Toxic Infant with a Full Fontanelle. Radiology Cases in Pediatric Emergency Medicine Volume 1, Case 1 Loren G. Yamamoto, MD, MPH

This is a 5-month old male with fever, irritability, and vomiting. His temperature at home was 38.0 rectally. He vomited five times since onset 8 hours ago. He is feeding soy formula. Past medical history is unremarkable.

Exam: VS T38.0R, P150, R40 (crying), BP unobtainable, wt 50%ile. Fussy, though consolable at times. He doesn't focus or interact well and appears somewhat "toxic" to the examiner. Anterior fontanelle is somewhat full, but he is crying so it is difficult to truly assess. Eyes moist. Pupils reactive. TM's are shiny and slightly red. Oral mucosa moist. Neck is hard to assess due to crying. Heart regular without murmur. Lungs clear. Abdomen soft on inspiration. No detectable tenderness evident. No hernias. Testes not swollen. CVA tenderness is not apparent. Color slightly pale. Capillary refill time 2-3 seconds. Muscle tone good.

A lumbar puncture is done to rule out meningitis. The CSF is homogeneously bloody (blood mixed with CSF). The blood does not clear. All three tubes appear to be equally bloody. A CBC, blood culture, and catheterized urine sample are sent to the lab. An IV is started and the child is given 50mg/kg of cefotaxime IV. A CT scan is done to rule out subarachnoid hemorrhage.

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CT Scan

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Loren Yamamoto, MD, MPH Associate Professor of Pediatrics University of Hawaii John A. Burns School of Medicine loreny@hawaii.edu