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Index of Suspicion

	Case 1 Presentation

On examination, the child appears toxic. Her oral temperature is 40°C (104°F), pulse is 120 beats/min, blood pressure is 98/44 mm Hg, and respiratory rate is 40 breaths/min. She has a macular rash on her trunk, with several petechiae and erythema of the pharynx. The remaining physical findings are normal.

Laboratory findings include oxygen saturation by pulse oximetry, 94%; white blood cell (WBC) count, 7.5 x 10⁹/L (7,500/cu mm) with 78% segmented neutrophils; hematocrit, 0.30 (30%); platelet count, 48 x 10⁹/L (48 x 10³/cu mm); erythrocyte sedimentation rate (ESR), 92 mm/h; activated partial thromboplastin time, 42.4 seconds (control, 31.6 sec); blood urea nitrogen, 11.1 mmol/L of urea (31 mg/dL); serum sodium, 131 mmol/L (131 mEq/L); serum potassium, 3.0 mmol/L (3.0 mEq/L); serum chloride, 100 mmol/L (100 mEq/L); arterial pH, 7.49; PO₂, 10.5 kPa (79.2 torr); PCO₂, 3.0 kPa (23.3 torr); and bicarbonate, 18 mmol/L (18 mEq/L). Urinalysis reveals a specific gravity of 1.030 and 3 + ketones. Radiography of the chest shows multiple delicate nodular opacities bilaterally.

After admission, the high fever persists despite intravenous hydration and empiric treatment with doxycycline, intended to treat brucellosis and spotted fever, diseases prevalent where she lives. By the third hospital day, the rash is gone, but rales are audible in the left lung, and her pulse is 120 beats/min, even when the fever is reduced by antipyretics. Her WBC count is 14 x 10⁹/L (14,000/cu mm) with 64% segmented neutrophils and 12% . . . [Full Text of this Article]

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