A 7-month-old with Fever and Facial Palsy.

Abstract

1. Jennifer Fundora, MD* 2. Chelsea Kotch, MD† 3. Janet Serwint, MD‡ 1. *Division of Neonatology 2. ‡Division of General Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 3. †Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA A 7-month-old full-term immunized Hispanic girl presents to the emergency department (ED) with 3 days of fever and vomiting. Laboratory results are notable for urinalysis with 20 to 40 white blood cell (WBC) count/high-power field and hemoglobin (Hb) of 10.7 g/dL (107 g/L; normocytic). She is discharged from the hospital on trimethoprim/sulfamethoxazole for presumed urinary tract infection. She returns on day 5 of illness with a maculopapular rash. Her laboratory results show a normocytic anemia, elevated transaminases, and pyuria. Urine culture obtained 2 days before is negative. She is hospitalized for presumed urinary tract infection. Repeat testing shows albumin of 3.0 g/dL (30 g/L), C-reactive protein of 217 mg/L (2,066 nmol/L; reference range, 0 to 7.5 mg/L), erythrocyte sedimentation rate of 71 mm/hour (reference range, 0 to 10 mm/hour). Blood and urine cultures remain negative. A chest radiograph demonstrates “early focal airspace disease.” She is started on azithromycin and discharged from the hospital with diagnoses of suspected viral illness and possible pneumonia. The patient follows up with her pediatrician where laboratory results show persistently elevated inflammatory markers and normocytic anemia (Hb, 7.9 m/dL). The patient presents to another ED on day of illness 15 with continued daily fevers and is discharged from the hospital with diagnosis of bronchiolitis. On day 22 of illness, she develops facial asymmetry, prompting the ED physician to obtain an abdominal ultrasound, head computed tomography, chest radiograph, lumbar puncture, and laboratory studies showing a Hb of 7.1 g/dL (71 g/L), WBC count of 23,300/ μ L (23.3 × 109/L), platelets of 922,000/ μ L (922 × 109/L), albumin of 2.8 g/dL …