Hematologic manifestations of long-term valproate therapy.

Sixty patients receiving long-term valproate (VPA) monotherapy were studied for hematologic side effects. All were patients in a long-term care facility and ranged in age from 2 to 29 years (mean 14.6 years). Twenty developed at least one prominent hematologic abnormality. Thrombocytopenia and macrocytosis were the most common findings. In patients with macrocytosis, platelet counts were inversely related to VPA levels. Serum B12 levels were increased in 51 of the patients. In 12 patients with macrocytosis who were extensively studied, no etiology for the increased MCV could be identified. An increased number of Pelger-Huet-like cells was noted in these 12 patients. None of the patients demonstrated hepatic dysfunction. Hematologic toxicity was never severe enough to discontinue therapy and always responded to small decrements in VPA therapy. VPA was discontinued in only 1 patient, owing to poor seizure control.

Delayed-onset Bochdalek hernia in a 3-year-old child.

A 3-year-old child presented to the emergency department (ED) with the sudden onset of shortness of breath and wheezing. The child had previously been in good health and had no problems during the neonatal period. Chest x-ray performed in the ED was consistent with a Bochdalek diaphragmatic hernia. Subsequently, the child had surgery. The diagnosis was confirmed, and recovery was uneventful. The differential diagnosis of late onset congenital diaphragmatic hernia is discussed with an emphasis on both early recognition and differential diagnosis of this rare but correctable entity.

Early syndrome of inappropriate secretion of antidiuretic hormone in a child with burn injury.

A 17-month-old boy presented with 10% to 12% first- and second-degree burns secondary to scald injury. He rapidly developed hyponatremia secondary to inappropriate antidiuretic hormone secretion, manifested by the occurrence of seizures. After appropriate therapy was instituted, the child had an uneventful recovery. To the best of the authors' knowledge, this problem has not been reported previously in a child with a relatively mild burn.

An infant with sepsis and methemoglobinemia.

A 3-week-old child arrived at the emergency room with the concurrent onset of sepsis and methemoglobinemia associated with diarrhea. Subsequently, the child had two recurrent episodes of methemoglobinemia with re-exacerbations of his diarrhea. Possible causes and associations of methemoglobinemia are presented: particular emphasis is placed on the early recognition and rapid diagnosis of this life-threatening condition.