Malaise, tachypnoea & abd...

A 4-year-old boy with unremarkable medical and family history presented to the emergency room with a 2-day history of malaise, lethargy, tachypnoea, sore throat, abdominal pain, vomiting and dehydration. In retrospect, the history revealed polyuria, polydipsia and a documented 4-kg weight loss in 3 weeks preceding admission. He was afebrile, tachypnoeic (46 breaths per minute) with Kussmaul respirations, his heart rate was 156 beats per minute, and his blood pressure was 90/55 mm Hg. The patient’s physical findings included light drowsiness, no jugular distension, with diffuse rhonchi in all lung areas. Immediate treatment consisted of insulin infusion, intravenous saline, potassium replacement and symptomatic respiratory treatment. Hypotension was controlled with volume expansion, vasopressors and inotropes. In spite of therapy, the patient’s status continued to deteriorate, and a few hours later, he suddenly developed severe dyspnoea, increased tachypnoea, restlessness and cyanosis. Auscultation of the chest disclosed diffuse crackles and rhonchi in all lung areas. Hypoxemia was confirmed, and chest radiographs were taken. Throat culture was positive for group A beta-haemolytic streptococci.