Failure to Thrive and Frequent PICU Admissions in a 2-year-old Boy.

Abstract

1. Tierney M. Morrison, MD* 2. Jacinta Cooper, MD, PhD† 3. Kelly O’Shea, MD* 4. Ndidi Unaka, MEd, MD‡ 1. *Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 2. †Department of Pediatric Emergency Medicine, University of Alabama at Birmingham, Birmingham AL 3. ‡Department of Pediatrics, University of Cincinnati College of Medicine, and Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH A 2-year-old boy with a history of delayed immunizations who has received all recommended vaccinations except for varicella presents to the emergency department with progressive bilateral lower leg and facial edema and 5 days of upper respiratory symptoms, including cough, congestion, and rhinorrhea. He is evaluated in the critical care area for treatment of hypoxemia with oxygen saturations in the 70s on room air, requires 18 L/min oxygen via high-flow nasal cannula with a fraction of inspired oxygen of 100%, and is subsequently admitted to the PICU. On physical examination, he is in the 12th percentile for weight, down from the 57th percentile at birth; poor weight gain is most notable during the 6 months before this admission. He has increased work of breathing with subcostal retractions and suprasternal tugging, diffuse crackles bilaterally, and end expiratory wheezing in all lung fields. The patient’s abdomen is soft and nontender but distended, with prominent hepatomegaly. The liver edge is palpable 3 cm below the right costal margin. Splenomegaly is not noted on presenting physical examination. Chest radiography demonstrates diffuse, bilateral pulmonary opacities. The cardiomediastinal silhouette is largely obscured by overlying pulmonary parenchymal opacities and is consistent with moderate cardiomegaly, and pulmonary vasculature is ill-defined. The differential diagnosis for the patient’s respiratory distress includes reactive airway disease (given the noted wheezing on auscultation) and pulmonary edema from acute respiratory distress syndrome (given lower extremity and facial edema …