Visual Diagnosis: The Blue Baby: An Infant Presenting with Severe Respiratory Distress

Presentation

An 8-month-old previously healthy girl presents to the emergency department with concerns of “not breathing right.” Just before arrival she awoke from her nap screaming. She appeared grey and was breathing rapidly. Her babysitter called 911, and she was brought to the emergency department for further care. The patient had an isolated tactile temperature 4 days before arrival and has been having nasal congestion for approximately 1 week. There are no sick contacts in the household, and the child attends an in-home child care. Her medical history includes term vaginal delivery, up-to-date immunizations, and a maternal uncle with cystic fibrosis.

In the emergency department the child is cyanotic and is crying vigorously. Her pulse oximetry is 66% on room air, although there is difficulty getting a proper reading on the pulse oximeter. She is afebrile, her heart rate is 186 beats/min, blood pressure is 112/66 mm Hg, and respiratory rate is 58 breaths/min. There is bilateral air entry on the respiratory examination without audible wheeze or crackles. Cardiac examination is significant for tachycardia but with regular rhythm and without gallop or appreciable murmur. The remainder of the child’s examination findings are normal. She is placed on a nonrebreather mask, her color improves, and pulse oximetry increases to the 80s. A venous blood gas shows pH 7.23, Pco₂ of 51 mm Hg, and a bicarbonate level of 21 mEq/L (21 mmol/L).

Given this child’s respiratory distress and decreased oxygen saturation, a portable anteroposterior chest radiograph is obtained (Fig 1).