Hot Seat #165. 7 yo with vomiting

Posted on: January 29, 2021, by :

Harrison Hayward, MD

HPI: 7-year-old male with an elevated BMI and otherwise healthy presents to an outside ED with 1 week of fever. He had COVID-19 one month ago, from which he fully recovered. Last week, he developed a fever and headache/abdominal pain. His PMD diagnosed him with a UTI and started cefdinir, which the patient has been taking without issue. Since then, the fever has persisted with Tmax 102F, refractory to antipyretics. Today, he has had PO intolerance, 4-5 episodes of NBNB emesis and 2-3 episodes of NB, watery diarrhea. He went to an outside ED, where initial exam was notable for:

Vital Signs T 39C, HR 160s, BP 70s/30s, RR 20s, 92% on RA, Wt 60kg

General Fatigued, but no acute distress

HEENT Normocephalic, atraumatic. +Conjunctival injection bilaterally without discharge. EOMI. Throat pink. +Stiffness of the neck. No LAD

CV Tachycardic. Extremities warm. No peripheral edema

Pulm Non-labored respirations with symmetric, fine crackles throughout; good aeration

Abdomen s/nt/nd

Neuro: A&Ox3

Skin: No rash

Initial work-up notable for:

-CBC: WBC 12.7, H/H 11.3/36.5, plt 121

-CMP: Na 131, K 5.3, Cl 103, CO2 21, BUN 18, Cr 0.76, AlkP 213, AST/ALT 61/47, Albumin 2.9

-CRP 30.6

-Trop <0.01, CK 109

-COVID PCR negative, RVP negative

Imaging done at outside ED:

-CXR: wnl. No acute lung or heart pathology

-CT ab/pelv impression: Prominent appendix with periappendiceal inflammation and mesenteric lymphadenopathy. Diffuse wall thickening of the ascending to transverse colon. No evidence of bowel ischemia or perforation.

LP was also done, notable for: Protein 78, RBC 42, WBC 124 63% neutrophils. Culture pending.

He is given ceftriaxone, vancomycin, Zosyn, and Decadron . Over the course of 8 hours, he received 2L NSB with improvement in the BP to 80s/40s. At this point, the OSH calls for transfer for “management of meningitis.”

 BPs remain 80/40 when CNH transport team arrives. A third NS bolus is given en route. On arrival, exam is notable for:

Vital Signs T 38C, HR 147, BP 74/36, RR 22, 100% on 2L NC

General Sleepy, but arousable. Slow to respond.

Neuro A&Ox3. No focal neuro deficits

CV Tachycardic. Cap refill time 4-5s. Extremities warm. No peripheral edema

Pulm +Mild retractions. Fine crackles and end expiratory wheeze throughout

Abdomen soft, nontender. +Mildly distended/tympanitic. No hepatomegaly

CXR shows no cardiomegaly or opacities. Norepinephrine is initiated. Remainder of Tier 1 & Tier 2 MIS-C labs are sent.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Mary Beth Howard
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