of upper respiratory infection, joint symptoms, rash, or exposure to drugs or toxins. The family, consisting of the patient, his mother, and an unemployed stepfather, had recently
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Manitoba User on 06/05/2015
moved to California from Ohio and were awaiting welfare assistance. History in¬ cluded a diagnosis of arrested hydrocephalus established at age 5 years after school authorities in New Jersey had requested an evaluation for delayed development. No routine immunizations had been obtained prior to starting school. On admission, he was disoriented and lethargic, with the following vital signs: temperature, 38.6 °C; pulse, 140/min; respi¬ rations, 48/min; and blood pressure, 100/70 mm Hg; weight, in the 16th percentile; and head circumference above the 97th per¬ centile. Pertinent physical findings were macrocephaly with frontal bossing, dry mucous membranes, distended abdomen with decreased bowel sounds, an abdominal fluid wave, normal genitalia, ankle edema, multiple ecchymoses of 1 to 5 cm diameter present over the face, chest, abdomen, buttocks, and legs, and petechiae over the abdomen and left leg. Muscle tone was decreased, tendon reflexes were absent, and an extensor plantar reflex was present on the right. Laboratory data included the following values: serum sodium, 116 mEq/L; potas¬ sium, 8.2 mEq/L; CO,,, 14 mEq/L; chloride, 76 mEq/L; glucose, 97 mg/dL; creatinine, 7.3 mg/dL; BUN, 176 mg/dL; WBC count, 14,000/cu mm; and hematocrit, 47.6%, with normal RBC morphology and platelets on blood smear. Results of clotting studies were normal. Urinalysis showed proteinuria (3 + ), many RBCs, a few WBCs, no casts, no bacteria, and a specific gravity of 1.009. Urine culture showed no growth. A spot urine specimen contained 111 mEq/L of sodium and 12 mEq/L of potassium. An EKG showed sinus rhythm with peaked waves. The chest roentgenogram was normal and abdominal roentgenograms showed gas-filled bowel and probable ascites. The admission diagnosis was acute renal failure of unknown cause. Peritoneal dialy¬ sis was followed by a dramatic increase in urine output with considerable improve¬ ment in serum electrolyte levels and rapid clearing of sensorium by 48 hours. At this point, a social service consultant deter¬ mined that the patient was a product of an out-of-wedlock pregnancy. The teenage mother had lived in conflict with her own parents until meeting her present husband one year previously. The stepfather had grown up in a violent setting in which he was often beaten by his mother and step¬ father. After leaving reform school at age 12 years, he lived in institutions and on the streets, often experimenting with drugs, including heroin. Whereas the patient's mother thought him slow and clumsy, the stepfather believed the patient was ex¬
tremely intelligent, possessing a photo¬ graphic memory. It was apparent that multiple risk factors for abuse existed in this family. Further studies were prompted by the social history, the findings of multiple ecchymoses, and the observation that fluid
1900, 1966.
Singh G, Krause JR, Breitfeld
V: Bone examination for metastatic tumors. Cancer 40:2317-2321, 1977. 9. Triche TJ, Ross WE: Glycogen-containing neuroblastoma with clinical and histopathologic features of Ewing's sarcoma. Cancer 41:1425\x=req-\ 8.
marrow
1432, 1978. 10. tron
Greenberg R, Rosenthal I, Falk GS: Elecmicroscopy of human tumors secreting cate-
cholamines: Correlation with biochemical data. J Neuropathol Exp Neurol 28:475-500, 1969. 11. Horvat BL, Caines M, Fisher ER: The ultrastructure of rhabdomyosarcoma. Am J Clin Path 53:555-564, 1970. 12. Mackay B, Masse SR, King OY, et al: Diagnosis of neuroblastoma by electron microscopy of bone marrow aspirates. Pediatrics 56:1045-1049. 1975. 13. Delta BG, Pinkel D: Bone marrow aspiration in children with malignant tumors. J Pediatr 64:542-546, 1964. 14. Finklestein JZ, Ekert H, Isaacs H, et al: Bone marrow metastasis in. children with solid tumors. Am J Dis Child 119:49-52, 1970. 15. O'Neill P, Pinkel D: Wilms' tumor in bone marrow aspirate. J Pediatr 72:396-398, 1968.
