A boy with high fever, dypsnea, and hypotension (Page 1/3)

Prepared by...
Chatchay Prempunpong , MD *
Tipvapa Suarod , MD **
Peninnah Oberdorfer , MD , PhD***
Rekwan Sittivangkul , MD ***
Virat Sirisanthana , MD ***
* Department of Pediatrics, Faculty of Medicine, Ramathibodi Hopital
** Department of Pediatrics, Faculty of Medicine, Thamasart University
*** Department of Pediatrics, Faculty of Medicine, Chiang Mai University

A 10-year-old boy from Meahongsorn, Maesareng, Thailand
Chief compliant: He was referred from a provincial hospital due to hypotension.
Present illness:
> 7 days before admission he developed high fever, headache, cough and rhinorrhea.
> 3 days before admission the parents took him to Meahongsorn hospital due to poor appetite, mild confusion, and dypsnea. He received ampicillin, cetriaxone and doxycycline but he did not improve. CBC: Hct 21 %, WBC 4200 cells/cu.mm. (neutroplil 69%, lymphocyte 23%, monocyte 6%), platlete count 47,000cells/cu.mm.. Peripheral blood smear was negative for malaria. The CXR showed mild cardiomegaly (CT ratio 55%), diffuse pulmonary alveolar infiltration (figure 1)
 
Figure 1
> 1 day before admission, he became drowsy and developed hypotension. The EKG showed occasional PVCs, low voltage in limb lead, and ST-T change in lead II, III aVF, V5-V6. He therefore was referred to our hospital.
Past history:
>

No history of any underlying disease
Physical examination:
GA: A boy with drowsy consciousness, dyspnea and tachypnea
V/S: BT 38.3 degree celcius, BP 120/65 mmHg, PR 140/min, RR 36/min, Body weight: 45kg.
HEENT: not pale, no jaundice, distended jugular vein
Lymph node: can’t be palpable
Heart: regular no murmur, no distant heart sound
Lung: decrease breath sound at right lower lungs
Abdomen: active bowel sound, liver and spleen not palpable, no distention
Skin: multiple skin lesions(~10) with dark center scabs more at the extrimities, as seen in the figure 2-4. The biggest lesion was at right upper arm and was 8 mm. in diameter. (Fig 2-4)
Figure 2
Figure 3
Figure 4
 
Neurological examination: normal muscle tone and power, intact cranial nerves, no stiffness of neck
Problem list:
1. Subacute fever with skin lesions
2. Dypsnea with abnormal CXR
3. Hypotension with abnormal EKG

What are differential diagnoses? Next to Page 2


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