A 2 year old girl is being seen for intermittent fever and almost continuous crying. Her mother reports the child was potty-trained but for the last 2 days, has been incontinent. Also, when the parents try to hold the child to try to comfort her, she screams and cries harder. Formulate the possible diagnoses for this child. Explain why you believe these are the most likely causes of her symptoms. Be sure to include the pathophysiologic basis for your differential diagnoses.

Possible diagnoses for this 2-year-old girl with intermittent fever and almost continuous crying can include:

1. Urinary Tract Infection (UTI): UTIs are common in young children, especially girls, due to their shorter urethra and proximity of the anus to the urethra. UTIs can cause fever, irritability, and incontinence due to the discomfort and urgency to urinate caused by the infection. The inflammatory response in the urinary tract leads to the release of cytokines, which can cause systemic symptoms like fever and behavioral changes.

2. Renal Calculi (Kidney Stones): Although uncommon in young children, kidney stones can cause severe pain and discomfort, leading to symptoms like crying and incontinence. The intermittent fever may be due to associated urinary tract infections. Kidney stones can obstruct the urinary tract, causing increased pressure and subsequent pain.

3. Intussusception: Intussusception occurs when one segment of the intestine telescopes into another, causing obstruction. It primarily affects children between the ages of 6 months and 2 years. Symptoms include severe colicky abdominal pain, incontinence, and sometimes fever. Intussusception can create pressure on adjacent organs and nerves, causing pain and irritability.

4. Urinary Retention: Urinary retention can occur due to various reasons such as anatomical abnormalities, neurological disorders, or obstruction of the urinary tract. In this case, if the child has difficulty urinating or is unable to pass urine, it can lead to discomfort, crying, and incontinence.

5. Meningitis: Meningitis is an infection of the meninges, the protective membranes surrounding the brain and spinal cord. It can cause high fever, severe headache, and irritability. In young children, symptoms may be nonspecific, and they may exhibit inconsolable crying. Meningitis can lead to alterations in the neurological system, causing changes in behavior and sensory sensitivity.

6. Urinary Obstruction: Urinary obstruction can occur due to various reasons such as anatomical abnormalities, stones, or tumors. It causes increased pressure and distension in the urinary system, leading to pain, incontinence, and possibly fever. The obstruction can interfere with normal voiding, leading to incontinence.

The most likely causes for these symptoms can be UTI, renal calculi, and intussusception. UTI is a common condition in young children and can cause fever, irritability, and incontinence. The pathophysiologic basis of UTIs in children is usually due to bacterial contamination from gastrointestinal flora entering the urethra and ascending the urinary tract. The resulting infection leads to inflammation, release of cytokines, and subsequent symptoms.

Renal calculi, though rare in young children, can cause severe pain and discomfort due to obstruction and increased pressure in the urinary tract. The pathophysiologic basis is the formation of crystals in the kidneys, which can lead to the development of stones. The obstructing stone causes stretching and irritation of the renal pelvis, resulting in pain and subsequent symptoms.

Intussusception is a condition where one segment of the intestine telescopes into the adjacent segment, leading to obstruction. The pathophysiologic basis involves the “telescoping” resulting from peristaltic movements in the intestines. This obstruction causes obstruction of blood flow, stretching, and inflammation, leading to symptoms like severe abdominal pain, incontinence, and crying.

While urinary retention, meningitis, and urinary obstruction are also plausible differential diagnoses, they may be less likely considering the specific symptoms reported in this case. Urinary retention typically presents with difficulty or inability to urinate, rather than incontinence. Meningitis may present with nonspecific symptoms like irritability and crying, but the absence of severe headache and other specific signs makes it less likely. Urinary obstruction would usually have more gradual symptom onset and may present with additional signs such as urinary frequency or incomplete emptying.

In conclusion, UTI, renal calculi, and intussusception are the most likely causes for the symptoms of intermittent fever, continuous crying, and incontinence in this 2-year-old girl. Each of these conditions has a distinct pathophysiologic basis that can explain the reported symptoms and should be further investigated through appropriate diagnostic tests for confirmation and appropriate management.