By Santa J. Bartholomew M.D. FAAP, FCCM
A mother brings her 12-year-old son in for evaluation to the emergency department. Over the past 24 hours he has become extremely fatigued and increased abdominal pain despite oral Ibuprofen and Tylenol. The child is otherwise healthy except for asthma, for which he utilizes an albuterol inhaler. She states last night he ate a normal dinner and went to bed without any pain or fevers. He awoke this morning with a low-grade fever of 99.5 and increased abdominal pain. She figured he simply had come down with the stomach flu. However, throughout the day, his abdominal pain progressed, and he has vomited twice before being brought to the Emergency Department. In the ED his temperature is 101.5 with rigors.
A full examination is completed, and history is obtained from the mother. The patient was found to be tachycardic with a heart rate of 135 beats per minute and tachypneic with a respiratory rate of 28 respirations per minute. His fever is mildly elevated at 100.8 degrees Fahrenheit; however, mom has administered both Tylenol and Ibuprofen. His blood pressure is low at 64/32. He appears clinically dehydrated. An IV is started and a fluid bolus is immediately administered. Laboratory work is completed.
History includes a recent snowmobile accident 2 days prior to his recent illness in which the patient hit a tree and the handlebars impacted the child’s abdomen at a speed of 45 mph. The child had been resting at home after this injury. He initially had bruising near his umbilicus, but otherwise seemed to recover without issue. He was eating normally. Mom is unsure of his bowel movements given his age and respect of privacy.
Emergency department laboratory work indicated an elevated white count of 18.4 with an elevated CRP of 13.4 mg/dL, evidence of acute kidney injury (AKI) in which his creatinine was elevated at 1.4 mg/dL, Hemoglobin of 9.2 g/dL and his AST and ALT were also elevated for his age. A CT was completed which indicated a bowel perforation with a 4 cm X 3.2 cm abscess. Blood cultures were drawn, and the patient was immediately started on IV empiric antibiotic therapy. The child required immediate surgical intervention for the bowel perforation by the pediatric general surgery team. Thereafter, the child was stabilized and sent to the pediatric ward for postoperative care and management.
This child suffered from acute severe sepsis in which if not properly diagnosed and treated could have resulted in long-term complications or additional sequela such as death. The child required immediate surgery, along with an abdominal washout, PICC line for long-term antibiotic therapy and temporary colostomy. A second surgery will be completed once his bowel has had time to rest and to reverse the diversional colostomy.
