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Index of Suspicion

	Case 1 Presentation

 
A 6-month-old boy has had 2 days of low-grade fever, rhinorrhea, and an evolving labial lesion. He is believed to have viral stomatitis, and ibuprofen is prescribed. Over the next 48 hours, the lesion at the right corner of his mouth becomes purulent. His oral intake is poor. Cefadroxil and oral rehydration therapy are prescribed. The next day, he is lethargic and taking nothing by mouth and is admitted to the community hospital.

Physical examination reveals a lethargic infant who has a sunken anterior fontanelle, a 1.5-cm purulent, ulcerative lesion centered on the vermilion border at the right corner of the mouth that resembles a red crater weeping with pus, and six erythematous papules and vesicles on his extremities. His temperature is 99.9°F (37.2°C), heart rate is 120 to 140 beats/min, respiratory rate is 30 breaths/min, and blood pressure is 61/39 mm Hg. Capillary refill time is 4 seconds.

Initial laboratory values include: WBC count, 3.4x10³/mcL (3.4x10⁹/L), with an absolute neutrophil count of 1.1x10³/mcL (1.1x10⁹/L); Hgb, 9.0 g/dL (90 g/L); platelet count, 25x10³/dL (25x10⁹/L); bicarbonate, 15 mEq/L (15 mmol/L); and glucose, 32 mg/dL (1.8 mmol/L). His CSF is bloody, but no cell count is performed. Peripheral intravenous access cannot be attained, and an intraosseous line is placed. Blood, urine, and CSF cultures are sent, and he is given 60 mL/kg of normal saline, dextrose, intramuscular ceftriaxone, and intraosseous acyclovir. He remains hypotensive and develops respiratory distress that necessitates tracheal intubation. Dopamine is started, and he is transferred to a tertiary care institution. The diagnosis is revealed the next day.

	Case 2 Presentation

 
A 14-month-old boy is brought to the ED because of increased work of breathing and increased respiratory rate. He has been treated since . . . [Full Text of this Article]

Christopher Mastropietro, MD
Marilyn Morris, MD
New York Presbyterian Hospital-Columbia University, New York, NY

Robin Stanfield, MD
James R. Stallworth, MD
University of South Carolina, Columbia, SC

Susan Caro, MD
Jonathan Fleenor, MD
Naval Medical Center, San Diego, CA

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