Smarter testing for anemia and infections

1. I see a fair number of children with mild anemia who do not respond to iron and have normal indices, red cell distribution width (RDW), iron/ferritin levels, reticulocyte counts, electrophoresis, and smears. I consider them in general to have “statistical anemia.” That is, these children are normal-at the lower end of the curve-just as there are people less than the second percentile in height who have no discernible medical cause. They do not need further evaluation or yearly testing.

2. It is well known that an acute viral illness, such as parvovirus, can cause transient red cell aplasia in a hemoglobinopathy such as sickle cell. Viruses can also suppress red cell production, to a lesser degree, in children without underlying blood disorders. Thus, if you find an otherwise healthy child with an acute viral illness who has a mild anemia during a routine checkup, consider retesting the child when he or she is well rather than, for example, conducting a trial of iron supplementation.

3. Similarly, when testing for causes of anemia, remember that ferritin is an acute phase variant, and can be spuriously elevated if a child is ill at the time.

4. The rash in Coxsackievirus can occur throughout the body. In my experience, it is found often enough in a fourth location that perhaps it should be called “hand-foot-mouth-buttocks.”

5. A positive leukocyte esterase urine test in an adolescent male suggests testing for Chlamydia and gonorrhea, which are much more likely than a urine infection.

6. Gluteal hair shaving or laser hair removal¹ can be used to prevent recurrent pilonidal infection. I have not seen any studies showing the value of over-the-counter depilatories here, but it makes some sense to me.

7. Pseudomonas can cause folliculitis from a hot tub² (no treatment needed); otitis externa³ (topical treatment will suffice); and wound infection from a puncture through a sneaker⁴ (systemic therapy will be needed).

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REFERENCES

1. Segre D, Pozzo M, Perinotti R, Roche B; Italian Society of Colorectal Surgery. The treatment of pilonidal disease: guidelines of the Italian Society of Colorectal Surgery (SICCR). Tech Coloproctol. 2015;19(10):607-613.

2. Centers for Disease Control and Prevention (CDC). Pseudomonas dermatitis/folliculitis associated with pools and hot tubs-Colorado and Maine, 1999-2000. MMWR Morb Mortal Wkly Rep. 2000;49(48):1087-1091.

3. Schaefer P, Baugh RF. Acute otitis externa: an update. Am Fam Physician. 2012;86(11):1055-1061.

4. Jacobs RF, McCarthy RE, Elser JM. Pseudomonas osteochondritis complicating puncture wounds of the foot in children: a 10-year evaluation. J Infect Dis. 1989;160(4):657-661.