From the Al-Hasa Specialty Services Division, Saudi Aramco– Al-Hasa Health Center, Saudi Aramco Medical Services Organization, Mubarraz, Kingdom of Saudi Arabia. Dr Narchi is currently with the Paediatric Department, Sandwell General Hospital, West Bromwich, England.
A PREVIOUSLY healthy 15-month-old boy had a 3-month history of abdominal distension without associated pain, vomiting, or abnormal stools. His developmental milestones and growth parameters were normal, and findings from the family history were unremarkable. Findings from physical examination revealed normal nutritional status, absence of pallor or jaundice, normal vital signs, and normal cardiorespiratory examination results. Moderate abdominal distension with shifting dullness and fluid thrill was noted, but the flanks were not bulging. There was no hepatosplenomegaly, bruising, or peripheral edema.
The following laboratory results were normal: tuberculin test; complete blood cell count; erythrocyte sedimentation rate; serum albumin and total protein levels; creatinine levels; electrolytes; liver function tests; levels for amylase, lipase, calcium, and phosphorus; antinuclear antibodies; and coagulation studies. The serum cholesterol level was 4.3 mmol/L (166 mg/dL), and triglyceride levels were 1.10 mmol/L (97 mg/dL). Results of urinalysis were normal. His sweat chloride level was 26 mmol/L. Findings from abdominal ultrasonography showed significant fluid containing debris and strands displacing the intestinal loops posteriorly. Abdominal paracentesis revealed hazy yellow fluid with analysis indicating a leukocyte level of 2.2 × 109/L with 2% polymorphonuclear forms and 95% lymphocytes; glucose, 5.2 mmol/L (94 mg/dL); total protein, 41 g/L; albumin, 30 g/L; cholesterol, 1.5 mmol/L (58 mg/dL); and triglycerides, 0.4 mmol/L (35 mg/dL). No malignant cells were present, and no organisms or acid fast bacilli were present on staining. Findings from bacterial and fungal cultures of the fluid were sterile. Results from Doppler ultrasonography of the portal vein and an upper and small-bowel radiographic examination were normal. An abdominal tap was repeated after a fatty meal, and fluid analysis showed a leukocyte count of 1.6 × 109/L with 100% lymphocytes; protein, 44 g/L; albumin, 30 g/L; and triglycerides, 0.26 mmol/L (23 mg/dL). Fluid urea and creatinine levels were less than their serum concentrations. Abdominal computed tomography was performed (Figure 1).
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