Idiopathic Linear Calcification the Ascending Aorta in an
evidence of calcification of the ascending aorta, but a subsequent roentgenogram, one month later, showed for the first time a linear calcification of the aorta (Fig 1, top). The roentgenologic evidence of linear calcification of the aorta has persisted since then with no further extension of the lesion. Her most recent physical examination showed an active, alert, acyanotic girl with normal vital signs. Blood pressures were as follows: right arm, 90/68 mm Hg; left arm, 92/70 mm Hg; and leg, 106/70 mm Hg. White, scaly, cutaneous lesions involved both the upper and lower extremities, both ears, and the oral mucous membrane. The fingernails and toenails were dystrophic. Examination of the heart disclosed no abnormalities; there was no thrill, parasternal heave, heart murmur, or ejection click. The hemoglobin level was 10.8 g/dL and the hematocrit reading was 32%. Total and differential WBC counts, urine analysis, serum electrolytes, total protein and albu¬ min-globulin ratio, and serum chemistry
levels, including serum bilirubin, fasting blood glucose, SGOT, SGPT, calcium, phos¬ phorus, and alkaline phosphatase values, were
of
all within normal limits. Immuno-
globulin electrophoresis, repeated twice, showed a normal profile. The results of
Adolescent
cated pregnancy and a full-term spontaneous delivery. Her birth weight was 3.4 kg. There was no family history of congenital heart disease, vascular disease, or candidiasis. She remained perfectly well until 9 months of age when, after an upper respiratory tract infection, oral thrush developed. Candida albicans grew from cultures of material obtained from the oral
VDRL and FTA-ABS tests, as well as fluorescent antinuclear antibody and skin tuberculin tests, were ngative. Laboratory values were as follows: total serum choles¬ terol, 176 mg/dL; triglycérides, 121 mg/dL; free fatty acids, 0.57 mEq/L; total serum lipids, 530 mg/dL; phospholipids, 57 mg/ dL; protein-bound serum iodine, 8.3 mg/ dL; T„ 22.5%; T4, 10.9 mg/dL; parathyroid hormone, 338 pg/mL; and serum cortisol, 6 pg/dL. The results of glucose tolerance tests were normal. Chromatographie anal¬ ysis of urine and serum amino acids disclosed a normal profile. Repeated 12-lead ECGs indicated no abnormalities. Retrograde aortography showed calcification involving the outer wall of the ascending aorta (Fig 1, bottom). There was no evidence of aneurysm of the aorta or sinuses of Valsalva. An echocardiogram was entirely within normal limits for the patient's age and weight, with no evidence of vegetations involving aortic valves, supravalvular aortic root, or left ventricular outflow tract.
lesions. Despite antifungal treatment\p=m-\ first with nystatin (Mycostatin) and later with amphotericin B\p=m-\themucocutaneous lesions spread and, during the next four years, involved the arms, legs, both ears, and all fingernails and toenails, which became dystrophic. At the age of 5 years, staphylococcal pneumonia developed from which she made a complete recovery with no adverse seque¬ lae. Cutaneous candidiasis persisted, how¬ ever. Three years later, the patient had another episode of severe upper respirato¬ ry tract infection. A chest roentgenogram obtained at that time did not show any
Com ment.—Linear calcification of the ascending aorta is extremely uncommon in infants or older chil¬ dren. Singleton and Merten- recently described two children with an unusu¬ al syndrome that was characterized by dental dysplasia, cardiomegaly, sub¬ stantial heart murmur, osteoporosis, marked widening of the medullary cavities of the metacarpale and pha¬ langes of both hands, and linear calci¬ fication of the ascending aorta. Car-
Although a frequent roentgenographic observation in elderly persons,1
linear
calcification
of
the
ascending aorta is extremely rare in infancy and childhood. Our purpose is to
report linear calcification of the
aorta in an adolescent in whom extensive investigations failed to establish causal basis for the lesion.
ascending
Report of a Case.\p=m-\Thepatient, a 12\x=req-\ year-old girl, was the result of an uncompli-
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Manitoba User on 06/05/2015
Chest roentgenograms obtained at age 8 years. Top, First roentgenologic evidence of linear calcification involving aorta (arrow). Bottom, Persistence of calcifica¬ tion of lateral wall of ascending aorta as shown in retrograde aortogram; arrow shows lateral wall of ascending aorta as site involved by calcification.
