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A 23-month-old girl with poor growth and decreased appetite over the past year (figure 1) and increased thirst (including night-time) for the last month was admitted with dehydration and somnolence without vomiting/diarrhoea. She appeared to be miserable and in pain. Capillary refill time was about 2 s. A 1 cm liver edge was palpable. Ear discharge was not evident. Her blood pressure was 75/40 mm Hg and pulse was 115 beats/min. A ‘seborrheic’ dermatitis of the scalp and of the suprapubic region—persisting for 1 year despite topical steroids and antibiotics—was evident (figure 2A–C). On biochemical examinations sodium was 143 mmol/L, glucose 4.1 mmol/L, urea 5.7 mmol/L, total serum proteins 43 g/L, albumin 22 g/L, alanine aminotransferase 227 IU/L, aspartate aminotransferase 181 IU/L, γ-glutamyl transferase 397 IU/L, C-reactive protein 89.3 nmol/L, erythrocyte sedimentation rate 80 mm/hour and creatinine 31.8 µmol/L. Urinalysis was normal, as well as international normalised ratio, prothrombin time and partial thromboplastin time. The abdominal ultrasound revealed a splenic hypoechoic area of about 1 cm. The child’s liquid intake and diuresis …
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