CASE:

This is a 6 year old male who was referred from a rural ED for fever and possible pneumonia. He was well until three days ago when he was stung by a bee on his right forearm. He developed a moderate local reaction with edema and erythema. He saw his primary care physician the next day at which time he also complained of chest pain. Chest radiographs were obtained that day and they were negative. The next evening (yesterday), he developed fever and worsening of the swelling and erythema of his right forearm. He was seen at a rural ED. Cellulitis and a hypersensitivity reaction were considered. He was placed on oral cephalexin and acetaminophen with codeine. He took two doses of cephalexin. He returned to the rural ED in the morning (today) because of abdominal pain. Chest radiographs were repeated. This was interpreted as showing a possible right lower lobe infiltrate. A CBC at that time showed: WBC 20.4, 67% segs and 18% bands.

Examination:

VS T38.5 (oral), P145, R44, BP 140/89, oxygen saturation 96% (room air). He was obese, crying, agitated, and uncooperative, making examination difficult. HEENT exam significant for slightly dry oral mucosa. Neck supple. Heart regular, tachycardic, without murmurs or gallops. Lungs coarse breath sounds with rhonchi in both bases. Abdominal guarding noted throughout with tenderness. Bowel sounds were hypoactive. His right arm was diffusely indurated and erythematous (difficult to distinguish cellulitis from hypersensitivity). He was given a fleets enema for suspected constipation. He passed large amounts of stool and seemed to be better in that he was less agitated and more cooperative. He was noted to be grunting at times. His abdomen was still tender. More blood studies were drawn. Radiographs of his chest and abdomen were obtained.

View CXR: PA view.

View CXR: Lateral view.