A 3-Year-Old Boy With Fever and Drowsiness

Gavin Christian K.W. Koh, MB, BChir, MA, MRCP, DTM&H; Richard J. Maude, BSc, MBChB Hons, MRCP, DTM&H; Pramot Srisamang, MD

Disclosures

July 28, 2017

Physical Examination and Workup

Upon physical examination, the boy is drowsy, but he is obeying instructions from his mother. His temperature is 102°F, respiratory rate is 36 breaths/min, and pulse rate is 132 beats/min and regular. Owing to lack of equipment, the patient's blood pressure and pulse oximetry are not readily available. He is not cyanotic or jaundiced, and no peripheral signs of chronic disease are noted.

The patient has moderately increased work of breathing, with use of the accessory muscles of respiration. Widespread fine crackles are audible over the chest bilaterally. The heart sounds are normal, with no rubs or murmurs. No palpable lymphadenopathy, visible skin lesions, or palpable organomegaly is noted. The abdominal examination is unremarkable.

The patient is placed on supplemental oxygen, leading to some improvement in his respiratory status. An intravenous line is placed, and initial laboratory investigations are performed, revealing the following values:

  • Hemoglobin level: 8.7 g/dL

  • Mean corpuscular volume: 60.1 µm3

  • Platelet count: 196 × 103 cells/µL

  • Total white blood cell count: 4.51 × 103 cells/μL (53% neutrophils, 32% lymphocytes , and 12% monocytes)

  • Serum sodium level: 134 mEq/L

  • Potassium level: 3 mEq/L

  • Chloride level: 98 mEq/L

  • Bicarbonate level: 24 mEq/L

  • Blood urea nitrogen level; 8 mg/dL

  • Creatinine level: 0.3 mg/dL

No arterial blood gas or glucose measurements are available.

The admission chest radiograph (Figure 1) demonstrates bilateral diffuse infiltrates. Broad-spectrum antibiotic therapy with intravenous ceftriaxone and metronidazole is initiated. The patient is admitted to the hospital.

Figure 1.

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