21 month old male presents with fever and URI symptoms x3 days. In addition to congestion and fussiness, parents have also noticed intermittent wheezing while sleeping. Two episodes of emesis 2 days ago. Parents have noticed a mild decrease in wet diapers but tolerating PO. No diarrhea, however he had a looser stool last night, and has typically been constipated over the past few months with straining and hard stools. Of note, patient has sick contact who is sibling with URI symptoms. 

Past medical history: No significant medica history. 

Family History: +Family history of possible osteogenesis imperfecta with no confirmed diagnosis  

Developmental Hx: Caregiver reports he does not talk much in comparison to sibling at this age and is not walking.  

Physical Exam  

VS: Temp 38.3 HR 144 RR 32 BP 82/57 SpO2 99% on room air  

Physical Exam:  

General: Alert, interactive, intermittently breast feeding  

Skin: Warm, dry, skin overall loose  

Eyes: PERRL, mildly blue sclera 

Ears, Nose, Throat: Oral mucosa moist, no pharyngeal erythema. Right T.M. with mild erythema and effusion. Left TM normal. 

CV: Mild tachycardia, normal rhythm 

Resp: Lungs clear to auscultation, respirations non-labored  

GI: Soft, non-tender, non-distended 

MSK: Moves all extremities, when placed on feet to bear weight, cries. Notable bony prominence at metaphysis at ankles and wrists. Unable to ascertain point tenderness  

Labs:  

COVID + 

Calcium: critically low at 6.2, AST 61, ALT  13, Alk phos 2,347, Vit D <4.0 

EKG: NSR, borderline long QTc, Prominent U waves  

Imaging results:  

Bilateral tibia/fibula: XR findings consistent with rickets and associated non-displaced distal tibia insufficiency fracture  

Bilateral forearms: XR findings consistent with rickets