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Case 2: A neonate in shock.

During the fall, a 17-day-old boy was brought to the emergency department because of progressive feeding difficulty and lethargy after developing nasal congestion three days before presentation. The infant was born following an uncomplicated full term pregnancy and delivery. The family history was notable only for a five-year-old brother with a bicuspid aortic valve. Both his parents and brother had been recently ill with a cold. 
 
The infant was hypotonic and pale with signs of respiratory distress. His heart rate was 140 beats/min, respiratory rate was 64 breaths/min, systolic blood pressure was approximately 80 mmHg, oxygen saturation was 90% on room air and his rectal temperature was 36.5°C. Physical examination revealed hepatomegaly (4 cm to 5 cm below the costal margin) and diminished femoral and radial pulses; no rash was noted. Fluid resuscitation was begun immediately. However, after receiving 60 mL/kg of crystalloid solution, the patient became bradycardic (60 beats/min), requiring chest compressions, intubation and continuous infusion of vasopressors for stabilization. Initial laboratory findings included a mixed respiratory and metabolic acidosis, lymphocytosis, elevated transaminases and evidence of early disseminated intravascular coagulopathy. A chest x-ray demonstrated cardiomegaly (Figure 1). Blood, cerebrospinal fluid (CSF) and urine samples were sent for bacterial culture. Broad-spectrum antibiotics were begun, and the patient was admitted to the paediatric intensive care unit. Further investigations revealed the diagnosis. 
 
 
 
Figure 1) 
 
Chest radiographs at presentation. Anteroposterior (A) and lateral (B) views demonstrate cardiomegaly and mildly increased vascular markings. There is no evidence of parenchymal pulmonary disease.