A Sweet Upper Respiratory Infection
A Sweet Upper Respiratory Infection
An 18-month-old boy presented to the emergency department (ED) with cough and rhinorrhea. He had decreased appetite for solids but was tolerating oral fluids. He had no fever and had good urine output. His mother became concerned when his activity level decreased on the third day of his illness and he had to work harder to breathe. She took him to his pediatrician, who noted wheezes and rales on lung examination. A respiratory syncytial virus (RSV) test was positive, and the patient was given one nebulized treatment with albuterol. The patient did not improve appreciably and was referred to the ED for further treatment of bronchiolitis. He was taken to the ED, where he was briefly seen by an emergency physician at the end of his shift. Believing that the boy was dehydrated and had coarse rhonchi in his lung fields, the physician ordered an intravenous bolus of normal saline, chest x-ray, and a nebulized albuterol treatment. After the change of shift, the newly arrived emergency physician examined the patient.
Vitals: temperature, 99.7 °F; heart rate, 160 beats/min; respiratory rate, 38 breaths/min; room air oxygen saturation, 100%; body weight, 15.4 kg
General: well-developed male who appears ill, dehydrated, and in moderate respiratory distress
Head, eye, ear, nose, and throat examination: head is normocephalic and atraumatic; pupils are equal, round, and reactive to light; tympanic membranes are clear; oropharynx reveals dry mucous membranes with no tonsilar hypertrophy or erythema; nares show encrusted discharge bilaterally
Cardiovascular: tachycardic heart rate; no murmurs, rubs, or gallops
Respiratory: a few inspiratory rales in the lung bases bilaterally; no wheezing; subcostal, intercostal, or suprasternal retractions; no nasal flaring or grunting; marked tachypnea
Abdomen: soft and nondistended; no hepatomegaly or splenomegaly; no tenderness on palpation; bowel sounds present in all 4 quadrants
Extremities: warm; 2+ radial pulses bilaterally; capillary refill time, 2.5 seconds
Skin: no rashes or lesions
Neurologic: awake but listless; interacts with his mother when she speaks to him; moves all extremities spontaneously; cranial nerves 2-12 grossly intact; normal muscle tone and bulk; deep tendon reflexes 2/4 bilaterally; sensation to light touch is intact
At this point, the patient had not yet received intravenous fluids. The oncoming physician ordered laboratory tests that included electrolytes, complete blood count with differential, and a blood culture. The patient received 2.5 mg of nebulized albuterol via mask and had a chest x-ray obtained. The patient's lung examination improved after the albuterol, with no rales or wheezes heard on auscultation. However, he remained tachypneic and continued to have retractions. The nursing staff established an intravenous line, started the fluid bolus, and obtained the laboratory tests. At this time, the physician's differential diagnosis included RSV bronchiolitis, pneumonia, sepsis, dehydration, and reactive airway disease.
Approximately 45 minutes later, the physician was informed that the patient's blood glucose level was 627 mg/dL. Venous blood gas and urinalysis were ordered, and the physician reexamined the patient. Upon further questioning, the mother reported that the patient had been increasingly thirsty and had 12 urine-filled diapers within the past day. She also thought that he had lost some weight, which she attributed to his decreased appetite.
Complete blood count: leukocyte count, 17cells/μL; hemoglobin, 13%; hematocrit, 37%; platelet count, 478,000 cells/μL
Metabolic panel: sodium, 127 mEq/L; potassium, 2.8 mEq/L; chloride, 115 mEq/L; carbon dioxide, 11 mEq/L; blood urea nitrogen, 27; creatinine, 0.6 mg/dL; glucose, 627 mg/dL
Venous blood gas: pH, 7.18; pO2, 65 mm Hg; pCO2, 32 mm Hg; HCO3, 10 mEq/L
Chest x-ray: no focal consolidation; mild peribronchial cuffing and thickening
Urinalysis: glucose, 3+; ketones, 2+; protein, negative; bilirubin, negative; nitrite, negative; leukocyte esterase, negative; leukocytes, 0-2 per high-power field; erythrocytes, 2-5 per high-power field
The patient was admitted to the pediatric intensive care unit with a diagnosis of diabetic ketoacidosis (DKA), RSV infection, and bronchiolitis. A continuous insulin intravenous infusion was started at 0.1 unit/kg per hour concomitantly with 0.45% saline. This was titrated to decrease his blood glucose level by no more than 100 mg/dL per hour. His respiratory rate slowly decreased, and his level of consciousness improved as his blood glucose level decreased. The patient was continued on the insulin infusion for the next 18 hours. He was then switched to subcutaneous insulin injections. His parents were educated on the use of a personal glucometer, insulin dosing, and insulin administration by the diabetes education nurse. The patient was discharged home 2 days after presentation and had a scheduled follow-up appointment with the local endocrinologist later that week. He had no long-term complications.
