Sudden Onset Respiratory Distress in a 4-year-old Girl

Case Presentation

A 4-year-old girl presents to the emergency department with complaints of sudden onset respiratory distress. Her father, who has accompanied her to the emergency department, has red papules around his nose and nasolabial folds with an appearance consistent with adenoma sebaceum, but he reports no history of seizures (Fig 1). The patient has a past history of admission for pneumonia 1 month before presentation, which had resolved with intravenous antibiotics. She was born full term to nonconsanguineous Indian parents. Except for mildly reduced language milestones, she is developmentally appropriate for her age. The patient was diagnosed with epilepsy at 1 year of age and takes phenobarbital for seizure control. Her grandmother had epilepsy and had died at the age of 40 years due to intractable seizures.

On examination, an ill-defined erythematous plaque showing gyrations over its surface is found over the patient’s scalp in the temporooccipital area along with multiple small hypopigmented macules (5 in number) with irregular margins over right thigh, abdomen, and right arm.

On arrival, she is febrile (103.4°F [39.7°C]), tachypneic (respiratory rate, 48/min) and hypotensive (blood pressure 70/44 mm Hg) with a prolonged capillary refill time (>3 seconds). Examination of her chest reveals hyperresonant percussion and reduced breath sounds noted on the right compared with the left lung fields. Her pulse oxygen saturation is 75% on room air. A chest radiograph reveals …