AN 18-YEAR-OLD BOY had fever, sore throat, generalized myalgia, abdominal pain, and occasional vomiting for 1 week. A presumptive diagnosis of influenza with dehydration was made, and he was treated with rimantadine hydrochloride and intravenous fluids for 5 days and then discharged from the hospital. Within 24 hours he had symptoms of high fever, respiratory distress, generalized myalgia, and extreme fatigue.
On admission to the pediatric intensive care unit, he had a temperature of 102°F; heart rate, 120 bpm; respirations, 32 breaths per minute; blood pressure, 120/62 mm Hg; and oxygen saturation, 93% to 95% on a fraction of inspired oxygen of 1.0. Findings from physical examination revealed a capillary refill time of 2 to 3 seconds, full distal pulses, and warm extremities. His pharynx was congested without exudate, retropharyngeal swelling, or uvular displacement. He had bilateral nontender cervical lymph nodes measuring 2 to 3 cm. His abdomen was mildly distended, the liver enlarged, and the bowel sounds hypoactive. The skin had no petechiae or purpura, but erythema was present over the lateral aspect of his left proximal fibula.
A chest radiograph was obtained (Figure 1). The complete white blood cell count was 2.5 ×103/µL; hemoglobin, 13.6 g/dL; platelet count, 24 × 103/L; and coagulation parameters, normal. The serum electrolyte levels were normal; blood urea nitrogen, 34 mg/dL; and creatinine, 0.9 mg/dL (79.6 µmol/L). Liver enzyme levels were elevated with total bilirubin of 1.3 mg/dL (22.3 µmol/L). Specimens were drawn for blood, urine, respiratory bacterial and viral cultures; mycoplasma cultures; Epstein-Barr and human immunodeficiency virus (HIV) antibody titers; Rocky Mountain spotted fever latex agglutination tests; and polymerase chain reaction for Ehrlichia species and HIV before beginning treatment with cefotaxime sodium, vancomycin, and azithromycin. Soon after admission, he required endotracheal and mechanical ventilation for respiratory failure. His blood culture was positive for gram-negative anaerobic bacilli, and computed tomography (CT) scans of the abdomen and chest were obtained (Figure 2).
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