Visual Diagnosis: A 3-month-old Male With Wheezing

Abstract

1. Kamakshya P. Patra, MD 2. Suman Shekar, MD 3. Robert D. Jackson, MD 4. Ernest A. Kiel, MD 5. Jon D. Wilson, MD 1. Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, Shreveport, LA. A 3-month-old boy presents to the emergency department with difficulty breathing and wheezing for the past week. His medical history is notable for being born at term via normal vaginal delivery, followed by an uneventful neonatal period. There is a family history of asthma in both parents. The patient’s mother has recently recovered from a viral upper respiratory tract infection. On physical examination, the infant’s vital signs include a temperature of 99°F, heart rate of 192 beats per minute, respiratory rate of 77 breaths per minute, blood pressure of 50/36 mm Hg, and 95% oxygen saturation in room air. The extremities are cool to touch, the peripheral pulses are thready, and the capillary refill time is 5 seconds. A gallop rhythm and a grade 3/6 holosystolic murmur with radiation to the left axilla are present. There are bibasilar crackles and wheezes. The liver edge is palpable 5 cm below the right costal margin, with a total span of 8 cm. There is generalized hypotonia and head lag. There are no obvious facial abnormalities. The rest of his physical findings are normal. A chest radiograph shows an enlarged cardiac silhouette (Fig 1). Complete blood cell count and metabolic profile results are normal for age. The serum creatine kinase level is elevated at 438 U/L (normal: 22–198 U/L). Electrocardiography demonstrates a short PR interval with tall and broad QRS complexes (Fig 2). Figure 1. Chest radiograph demonstrates a large cardiac silhouette. Figure 2. Electrocardiogram demonstrates high-voltage QRS complexes and shortened PR intervals. Further tests confirm the suspected underlying diagnosis. Doppler echocardiography demonstrated severe mitral regurgitation and a concentric, hypertrophied left ventricle (Fig …