Index of suspicion: Case 1: Abdominal trauma, pain, and tenderness associated with anemia and hematuria in a 14-year-old boy. Case 2: Ptosis, diplopia, tremors, and mild exophthalmos in a 9-year-old girl. Case 3: Persistent cough, shortness of breath, and localized decreased aeration in an 18-year-old girl

* ALT: : alanine aminotransferase AST: : aspartate aminotransferase BUN: : blood urea nitrogen CBC: : complete blood count CNS: : central nervous system CSF: : cerebrospinal fluid CT: : computed tomography ECG: : electrocardiography ED: : emergency department EEG: : electroencephalography ESR: : erythrocyte sedimentation rate GI: : gastrointestinal GU: : genitourinary Hct: : hematocrit Hgb: : hemoglobin MRI: : magnetic resonance imaging WBC: : white blood cell A 14-year-old boy is transferred from a local hospital. He was playing football and was struck in the abdomen by the head of another player who was wearing a helmet. He then fell on his abdomen. He immediately complained of left upper quadrant pain, and nausea. He was taken to a local ED and hospitalized. On admission, he was alert and oriented but experienced episodic hypotension. On examination, he looked pale and was found to have significant left upper quadrant abdominal tenderness. His initial Hct was 37%. Abdominal CT showed a 12×10×11 cm lobular enhancing mass over the left kidney, with questionable involvement of the colon and perinephric hematoma (Fig. 1). There was no free air. He was transfused with 1 unit of packed red blood cells and received 1 L of normal saline. His pain was controlled with morphine and he was transported to this institution. Figure 1. A CT scan of the abdomen shows a lobular enhancing mass over the left kidney. On arrival, he appears to be well developed and is in no acute distress, having a heart rate of 86 beats/min, respiratory rate of 20 breaths/min, blood pressure of 120/84 mm Hg, and oxygen saturation of 100% in room air. His abdomen is nondistended and has normal bowel sounds. However, he has left upper quadrant and left flank tenderness. Laboratory evaluations show Hct of 31.6%, normal coagulation studies and liver enzymes, lactose dehydrogenase concentration of 258 U/L (normal, 150 to 300 U/L), and urinalysis positive for blood and protein. Chest radiograph shows normal heart and lung fields. Additional investigation leads to the diagnosis. A 9-year-old girl presents with a 4-week history of a drooping right eyelid and occasional double vision. She does not complain of easy fatigability, and she is able to ride her bike long distances without …