Case Presentation
An 18-month-old boy presented to the emergency department (ED) with cough and rhinorrhea. He had decreased appetite for solids but was tolerating oral fluids. He had no fever and had good urine output. His mother became concerned when his activity level decreased on the third day of his illness and he had to work harder to breathe. She took him to his pediatrician, who noted wheezes and rales on lung examination. A respiratory syncytial virus (RSV) test was positive, and the patient was given one nebulized treatment with albuterol. The patient did not improve appreciably and was referred to the ED for further treatment of bronchiolitis. He was taken to the ED, where he was briefly seen by an emergency physician at the end of his shift. Believing that the boy was dehydrated and had coarse rhonchi in his lung fields, the physician ordered an intravenous bolus of normal saline, chest x-ray, and a nebulized albuterol treatment. After the change of shift, the newly arrived emergency physician examined the patient.
Physical Examination
Vitals: temperature, 99.7 °F; heart rate, 160 beats/min; respiratory rate, 38 breaths/min; room air oxygen saturation, 100%; body weight, 15.4 kg
General: well-developed male who appears ill, dehydrated, and in moderate respiratory distress
Head, eye, ear, nose, and throat examination: head is normocephalic and atraumatic; pupils are equal, round, and reactive to light; tympanic membranes are clear; oropharynx reveals dry mucous membranes with no tonsilar hypertrophy or erythema; nares show encrusted discharge bilaterally
Cardiovascular: tachycardic heart rate; no murmurs, rubs, or gallops
Respiratory: a few inspiratory rales in the lung bases bilaterally; no wheezing; subcostal, intercostal, or suprasternal retractions; no nasal flaring or grunting; marked tachypnea
Abdomen: soft and nondistended; no hepatomegaly or splenomegaly; no tenderness on palpation; bowel sounds present in all 4 quadrants
Extremities: warm; 2+ radial pulses bilaterally; capillary refill time, 2.5 seconds
Skin: no rashes or lesions
Neurologic: awake but listless; interacts with his mother when she speaks to him; moves all extremities spontaneously; cranial nerves 2-12 grossly intact; normal muscle tone and bulk; deep tendon reflexes 2/4 bilaterally; sensation to light touch is intact
ED Course
At this point, the patient had not yet received intravenous fluids. The oncoming physician ordered laboratory tests that included electrolytes, complete blood count with differential, and a blood culture. The patient received 2.5 mg of nebulized albuterol via mask and had a chest x-ray obtained. The patient's lung examination improved after the albuterol, with no rales or wheezes heard on auscultation. However, he remained tachypneic and continued to have retractions. The nursing staff established an intravenous line, started the fluid bolus, and obtained the laboratory tests. At this time, the physician's differential diagnosis included RSV bronchiolitis, pneumonia, sepsis, dehydration, and reactive airway disease.
Approximately 45 minutes later, the physician was informed that the patient's blood glucose level was 627 mg/dL. Venous blood gas and urinalysis were ordered, and the physician reexamined the patient. Upon further questioning, the mother reported that the patient had been increasingly thirsty and had 12 urine-filled diapers within the past day. She also thought that he had lost some weight, which she attributed to his decreased appetite.
Laboratory and Radiographic Findings
Complete blood count: leukocyte count, 17cells/μL; hemoglobin, 13%; hematocrit, 37%; platelet count, 478,000 cells/μL
Metabolic panel: sodium, 127 mEq/L; potassium, 2.8 mEq/L; chloride, 115 mEq/L; carbon dioxide, 11 mEq/L; blood urea nitrogen, 27; creatinine, 0.6 mg/dL; glucose, 627 mg/dL
Venous blood gas: pH, 7.18; pO2, 65 mm Hg; pCO2, 32 mm Hg; HCO3, 10 mEq/L
Chest x-ray: no focal consolidation; mild peribronchial cuffing and thickening
Urinalysis: glucose, 3+; ketones, 2+; protein, negative; bilirubin, negative; nitrite, negative; leukocyte esterase, negative; leukocytes, 0-2 per high-power field; erythrocytes, 2-5 per high-power field
Hospital Course
The patient was admitted to the pediatric intensive care unit with a diagnosis of diabetic ketoacidosis (DKA), RSV infection, and bronchiolitis. A continuous insulin intravenous infusion was started at 0.1 unit/kg per hour concomitantly with 0.45% saline. This was titrated to decrease his blood glucose level by no more than 100 mg/dL per hour. His respiratory rate slowly decreased, and his level of consciousness improved as his blood glucose level decreased. The patient was continued on the insulin infusion for the next 18 hours. He was then switched to subcutaneous insulin injections. His parents were educated on the use of a personal glucometer, insulin dosing, and insulin administration by the diabetes education nurse. The patient was discharged home 2 days after presentation and had a scheduled follow-up appointment with the local endocrinologist later that week. He had no long-term complications.
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