LAUSR

A 3-month-old, full-term, fully vaccinated male with a history of mild eczema presented in the winter to a local emergency department (ED) with 1 day of fever. Parents denied rhinorrhea, cough, abnormal breathing, vomiting, diarrhea, or rash. On presentation to the ED, he had normal vital signs for age, no signs of respiratory distress, and an unremarkable physical examination. He tested negative for influenza but was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on nasopharyngeal polymerase chain reaction (PCR) test. No other laboratory values were checked. As he was wellappearing and appeared adequately hydrated, he was sent home with supportive care and on quarantine protocol. On the following day, the family returned to a local children’s hospital ED for persistent fever and new rhinorrhea. Otherwise, no new symptoms were reported. The patient continued to feed well and had normal urine and stool output. Review of past medical history revealed a normal birth history with spontaneous vaginal delivery, routine newborn nursery care, and no complications during birth or pregnancy. Prior to admission, the patient was growing well and meeting developmental milestones appropriately for age. Family history was unremarkable. Parents reported that the patient lived at home with his mother, father, and 2 older siblings in a safe environment and did not attend daycare. His father had a presumed exposure to SARS-CoV-2 at his job site but tested negative in the week prior to patient’s illness. Mother also tested negative for SARS-CoV2. No one in the household had any symptoms and there were no other known sick contacts. In the ED, patient had persistent tachycardia to 170 to 230 beats per minute (BPM) despite fluid resuscitation with fever up to 105 °F. Oxygen saturation and respiratory status remained normal, and he was normotensive. His physical examination was notable for clear rhinorrhea, liver edge palpated 1⁄2 cm below right costal margin, and diffusely dry skin with patchy areas of hypopigmentation. Otherwise, physical examination was normal. Initial chest X-ray revealed bilateral perihilar opacities. Urinalysis was normal and urine culture was without growth. Initial complete blood count revealed normal white blood cell count and differential, mild normocytic anemia (hemoglobin 10.4 g/dL), and thrombocytopenia (platelet 56 k/μL). These cytopenias were attributed to viral suppression at the time. Complete metabolic panel showed a transaminitis with alanine aminotransferase of 142 IU/L and aspartate aminotransferase of 183 IU/L, as well as an elevated C-reactive protein to 5.5 mg/dL. Due to persistent fever and tachycardia in an infant, he was admitted to the general pediatrics floor for stabilization and further workup.