Case 3: Abnormal Eye Movements and Congestion in a 3-month-old Boy

1. Joanna Wigfield, DO* 2. Aadil Kakajiwala, MD* 3. Michael L. Forbes, MD* 4. Prasad Bodas, MD* 1. *Akron Children's Hospital, Akron, OH. A 3-month-old Amish boy presents to the emergency department with recurrent nasal congestion since birth. He has had no fevers, cough, or difficulty breathing. He was born at term without complications. His parents report that his growth and development are overall appropriate, but his mother expresses concern about abnormal eye movements. The father has moderate deficiency of Factor IX. Physical examination results include: temperature 98.4°F (36.9°C), heart rate 140 beats/min, respiratory rate 40 breaths/min, and pulse oximetry 99% in room air. His length is 59.7 cm (7th percentile), weight is 6.1 kg (22nd percentile), and head circumference is 40.6 cm (15th percentile). He has minimally reactive and dilated pupils, with consistent downward gaze and disconjugate ocular movements. Anterior fontanelle is soft and flat. He has prominent upper airway sounds. A nasal catheter cannot be passed through the right nare. Lungs are …