A 2-year-old boy with a history of delayed immunizations who has received all recommended vaccinations except for varicella presents to the emergency department with progressive bilateral lower leg and facial edema and 5 days of upper respiratory symptoms, including cough, congestion, and rhinorrhea. He is evaluated in the critical care area for treatment of hypoxemia with oxygen saturations in the 70s on room air, requires 18 L/min oxygen via high-flow nasal cannula with a fraction of inspired oxygen of 100%, and is subsequently admitted to the PICU.

On physical examination, he is in the 12th percentile for weight, down from the 57th percentile at birth; poor weight gain is most notable during the 6 months before this admission. He has increased work of breathing with subcostal retractions and suprasternal tugging, diffuse crackles bilaterally, and end expiratory wheezing in all lung fields. The patient’s abdomen is soft and nontender but distended,...

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