[dr.Ira]

Думаю, что быстрей всех эту задачу решат анестезиологи-реаниматологи.

A 10-month-old boy is brought to a community ED because he started vomiting last night and “has not and “has not been the same since.” This morning, his mother noted that he was breathing fast. He had a low-grade fever this morning, but none prior. He has had no weight loss or diarrhea and
has not been exposed to illness. Intravenous access is obtained, and the child is intubated because of respiratory distress and is flown to a children’s
hospital.On examination, the boy’s temperaturei s 37.6°F (99.7°C), heart rate is 158 beats/min, and blood pressure is 90/44 mm Hg. His respiratory rate had been 60 breaths/min prior to being intubated.He is a plump, robust infant who is sedated on the ventilator. Faint crackles are audible in his lungs. His skin is warm and well perfused.The rest of his findings are normal.
Laboratory findings include glucose,
176 mg/dL (9.8 mmol/L);
sodium 140 mEq/L (140 mmol/L);
potassium, 3.1 mEq/L (3.1 mmol/);
chloride, 115 mEq/L (115 mmol/L);
bicarbonate, 10 mEq/L (10 mmol/L);
calculated anion gap, 15 mEq/L(15 mmol/L);
BUN, 5 mg/dL (1.8 mmol/L);
creatinine,0.3 mg/dL (26.5 mcmol/L).
A blood gas reveals a pHof 7.29 with
a bicarbonate level of 14 mEq/L(14 mmol/L),a carbon dioxide concentration
of 14 torr, and a base deficit
of
18.6 mEq/L.
His WBC count is
14.9103/mcL (14.9109/L) with
71% neutrophils and 2% bands.
He is started on vasoactive medication for hypotension and treated for sepsis, but the clinicians are concerned that he has had minimal fever and no rash, and the laboratory findings are puzzling.

An additional blood test reveals the diagnosis.