A boy age 3 years and 4 months was brought to the emergency department at 6:40 a.m. with complaints of cold symptoms, including congestion, runny nose, and a fever for two days. His past medical history included typical childhood illnesses, and his immunizations were up-to-date.

Vital signs were temperature 103.6ºF, heart rate (HR) 156, and respiratory rate (RR) 40, and he weighed 14.6 kg. Other than nasal congestion, his exam was normal. It was documented that he was alert, making good eye contact, and cooperative. His heart, lung, abdomen, extremity, and neurological examinations were all normal. Notably absent were meningismus, Kernig’s, and Brudzinski’s signs.

He was given an antipyretic and observed, during which time his temperature decreased to 101.4ºF and then 98.9ºF. He remained awake, alert, and appropriate. He was diagnosed with an upper respiratory infection, and his parents were told to follow up with his primary care physician (PCP) in one to two days or return to the emergency department if he became worse.

That afternoon, he was seen by his PCP for persistent fever and cough. His exam was unchanged, and symptomatic treatment was continued.

The next day at 7:10 a.m., he was brought back to the emergency department with complaints of rapid breathing and weakness. His history included fever, cough, and vomiting six times. In addition, his shortness of breath was reported to be increasing. Sore throat and chest and abdominal pain were denied.

Vital signs were temperature 100.8ºF, HR 155, RR 38, blood pressure 124/91, and oxygen saturation of 99 to 100 percent on room air. He weighed 14 kg. He again made good eye contact, and other than the nasal congestion, his exam was unremarkable. Specifically, he had moist mucous membranes, no rash, and no focal neurological or meningeal signs, and he was consolable.

At 7:30 a.m., he was given trimethobenzamide for nausea and an oral fluid challenge. At 8:30 a.m., a point-of-care glucose test was 97. At 9:41 a.m., a chest X-ray and urinalysis were obtained, and the child was noted to have difficulty bearing weight.

At 10 a.m., an IV was started, and labs were drawn. The boy’s urine was positive for glucose, protein, and ketones. His hemoglobin was 14.2, and the white blood cell count was 0.6. The decision was made to transfer him to a hospital with a pediatric intensive care unit (PICU), and he received ceftriaxone and a 300 ml (20 mL/kg) IV fluid bolus. A lumbar puncture (LP) was performed, yielding cloudy fluid, which later grew Streptococcus pneumoniae.

At 11:30 a.m., the patient was placed in an ambulance. His most recent vital signs were temperature 101.4ºF, HR 138, and RR 54. Following the 10-minute transfer, as he was being wheeled to the PICU, he arrested and was resuscitated. However, he died later that day. A lawsuit was subsequently filed, and the plaintiffs were awarded more than $1 million as a settlement.