Make the Diagnosis: Winter 2021

An 8-year-old female with no significant past medical history presented to the Emergency Department due to fever and abdominal pain. She was otherwise well until two days before, when she developed high fever (40o C), nausea, vomiting, and abdominal pain. In the local ED, she received an abdominal CT to evaluate for appendicitis, which demonstrated a normal appendix and nonspecific mesenteric adenitis. She had a positive rapid streptococcal pharyngitis test, and she was noted to have bilateral conjunctival injection. However, she quickly began to decompensate with oxygen requirement and hypotension requiring intravenous fluid resuscitation, and she received broad-spectrum antibiotics with concern for sepsis and toxic shock syndrome. Laboratory markers were significant for elevated CRP (35 mg/dL), ESR (27 mm/hr), ferritin (1395 ng/mL), procalcitonin (30 ng/mL), B natriuretic peptide (191 pg/mL), fibrinogen (504 mg/dL), and D-dimer (> 20 ug/mL), along with transaminitis (ALT 52 and AST 76 IU/L), leukopenia (WBC 3.8), neutrophilia (85%), lymphopenia (7%), thrombocytopenia (platelets 114), and hypoalbuminemia (3.3 g/dL).

Her father had COVID-19 about one month before her illness, but her SARS-CoV-2 PCR was negative in the ED. After starting norepinephrine and escalating her respiratory support to BiPAP, she was transferred to the CHOP PICU. 

No one guessed the correct answer to last issue’s Make the Diagnosis challenge. It was inflamatory bowel disease, the subject of this issue’s cover article.