(Figure 1) Exudative pharyngitis is demonstrated 13 days prior to BMSCH admission
Due to continued and increased severity of sickness, she arrived to the ER at her local hospital due to continued fevers, new onset of cough, swollen glands, worsening sore throat, shortness of breath, increased work of breathing, new rash on her left wrist, scleral icterus, and blurry vision characterized by enhanced brightness. This was 12 days after her arrival to her hometown. Her ER vitals include temperature 98.4 °F, O2 saturation 93% room air, blood pressure 98/67, respiratory rate 40 breaths per minute, and tachycardia at 116 beats per minute. Physical exam was pertinent for decreased breath sounds at bases bilaterally on lung exam, erythema of posterior pharynx with mild exudate present (as in figure 1), mild anterior cervical lymphadenopathy and tenderness of neck, and diffuse mild tenderness on abdominal palpation.
There were four COVID PCR tests reported as negative. Imaging included chest x-ray and CT scan of the chest, which showed bilateral cavitary pneumonia with left pleural effusion. Her blood work included blood culture, CBC with WBC of 3.9 thousand/ul, absolute neutrophil count of >2000 thousand/ul, C-reactive protein 30.75 mg/dL, ferritin >1600 ng/mL, and procalcitonin 100 ng/ml. Other studies were negative for pulmonary embolism on CTA, HIV, urine legionella, urine streptococcus antigen, CMV, EBV IgM (positive for IgG), throat culture, acid-fast bacillus, mycoplasma pneumonia IgM by IFA, and Rocky mountain spotted fever.
Laboratory reports at the hospital revealed blood culture positive for anaerobic gram-negative rods identified as Fusobacterium nucleatum . Due to significant drop in platelets at 11,000; she received plasma and platelet transfusion.
During this time period, she developed left wrist pain that gradually migrated to entire left hand and arm, improved, but then migrated to left shoulder causing limited mobility.
Her treatment at this hospital includes doxycycline and ceftriaxone, followed by left pleurocentesis, which removed 950 mL pleural fluid. Pleural fluid showed LDH 2,786 IU/L, glucose <5 mg/dL, and protein 1.5 g/dL, suggestive of an exudative pleural effusion. Surgical pathology report was impressive for left pleura-fibrinopurulent exudate, and cytology for pleural fluid was negative for malignancy.
Due to concerns of impending septic shock and worsening respiratory distress, she was then transferred to BMSCH after 1 day at former hospital for further evaluation and management. Multiple specialists including Pediatric Infectious Disease, Pediatric Surgery, Pediatric Ear Nose and Throat, Orthopedics, and Pediatric Pulmonary were consulted throughout hospital course.