1. History

Joe, aged 12 years, presented to his primary care provider with a suspected upper respiratory infection. His mother stated that he had been complaining of a slight sore throat and fatigue for two to three days, and she had kept him home from school. Assuming the illness would run its course, she became concerned when his symptoms worsened three days later. 

2. Physical Exam

Joe was a normally developed male with height and weight appropriate for his age. His blood pressure and pulse were 108/60 mm Hg and 82 beats per minute, respectively. His respiratory rate was 30 breaths per minute, but this was normal for him ever since the surgical correction of a congenital cardiac condition when he was an infant.

He had recovered from that surgery and was released from follow-up several years before this illness. His temperature was 99°F, and his lungs were clear to auscultation bilaterally. Conjunctiva were clear and slightly watery, his oropharynx was bright red without tonsilar exudates, and his nasal mucosa was slightly red. Mild swelling and tenderness of both anterior cervical lymph node chains was noted. Joe did not complain of any actual pain or discomfort.

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When Joe’s mother brought him back to the office, his temperature was spiking up to 103°F, and he was now anorexic and very lethargic. He appeared very ill, pale, and listless. He was alert and oriented to person, place, and time, but he had to lie down on the exam table because he was too weak to remain sitting.

Auscultation of his lungs revealed bilateral basilar rales that did not clear with cough. A complete blood count in the office showed a marked left shift with a total white blood cell count of 26,000 cmm, hemoglobin level of 8.2 mg/dL, hematocrit level of 25%, and a platelet count of 19,000 μL. He was emergently admitted to the local children’s hospital.

3. Hospital Course

Joe’s vital signs on admission were: blood pressure of 82/40 mm Hg, respiratory rate of 62 bpm, tympanic temperature of 103°F, oxygen saturation of 78%, and pulse rate of 102 bpm. His serum creatinine was 4.2 mg/dL.

A chest x-ray showed bibasilar infiltrates. He was immediately started on IV fluid support and broad spectrum antibiotics after blood cultures were drawn. Nasal cannula oxygen at 3 lpm was begun for respiratory support.

By his third hospital day, his creatinine level had increased to 9.2 mg/dL. A cardiac echocardiogram showed no signs of valvular vegetation. No wounds or other sites of principle infection were identified. The decision was made to begin hemodialysis.

A central vascular access was inserted and hemodialysis started. The frequency of his dialysis sessions was based on his creatinine levels. During this time, Joe’s hemoglobin and hematocrit levels also decreased to 6.5 mg/dL and 22%, respectively, requiring two transfusions with packed red blood cells.

In spite of the level of treatment, Joe was very slow to respond to the therapy. His respiratory status worsened, which required him to be placed on positive pressure oxygenation. On day 20, Joe’s oxygenation continued to worsen.

A repeat chest x-ray showed a large right pleural effusion. A chest tube was inserted, and more than 1,300 mL of sero-sanguinous fluid was removed. His respiratory rate slowed to 43 bpm, and his PaO2 improved to 87%. He remained on positive pressure oxygenation. Ultimately, Joe began to recover. Dialysis frequency and treatment length were gradually decreased and then terminated. Serum creatinine continued to normalize, reaching 1.1 mg/dL by discharge.