A 5-year-old boy is brought to the emergency department (ED) by his parents. They report that, for the past week, the child has had a high fever (temperature up to 40oC [104oF]), generalized weakness, lethargy, and lack of appetite. The boy’s eyes are bloodshot and he has refused food and drink. The child has no history of cough, shortness of breath, hematemesis, melena, headaches, vision problems, or seizures. He has not been in contact with sick persons, has not traveled abroad, does not have a pet, and is not taking any medications. His immunizations are up-to-date.
In the ED, the child is given amoxicillin for suspected pharyngitis and discharged. A maculopapular rash develops within 12 hours of the first amoxicillin dose, and the parents return to the ED with the child. Cephalexin is substituted, and the child is hospitalized. Despite therapy, the fever persists and the rash now covers the boy’s entire body.
Physical examination. The patient is a fairly wellbuilt and well-nourished boy who looks ill: he is lethargic and very fussy. He weighs 20 Kg. His pulse rate is 120 beats/min and regular; temperature, 38.8oC (102oF); respiration rate, 22 breaths/min; blood pressure, 96/40 mm Hg. The sclera are icteric and the conjunctiva are severely injected. The lips are dry and chapped, and he has erythematous “strawberry” tongue and pharyngeal erythema. A large (1 X 2-cm) left anterior cervical node is noted. The diffuse erythematous maculopapular rash feels like sandpaper. His hands and feet are puffy; his palms and soles are erythematous.
Cardiovascular examination reveals tachycardia, displaced apex, and grade 2/6 holosystolic ejection murmur without a gallop. Expiration is prolonged with scattered wheezes and reduced air entry at bases. The boy’s abdomen is diffusely tender with guarding in the right upper quadrant. There is no palpable organomegaly; bowel sounds are present.
Laboratory studies. White blood cell (WBC) count, 37,400/μL. Hemoglobin, 9.9 g/dL; platelet count,468,000/μL; polymorphonuclear leukocytes, 74%; erythrocyte sedimentation rate (ESR), 98 mm/h. Serum sodium level, 134 mEq/L; potassium, 4 mEq/L; chloride, 93 mEq/L; carbon dioxide, 20 mEq/L; blood urea nitrogen, 67 mg/dL; serum creatinine, 1.1 mg/dL; total bilirubin, 8.1 mg/dL; conjugated bilirubin, 6.7 mg/dL; alkaline phosphatase, 295 U/L; aspartate aminotransferase, 80 U/L; alanine aminotransferase, 100 U/L; albumin, 2.1 g/dL; amylase/lipase, normal. Urinalysis: protein 1+, bilirubin 2+. Ictotest, positive; WBC, 5 to 6 per highpower field (HPF); red blood cells, 4 to 5 per HPF. Lumbar puncture reveals 4 cells (all monocytes), with a protein level of 42 mg/dL and a glucose level of 75 mg/dL.
Ultrasonography of the abdomen shows free fluid. Results of blood tests, urinalysis, and cerebrospinal cultures are negative. An abdominal CT is ordered.
What abnormalities does the CT show—and to what diagnosis does the general clinical picture point?
(Answer and discussion begin on the next page.)
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