diac catheterization studies showed aortic stenosis in both patients, one having a patent ductus arteriosus as well. A high prevalence of aortic stenosis has also been reported in adults with calcification of the ascend¬ ing aorta that is of nonsyphilitic origin' and it has been suggested that such calcification results from turbulent blood flow distal to the stenotic lesion. In our patient, howev¬ er, there were no clinical, ECG, or roentgenographic features suggestive of aortic valvular disease, or dissect¬ ing aneurysms, nor was there a histo'
'
ry of trauma before the detection of aortic calcification. Finally, the nor¬
mal serum lipid profile, negative sero¬ logie findings, and the young age of our patient do not favor a causal role of atherosclerosis or syphilis, the two conditions most commonly associated
with linear calcification of the ascend¬ ing aorta in adults. In recent years, the role of candidia¬ sis as a causative agent for endocardi¬ tis has become increasingly clear, especially in heroin addicts,"· immunosuppressed hosts," and patients who have a prosthetic valve.7 Furthermore, Gottlieb et als have shown that, contrary to earlier reports," candidia¬ sis can invade the normal aortic valve. In another case, reported by Gomes et al,1" fungal vegetations due to Candi¬ da infections involved ventricular as well as the aortic surface of the aortic valves. It is conceivable that distal spread of such infection could cause aortitis of the ascending aorta, deposi¬ tion of atheromatous material, and subsequent calcification. To our knowledge, however, isolated aortitis due to Candida infection has not been reported. Moreover, the patients de¬ scribed by both Gottlieb et als and Gomes et al1" had systemic candidia¬ sis, were heroin addicts, and had substantial heart murmurs indicative of aortic valvular disease. Echocardiography showed abnormal echoes pro¬ duced by fungal vegetations in the aortic root during diastole, on the aortic valve during systole and dias¬ tole and in the left ventricular outflow tract. By contrast, candidiasis in our
patient
was
of the mucocutaneous
type without any evidence of involve¬ ment of
deeper structures; clinical finding did not suggest aortic valvular disease, and echocardiography showed
normal aortic valves with no evidence of abnormal echoes either in the aortic root or in the left ventricular outflow
region. We, therefore, do
not believe that
linear calcification of the ascending aorta in our patient is related to chronic cutaneous candidiasis. In the absence of a recognizable cause, the calcification seems to be truly idio¬
pathic.
NARAYAN RANGASWAMI, MD, DCH SUBHASH CHAUDHARY, MD GEORGE FLINN, MD SHYAMAL K. SANYAL, FAAP, FACC Cardiopulmonary Disease, Infectious Disease, and Radiology Services St Jude Children's Research Hospital Memphis, TN 38101
Nonproprietary
Name and Trademark of Drug
Amphotericin B—Fungizone. 1. Lee YT, Hsu CJ: Radiologic calcification of the aorta: Its incidence and clinical significance. J Formosan Med Assoc 71:176-188, 1972. 2. Singleton EB, Merten DF: An unusual syndrome of widened medullary cavities of the metacarpals and phalanges, aortic calcification and abnormal dentition. Pediatr Radiol 1:2-7, 1973. 3. Higgins CB, Reinke RT: Nonsyphilitic etiology of linear calcification of the ascending aorta. Radiology 113:609-613, 1974. 4. Buchbinder NA, Roberts WC: Left-sided valvular active infective endocarditis: A study of 45 necropsy patients. Am J Med 53:20-35, 1972. 5. McLoughlin MJ, Pasternac A, Morch J, et al: Idiopathic calcification of the ascending aorta and aortic valve in two young women. Br Heart J 36:96-100, 1974. 6. Rosner F, Gabriel FD, Taschdjian CL, et al: Serologic diagnosis of systemic candidiasis in patients with acute leukemia. Am J Med 51:54-62, 1971. 7. Schelbert HR, Mueller OF: Detection of fungal vegetations involving a Starr-Edward mitral prosthesis by means of ultrasound. Vasc Surg 6:20-25, 1972. 8. Gottlieb S, Khuddus SA, Balooki H, et al: Echocardiographic diagnosis of aortic valve vegetations in Candida endocarditis. Circulation 50:826-830, 1974. 9. Louria DB, Hensle T, Rose J: The major medical complications of heroin addiction. Ann Intern Med 67:1-22, 1967. 10. Gomes JA, Calderon J, Lajam F, et al: Echocardiographic detection of fungal vegetations in Candida parasilopsis endocarditis. Am J Med 61:273-276, 1976.
