Case 2: Acute Respiratory Distress and Facial Petechiae in a 4-month-old Boy

Presentation

A 4-month-old twin infant boy presents to the emergency department (ED) with a 10-hour history of increased work of breathing, poor feeding, and decreased activity. Prior to arrival, the patient’s mother administered 2 albuterol treatments via nebulizer, which helped transiently. Then she took the child to his pediatrician’s office, where he was given an additional albuterol treatment and subsequently referred to the ED for persistent respiratory distress. The infant has had 2 hospital admissions for bronchiolitis. His parents deny any history of fever, cough, wheezing, runny nose, or vomiting. His twin brother remains asymptomatic.

In the ED, the child is alert but tachypneic, with intercostal and subcostal retractions and nasal flaring. His initial vital signs include a temperature of 37.8°C (100°F), heart rate of 174 beats per minute, respiratory rate of 34 breaths per minute, blood pressure of 111/53 mm Hg, and pulse oximetry of 80% in room air. He weighs 4.8 kg (less than the third percentile). Findings on physical examination include a reddish discoloration on both sides of the neck and petechiae on the right cheek. A subconjunctival hemorrhage is also noted in the right eye. His lungs are clear to auscultation bilaterally, without wheezing, stridor, rales, or crackles, despite persistent and …