The exceptionally rare (sic) Common Scoter.
A 1-month-old infant with congenital heart disease underwent initial cardiac surgery (Mee Shunt) at day 20 but was later readmitted because of poor shunt flow and hypoxemia. Despite therapy, the infant deteriorated and suffered a cardiopulmonary arrest. After 40 minutes of resuscitation, spontaneous cardiac output was reestablished, and subsequently, the child was placed on extracorporeal circulation membrane oxygen (ECMO) support. The infant deteriorated further over the next 3 days with persistent acidosis, marked abdominal distension associated with significant nasogastric aspirates, and the passage of small amounts of bloodstained stool. The presumed diagnosis was necrotizing enterocolitis, and despite the grave prognostic indicators, the decision was taken to undertake laparotomy. At surgery, there was 350 mL of unclotted venous blood in the peritoneal cavity. The bowel was grossly normal. A ruptured, infarcted, hemorrhagic spleen was discovered to be the cause of the bleeding. A splenectomy was performed, and the child made rapid recovery, sufficiently well to undergo redo Mee shunt 2 days later. A splenic infarct was confirmed at pathological examination. The cause of the splenic infarct and rupture is uncertain in this baby but may have been related to either cardiopulmonary resuscitation and/or ECMO. The importance of this case is the similarity in presentation in a baby with congenital heart disease between necrotizing enterocolitis (which is relatively common) and hemoperitoneum secondary to splenic rupture (which is very rare). Medical practice contains many useful maxims such as, "What walks like a duck, talks like a duck, is often a duck." This case demonstrates that not all ducks are the common Mallard (Anas platyrhynchos) but occasionally the exceptionally rare (sic) Common Scoter (Melanitta nigra). The management of neonatal cardiac patients on ECMO therapy continues to be a challenge, and particular diagnostic rigor should be applied in their care.