Case #91 "Limp and Pale"
by Charlene Babcock Irvin, MD, FACEP  

An 18 month old male is brought in by his mom for fever and problems breathing. She noted he began to cough about 3 days ago. He hasn’t been his usual active self for about the past week. She was worried he was coming down with something. This morning he seemed to be breathing very fast, so she brought him to the ED. He has a history of asthma, and mom tried an albuterol nebulizer, but it wasn’t helping.

ROS: Fevers (tactile) for 3 days. Cough (dry). Decreased appetite - first for food then liquids. Last wet diaper - 18 hours ago. Vomiting - 2 days ago. No vomiting yesterday. No diarrhea. No rashes.

PMH: Asthma.

Meds: Albuterol PRN.

PE: Limp, very pale, baby, with very dry mucus membranes, and tenting to the skin. In general, he is irritable with cool extremities, and labored fast breathing.

VS: BP: 120/44, HR=179, RR=55, Sat=90% (RA), 100% sat on 100% NRB, Rectal temp 97.6F.

HENT: Unremarkable, Neck supple. Fontanel closed. MM dry.

HEART: Tachy, No murmurs heard.

Lungs: Rhonchi inspiratory and expiratory with wheezing bilaterally.

Abd: Unremarkable.

Ext: Peripherally cold. No rashes.

Neuro: Moves all ext to pain with a weak cry. No focal deficits. Poor eye contact.

Labs:
WBC= 71.2 K/mm (Neutrophils: 3%, Lymphs 29%, Blasts 67%)

Hbg=2.6

HCT=8.0

Platelet = 10K/mm

Renal Panel: Glu=164, BUN=19, Cr=0.3, Na=145, K+=5.3, Cl=108, CO2=8

Venous Blood Gas: pH=7.028, PCO2=31.5, PO2=31.5, Bicarb=8.1
CXR= Bilateral infiltrates

Questions:

1. What diagnosis should you be very concerned about?

2. What is the most common cause of death in this disease?

3. The elevated potassium suggests a complication of this disease. What additional tests and treatment are needed?

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