A 15-year old adolescent is brought to the emergency department by his parents. The adolescent is febrile with chills that started suddenly. He states, "I had a sinus infection and sore throat a couple of days ago." The nurse suspects bacterial meningitis based on which findings? Select THREE that apply

Rationale:

A. Bounding pulses, heart failure within weeks, activity intolerance: Truncus arteriosus involves a single large vessel overriding both ventricles. This results in increased pulmonary blood flow, leading to early-onset heart failure. Bounding pulses occur from wide pulse pressure, and activity intolerance is related to poor oxygen delivery to tissues during exertion.

B. Cracked lips, joint pain, thrombocytosis: These symptoms are more consistent with Kawasaki disease, rather than a congenital heart defect like truncus arteriosus. Kawasaki disease often presents with mucocutaneous changes, arthritis, and elevated platelet counts.

C. High upper extremity blood pressure (BP), weak distal pulses: This is more indicative of coarctation of the aorta, where narrowing of the aorta leads to hypertension in the upper extremities and diminished pulses in the lower extremities. It is not characteristic of truncus arteriosus.

D. Squatting, irritability, peri-oral cyanosis: These symptoms are typical of Tetralogy of Fallot. Squatting helps increase systemic vascular resistance to reduce right-to-left shunting, and peri-oral cyanosis results from chronic hypoxemia, which is not the hallmark of truncus arteriosus.

Rationale:

A. Acute Lymphoblastic Leukemia (ALL): ALL is the most common pediatric cancer, typically affecting children between the ages of 2 and 5. Clinical signs include pallor, fatigue, petechiae, recurrent fevers, and bone marrow suppression. A CBC often shows elevated WBCs with a predominance of immature lymphoblasts on a peripheral smear.

B. Hodgkin's Lymphoma: This cancer usually presents in older children and adolescents, often with painless cervical lymphadenopathy, night sweats, fever, and weight loss. It does not typically present with massive lymphoblast proliferation in peripheral blood, as seen in this case.

C. Acute Myelogenous Leukemia (AML): AML is more common in adults but can occur in children. It presents with similar symptoms of bone marrow failure but is characterized by myeloblasts rather than lymphoblasts on the blood smear.

D. Non-Hodgkin's Lymphoma: Pediatric non-Hodgkin's lymphoma often presents with rapidly enlarging lymph nodes, mediastinal mass, or abdominal symptoms. It is not primarily a bone marrow disease and would not typically show high lymphoblast counts in the peripheral blood.