[Difficulties in diagnosing febrile states in 21-month-old patient: case report]

A 21-month-old girl was admitted to our Department of Pediatrics to diagnose febrile states lasting for previous two weeks, anemia and increased erythrocyte sedimentation rate (ESR - erythrocyte sedimentation rate). The physical examination revealed the paleness of skin and oral mucosa, silent systolic murmur and hypotrophic constitution. The laboratory tests confirmed anemia and showed increased ESR and moderately increased C Reactive Protein (CRP - C Reactive Protein). The blood culture, the urine culture, the stool culture, the tests of the stool in direction of parasites and the serologic tests carried out in direction of infection caused by Toxoplasma ghondi, Mycoplasma pneumoniae, HAV, HCV, CMV, EBV and Parvovirus B19 were all negative. The chest X-ray picture and ultrasonographic examination of abdomen showed no abnormality. The consulting hematologist carried the bone marrow biopsy out--the bone marrow was poorly cellular. The urinary level of catecholamines and plasma level of neuron-specific enolase (NSE) were greatly increased. The computer tomography scan of head, neck, thorax and abdomen did not confirmed the presence of the tumor. Nevertheless the bone scintigraphy demonstrated the presence of foci of abnormally increased activity in left femur and the right hip-bone--pathognomonic of metastatic disease. During the hospitalization we did not observe the fever, but only the deepening anemia, weakness, irritability, limping and the presence of spectacle-shaped hematomas. The blood parameters temporarily were normal after blood transfusion. The patient was transmitted to the Department of Children's Oncology and Hematology. The trepanobiopsy of the bone marrow showed the presence of metastases of neuroblastoma. The magnetic resonance imaging (MRI) was made, but it did not revealed the presence of the primary tumor. The patient underwent a course of chemotherapy.