Infant has respiratory distress and weak cry

Key Points

The Case

You're the pediatric attending on call at a major metropolitan children's hospital, and you receive an overnight page from an outside hospital emergency department (ED). It is late December, and they are requesting to transfer a 4-month-old girl with 6 days of worsening cough and increasing irritability with poor oral intake. You accept the patient thinking that it's a straightforward case of bronchiolitis and sign out the case to the on-call resident.

On arrival to the medical floor, the resident gathers information from the patient's parents. She is a previously healthy, full-term baby who was well until 12 days before admission, when she developed a wet cough and a "weak cry." She was seen at the office of her primary medical doctor (PMD), where she had a fever of 39^o C and was having coughing episodes associated with facial discoloration and gasps for air. She also was noted to have a weak, hoarse cry.

Five days before this admission, the patient was reevaluated by her PMD for worsening symptoms. She was found to have scattered oral ulcers and was started on a 5-day course of acyclovir and albuterol every 6 hours.

Her symptoms persisted without apnea or cyanosis. She had decreased oral intake, along with some mild weight loss, but without emesis, diarrhea, or rash. Her 3-year-old brother had a similar cough, but there was no recent travel or animal exposure. Her immunizations are up-to-date except for her second dose of rotavirus and pneumococcal vaccines. Her birth history and family history were noncontributory.

Previous evaluation

Initial vital signs from the outside ED were: temperature, 37^o C (rectally); heart rate, 168 beats per minute; respiratory rate, 40 breaths per minute; blood pressure, 97/51 mm Hg; and oxygen saturation, 88% on room air.

All her growth parameters have remained constant since birth. She weighs 5.7 kg, placing her in the 15th percentile. Her length is in the 27th percentile, and her head circumference is in the 14th percentile.

She had a prolonged capillary refill of 3 seconds, dry mucous membranes, and scattered rhonchi with right basilar crackles. Peripheral pulses were intact; there was no murmur appreciated, and the rest of her exam was unremarkable.

Because of concerns for possible sepsis, she was given 2 20-cc/kg boluses of normal saline, started on 1.5 Lpm of oxygen via nasal canula (NC), and had a full sepsis evaluation including blood, urine, and cerebrospinal fluid (CSF) cultures.

Laboratory results reveal a CSF with clear fluid; 1 white blood cell count (WBC); 0 red blood cell count; glucose, 57 mg/dL; protein, 9 mg/dL; and negative gram stain. Chest x-ray and respiratory syncytial virus (RSV) direct antigen screen are negative; C-reactive protein is 0.13 mg/dL.

A basic chemistry panel, urinalysis, and capillary blood gas all are within normal limits. A complete blood count (CBC) reveals a WBC of 5.5 K/µL, with a manual differential of 39% segs, 24% lymphocytes, 12% monocytes, 7% eosinophils, and 6% bands; hemoglobin, 10.6g/dL; hematocrit, 31.6%; and 594 K/µL platelets. She was given a dose of intravenous antibiotics before arriving at your hospital.