Visual Diagnosis: Tachypnea and Abdominal Distention in a 5-week-old Boy

1. Anjali Rai, MD* 2. Amanda Cantor, MD* 3. Debora L. Kogan-Liberman, MD*,† 1. *Department of Pediatrics, 2. †Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Hospital at Montefiore, Bronx, NY A 5-week-old boy born at 35 weeks’ gestation develops acute, worsening abdominal distention and tachypnea while recovering from surgical aortic switch, ventricular septal defect (VSD) repair, and placement of a pacemaker for a history of double-outlet right ventricle, transposition of the great arteries, and congenital heart block. His postoperative course is complicated by a wound infection requiring a wound vacuum, septic shock, and bilateral chylothorax that is drained with a chest tube. He is receiving supplemental oxygen support with a nasal cannula at 2 L/min (weaned from 6 L/min of high-flow nasal cannula just 2 days earlier). His blood pressure the past few days has been stable, and he is taking furosemide. For the past 2 days the infant has become increasingly tachypneic, with a respiratory rate of 80 to 90 breaths/min. For nutrition, he is enterally fed with a high–medium chain triglyceride (MCT)–containing formula owing to the postoperative chylothorax, and he is supplemented with parenteral nutrition. His nasal cannula flow is increased to 6 L/min. He has no fever, cyanosis, diaphoresis, feeding intolerance or tiring with feeds, rhinorrhea, nasal congestion, diarrhea, constipation, or increased fussiness. His anterior fontanelle is open and flat. He has a nasogastric tube in place. He is tachypneic, with deep subcostal retractions and head bobbing; however, no crackles, rhonchi, or stridor is noted. He has good aeration bilaterally. Normal S1 and S2 heart sounds are noted. A grade II/VI systolic ejection murmur is heard best at the left …