Malek Mazzawi, MD, Children’s National Medical Center

HPI:

Outside hospital calls requesting transfer of a 5-year-old previously healthy girl with fever and rash for 7 days. She was diagnosed with roseola 5 days prior at urgent care then started having worsening headache, somnolence and decreased PO. She developed a diffuse, non-pruritic, erythematous rash on her trunk that spread to her extremities. Fevers have been daily but unsure Tmax. She complains of photophobia and some pain with neck movement. Has had a few episodes of NBNB emesis, one episode of diarrhea, no dysuria. No recent travel, no bug bites, no known COVID contacts.

Review of Systems:

Constitutional symptoms: +Fever, +Fatigue, +Somnolence

Skin symptoms: +Non-pruritic rash on trunk and limbs

ENMT symptoms: No sore throat

Respiratory symptoms: No shortness of breath, +Cough, +Congestion

Cardiovascular symptoms: No chest pain

Gastrointestinal symptoms: +Vomiting, +Diarrhea, +Mild abdominal pain

Musculoskeletal symptoms: +Neck pain

Neuro symptoms: +Photophobia, +Irritability, No seizures

PMHx/PSHx

• Previously healthy, has had several dental surgeries for poor dental hygiene
• Fully immunized
• No meds or allergies

OSH Exam:

HR 130-150, RR 26, temp pending but feels very warm, O2 sat 95-96, unable to get BP.

She is in no respiratory distress, she is flushed, brisk cap refill. Has flat, erythematous rash. Irritable but consolable. Looks sick.

OSH Course:

Labs and imaging at OSH were:

WBC 19K (28% bands), Hgb/Hct of 9.6/28, Plt 355

Chem normal, BUN/Cr of 19/0.49, Albumin 2.4

ALT 22, AST 40, Tbil 0.4. Ca 8.2

PTT 26.5, INR 1.36.

Lactate 2.3, Procal 25.36 , CK 34

CRP 199.4

COVID, Rapid Strep, Flu and RSV all negative

BCx pending

CXR normal

There is no PICU bed available so the patient must come to the ED. Transport team is available, round trip time 20 min by air.

While awaiting transport the OSH attempted LP and failed. No CT was done. They gave Ceftriaxone and fluid resuscitated. You get Med Control from transport team who reports ill-appearing child with BP that has dropped from 112/59–>78/37. She is started on Norepi drip. Patient is protecting airway and is not intubated.

Physical Exam upon Arrival:

Initial vitals:  T 40.5C, HR 145, RR 32, SpO2 99% on RA, unable to obtain BP

Wt 19.5 kg

General: Moderate distress, responds to commands, irritable but consolable

Skin:  Erythematous non-raised rash on the back and trunk and bilateral extremities.

HEENT:  NCAT. Conjunctiva clear. Nares patent. Moist oral mucosa. PERRL. + conjunctival injection.

Neck: Mild nuchal rigidity

ENT:  Tympanic membranes clear.  Oral mucosa moist.  2-3 cm area of swelling posterior and inferior to the left angle of the mandible, mobile, without overlying erythema, nontender to palpation.  Both tonsils appear enlarged, mildly erythematous, without exudate. Left tonsil > right.

Cardiovascular:  RRR, normal S1/S2, no murmur. Distal pulses 2+ and cap refill < 2 sec

Respiratory:  Lungs CTAB. No wheezes, rales or rhonchi.

Musculoskeletal:  No deformity. Full ROM of extremities. Normal back.

Gastrointestinal:  Soft, diffusely tender to palpation. No hepatosplenomegaly

Neurological:  Responds to commands however no verbal interaction with examiner or parents, unable to assess orientation, moving all 4 extremities equally.

CT scan was performed. Radiologist read was “Findings indicate cerebral leptomeningeal enhancement, suggestive of meningitis. Recommend clinical correlation with lumbar puncture for further evaluation of etiology. No evidence of extra-axial fluid collections.”

LP Results:

Clear

CSF RBCs 0

CSF Nucleated Cells 3 Cell count 31

Further workup included MIS-C labs which resulted as following:

BNP 19,817

ESR 83

CRP 17

Ferritin 307

Fibrinogen 526

D-dimer 3.62

Trop 0.04

COVID IgG Positive

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