sinusitis, orbital cellulitis, or dental abscess Often these patients will present with a history of dental or facial pain, sinus congestion, erythema, or fever A history of environmental exposure should lead to the diagnosis of other common causes of localized swelling including sunburn, frostbite, and plant-induced dermatitis (poison ivy) Although rarely seen, pit viper envenomation may cause rapid onset of painful swelling at the site of injury (see Chapter 90 Environmental Emergencies, Radiological Emergencies, Bites and Stings ) Occasionally, an infant will present with unexplained, localized swelling of an extremity that has been present since birth In this situation, the possibility of an injury secondary to birth trauma should be explored Less commonly, congenital lymphedema (Milroy disease), Turner syndrome (bilateral leg edema), and Noonan syndrome (pedal edema) should be considered Meige disease (lymphedema praecox) is a hereditary disorder that also results in lymphedema, but patients will present later in childhood or around puberty, usually with swelling of the feet or lower legs FIGURE 25.1 Edema in children GI, gastrointestinal; SIADH, syndrome of inappropriate secretion of antidiuretic hormone Sickle cell anemia may cause swollen and painful digits in young children, referred to as dactylitis (see Chapter 93 Hematologic Emergencies ) Thrombophlebitis or deep venous thrombosis rarely occurs in the prepubertal child but may affect adolescents; inherited hypercoagulable states, weightlifting, indwelling catheters, and the use of oral contraceptive pills predispose patients to this condition Evaluation of these patients should include an ultrasound of the venous system of the affected limb and a thorough laboratory evaluation Superior vena cava syndrome is a medical emergency caused by obstruction of blood flow through the vessel, resulting from compression from a tumor, thrombosis, or neoplastic invasion This usually presents with shortness of breath and swelling to the head, neck, or upper extremities, often with some degree of cyanosis or plethora GENERALIZED EDEMA Generalized edema, with an otherwise normal examination, occurs most commonly in patients with renal disease, particularly nephrotic syndrome (see Chapter 100 Renal and Electrolyte Emergencies ) The initial diagnosis is based on significant proteinuria (3+ or >200 mg/dL on a urinalysis) A urinalysis should therefore be included early in the evaluation of any pediatric patient presenting with generalized edema The presence or absence of urine red blood cells, white blood cells, or casts in the urine, along with further laboratory testing including chemistries, albumin, total protein, complement, and triglyceride levels may help to confirm the diagnosis Various factors, including the presence of hypertension or significant fluid collections in the pleural or peritoneal spaces, must be considered to determine the appropriate initial management of these patients Other forms of renal disease or vasculitis, including glomerulonephritis, hemolytic uremic syndrome, or Henoch–Schönlein purpura (HSP) may cause generalized edema In the child with HSP, the swelling primarily affects the lower extremities, where the purpuric rash predominates, or is isolated to specific joints when arthritis is present The purpuric rash, despite normal platelet count and coagulation studies (consistent with a vasculitis), is usually, but not universally, present The evaluation of the child presenting with generalized edema must also include a complete and thorough cardiovascular examination Patients with CHF, pericarditis, myocarditis, or cardiomyopathy may present with edema, but these children will often have additional signs and symptoms An edematous child presenting with a gallop, tachycardia, tachypnea, inspiratory crackles, or hepatomegaly should be evaluated for cardiac disease (see Chapter 86 Cardiac Emergencies ) In an edematous patient with a normal cardiac examination and no proteinuria, further evaluation should include a search for hepatic and other gastrointestinal diseases, as well as other forms of vasculitis Patients with protein-losing enteropathy, from milk protein allergy, celiac disease, giardiasis, primary intestinal lymphangiectasia (Waldmann disease) or inflammatory bowel disease, can present with generalized edema with few other physical examination findings These patients may have significant protein loss through the GI tract and will often present with hypoalbuminemia An initial laboratory evaluation, including liver function tests, electrolytes, erythrocyte sedimentation rate, creactive protein and measurement of total protein and albumin, may reveal abnormalities However, further evaluation, including more specific blood, urine, and stool testing, is often required to definitively diagnose the etiology of edema in this subset of patients As noted throughout this chapter, generalized edema may be a sign of a serious underlying disease However, less serious conditions may be causative as well Certain medications (oral contraceptive pills, corticosteroids, lithium, nonsteroidal anti-inflammatory agents, calcium channel blockers, and others) may cause some patients to become edematous This swelling usually resolves when the drug is discontinued Cyclical edema related to menstruation occurs frequently in young women The etiology of this edema is likely hormonally mediated, although the exact mechanisms are unclear Pregnancy may result in edema as well In conclusion, it is important to remember that a complete history and physical examination of the patient with either localized or generalized edema may be enough to arrive at a likely diagnosis It is of particular importance to focus on the renal, cardiovascular, and gastrointestinal systems when searching for an etiology for generalized edema Commonly, patients presenting with symptoms of localized edema will have an allergic, traumatic, or infectious etiology and, with appropriate management, will have resolution of their symptoms without serious sequelae Suggested Readings and Key References Braamskamp MJ, Dolman KM, Tabbers MM Clinical practice Protein-losing enteropathy in children Eur J Pediatr 2010;169:1179–1185 Downie ML, Gallibois C, Parekh RS, et al Nephrotic syndrome in infants and children: pathophysiology and management Paediatr Int Child Health 2017;37(4):248–258 Farkas H, Martinez-Saguer I, Bork K, et al International consensus on the diagnosis and management of pediatric patients with hereditary angioedema with C1 inhibitor deficiency Allergy 2017;72(2):300–313 Hsu DT, Pearson GD Heart failure in children: Part I: history, etiology, and pathophysiology Circ Heart Fail 2009;2:63–70 Katz BZ Epstein-Barr virus infections In: Long SS, Prober CG, Fischer M, eds Principles and Practice of Pediatric Infectious Disease 5th ed New York: Churchill Livingstone; 2018:1088–1095 ... the affected limb and a thorough laboratory evaluation Superior vena cava syndrome is a medical emergency caused by obstruction of blood flow through the vessel, resulting from compression from... mg/dL on a urinalysis) A urinalysis should therefore be included early in the evaluation of any pediatric patient presenting with generalized edema The presence or absence of urine red blood cells,... H, Martinez-Saguer I, Bork K, et al International consensus on the diagnosis and management of pediatric patients with hereditary angioedema with C1 inhibitor deficiency Allergy 2017;72(2):300–313