Child Abuse: Acute Renal Failure From Ruptured Bladder In assessment of pediatric emergencies, failure to consider the possibility of child abuse may result in delayed initiation of appropriate diagnostic procedures or definitive treatment. This
report concerns a 6-year\x=req-\ boy with acute renal failure resulting from a ruptured bladder, to our knowledge a previously undescribed old
manifestation of child abuse.
Report of a Case.\p=m-\A6-year-old boy was admitted to the University of California, Davis Medical Center in Sacramento because of elevated levels of serum potassium and BUN. During the preceding five days, a complaint of abdominal pain and constipation was followed by intermittent vomiting, a noticeable decrease in urine output, several episodes of gross hematuria and hematochezia, and a progressive deterioration of mental status to the point of noticeable lethargy and confusion. Except for a fall in the shower, there was no history of trauma or of upper respiratory infection, joint symptoms, rash, or exposure to drugs or toxins. The family, consisting of the patient, his mother, and an unemployed stepfather, had recently
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Manitoba User on 06/05/2015
moved to California from Ohio and were awaiting welfare assistance. History in¬ cluded a diagnosis of arrested hydrocephalus established at age 5 years after school authorities in New Jersey had requested an evaluation for delayed development. No routine immunizations had been obtained prior to starting school. On admission, he was disoriented and lethargic, with the following vital signs: temperature, 38.6 °C; pulse, 140/min; respi¬ rations, 48/min; and blood pressure, 100/70 mm Hg; weight, in the 16th percentile; and head circumference above the 97th per¬ centile. Pertinent physical findings were macrocephaly with frontal bossing, dry mucous membranes, distended abdomen with decreased bowel sounds, an abdominal fluid wave, normal genitalia, ankle edema, multiple ecchymoses of 1 to 5 cm diameter present over the face, chest, abdomen, buttocks, and legs, and petechiae over the abdomen and left leg. Muscle tone was decreased, tendon reflexes were absent, and an extensor plantar reflex was present on the right. Laboratory data included the following values: serum sodium, 116 mEq/L; potas¬ sium, 8.2 mEq/L; CO,,, 14 mEq/L; chloride, 76 mEq/L; glucose, 97 mg/dL; creatinine, 7.3 mg/dL; BUN, 176 mg/dL; WBC count, 14,000/cu mm; and hematocrit, 47.6%, with normal RBC morphology and platelets on blood smear. Results of clotting studies were normal. Urinalysis showed proteinuria (3 + ), many RBCs, a few WBCs, no casts, no bacteria, and a specific gravity of 1.009. Urine culture showed no growth. A spot urine specimen contained 111 mEq/L of sodium and 12 mEq/L of potassium. An EKG showed sinus rhythm with peaked waves. The chest roentgenogram was normal and abdominal roentgenograms showed gas-filled bowel and probable ascites. The admission diagnosis was acute renal failure of unknown cause. Peritoneal dialy¬ sis was followed by a dramatic increase in urine output with considerable improve¬ ment in serum electrolyte levels and rapid clearing of sensorium by 48 hours. At this point, a social service consultant deter¬ mined that the patient was a product of an out-of-wedlock pregnancy. The teenage mother had lived in conflict with her own parents until meeting her present husband one year previously. The stepfather had grown up in a violent setting in which he was often beaten by his mother and step¬ father. After leaving reform school at age 12 years, he lived in institutions and on the streets, often experimenting with drugs, including heroin. Whereas the patient's mother thought him slow and clumsy, the stepfather believed the patient was ex¬
tremely intelligent, possessing a photo¬ graphic memory. It was apparent that multiple risk factors for abuse existed in this family. Further studies were prompted by the social history, the findings of multiple ecchymoses, and the observation that fluid
