A 6-WEEK-OLD INFANT, the product of a full-term, uncomplicated pregnancy and the first child of unrelated parents, had a history of irritability and poor feeding. The mother reported that the infant had been irritable and crying for a few days, especially during feeding, with episodes of pallor and breathlessness.
On physical examination, the infant appeared well nourished and had no dysmorphic features. She was irritable and cried constantly. Her respirations were 50/min with intermittent grunting; pulse, 160/min; and temperature, 37°C. Oxygen saturation was 97% by pulse oximetry. Her skin was pale and extremities cool. On chest examination there were mild intercostal retractions, clear lung fields to auscultation, and a grade 3/6 systolic murmur along the left sternal border with a loud second heart sound and a gallop rhythm. The abdomen was soft with the liver edge palpable 4 cm below the right costal margin. Pulse and blood pressure were equal in all 4 extremities. A chest x-ray film (Figure 1) and electrocardiogram (Figure 2) were obtained.
Narchi H, Santos M, Tunnessen WW. Picture of the Month. Arch Pediatr Adolesc Med. 1999;153(9):997. doi:10.1001/archpedi.153.9.997