I scanned the patient's chart: "14-month-old boy with a cold, not eating." The child's father, a brown-skinned man in his forties, held his son in his lap. The baby was listless, his skin a pale yellowish-white. Jaundice was my first suspicion.
After introducing myself, I asked the father, "Does your son have any medical problems?"
He answered slowly, with the accent of his native Philippines: "My son has asthma."
Asthma does not cause jaundice. The boy's lips were pale, almost gray, with no pink color at all. His fingernails, too, were so pale they looked almost chalky. Normally, his skin color would have been much like his father's, a rich, light yellowish-brown, but all the red and pink tones had vanished. This baby was probably severely anemic, which meant he was low in oxygen-carrying red blood cells. But asthma doesn't give you anemia either.
The baby was breathing somewhat rapidly, and I heard a few wheezes, but I saw no sign of a breathing obstruction. The boy gazed at me, slumped in his father's lap, hardly moving.
When I checked the computer for his medical records, the most recent entry gave me a jolt. Four months ago, he was admitted to the hospital with the diagnosis "asthma with acute respiratory failure"—a serious and sometimes fatal condition. Fortunately, the boy had recovered fairly quickly.
I listened to his lungs again. Although they didn't sound bad, I called to the nurse: "Let's check his oxygen. Give him oxygen if he needs it, and let's also give him an albuterol breathing treatment."
I wasn't going to take a chance. Although the boy's asthma seemed mild, I would treat it aggressively, hoping to head off a severe episode. Still, I wondered, why was he so pale?
The only medication he was taking was for his asthma. The father added that the boy had been pale and lethargic for the last two or three months. He had not been eating—only drinking milk. He no longer babbled, and he had lost interest in crawling or walking.
Was some progressive disorder causing anemia and affecting his brain? Leukemia could do that, as could some other rare disorders. I examined the boy for signs of leukemia or another malignancy, like an enlarged spleen, swollen lymph nodes, or signs of bleeding in the skin. Fortunately, I saw no warning signs. I also checked to see if the anemia had progressed to the point that his blood no longer carried enough oxygen for his body's needs. His heart and lungs were working hard, but he didn't seem in immediate danger.
When I saw that he was stable, I sent him for tests to determine the level of hemoglobin—the oxygen-carrying molecule—in his blood. The results would show the severity of his anemia. Normally, a 14-month-old's hemoglobin is around 10 to 13. A few minutes later, the lab clerk called.
"Dr. Cohen, we have a critical value. The hemoglobin is 2.2."