Pediatric Case of the Week 13: Let the BAD times roll...

HPI: Harley, a 3 year old male, presents with 4-5 days of fever, increasing irritability and decreased po intake.  His parents note that he has had increased difficulty eating and drinking due to painful cracked lips and a swollen red tongue that developed a couple of days after the fever.  In addition they are concerned about a rash that developed over his back and "red eyes" which they initially chalked up to a "some sort of viral thing." Today, they became more concerned because he has developed swelling in both of his hands and feet.   His past medical history is only notable for one prior episode of otitis media. His immunizations are up to date.

VS:  Temp 103,  HR 110,  BP  110/70,  RR 30,  Sats 100% RA

PE:

Lab: Lab: CBC WBC 19,500 with 75% segs, 20% lymphs, 5% monos. Platelet count 475. Hgb 10. AST 56, ALT 62, bilirubin 1.2, albumin 2.8. Urinalysis with WBC 5-10, no organisms, negative for protein, blood, leukocyte esterase or nitrites. Urine and blood cultures are obtained.

Could you, would you, form a differential diagnosis?

For academic sake, how about considering 3 possibilities?

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What should you do for this child?

A. Start your favorite eye antibiotic and provide his daycare with a note authorizing a full return
B. Start broad spectrum antibiotics, admit, and let them sort it out upstairs.
C. Give him an aspirin and admit to the hospital for further specific treatment
D. Perform a bedside ECHO (you just took the USE-IT course and are feeling extremely confident.)
E. Administer a pediatric dose of Benadryl hoping he will fall asleep until the pediatrician arrives.

What is the MAJOR COMPLICATION of this disease that can lead to a significant level of morbidity and even mortality in some cases?

What company's slogan is: "LET THE GOOD TIMES ROLL"