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Lessons From the Past and Present

A 5-month-old Caucasian male with trisomy 21 and a past medical history of a transitional atrioventricular canal defect and gastroesophageal reflux disease presented to the emergency department with a 2-day history of persistent fever and emesis. The previous day the patient was seen by his primary care physician where he tested negative for respiratory syncytial virus and influenza. He had only received his birth hepatitis B and 2-month immunizations. He was diagnosed with acute otitis media at that time and sent home on a course of cefdinir. His mother reported that the fever remained unchanged but was controlled with acetaminophen. She reported decreased oral intake and urine output in addition to non-bloody and non-bilious emesis that started earlier on the day of presentation. The patient was originally brought to an outside hospital where initial blood cultures were drawn. The patient was subsequently transferred to our institution for further management. On examination, the patient appeared lethargic. His temperature was 38.4°C, pulse was 130 beats per minute, respiratory rate was 38 breaths per minute, and oxygen saturation was 81%. Physical examination revealed facial anomalies of trisomy 21 and rhinorrhea. Additionally, bilateral tympanic membranes were erythematous, and the middle ears contained fluid. Cardiac examination revealed a grade 2/6 high-pitched blowing holosystolic murmur. Pulmonary examination was positive for subcostal retractions, and his skin exhibited mottling and pallor with a capillary refill time of 2 to 3 seconds.