Respiratory Distress and Abdominal Pain: Are They Linked?

1University of Michigan, Ann Arbor, MI
2University of Michigan, Ann Arbor, MI
3University of Michigan Medical School, Ann Arbor, MI
4University of Michigan, Ann Arbor, MI

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 314

Case Presentation:

A 21‐month‐old previously healthy girl presented with 5 days of cough, rhinorrhea, and fever. One day prior to presentation, she also developed emesis and diarrhea, followed by a decrease in oral intake and urine output. On presentation, she had a temperature of 38.7°C, a respiratory rate of 60 breaths/minute, a pulse of 160 beats/minute, and an oxygen saturations of 99%–100% on 10 L/minute via a nonrebreather mask. She was in moderate respiratory distress with intercostal and subcostal retractions, crackles, and coarse breath sounds bilaterally. She had dry mucous membranes with a delayed capillary refill and abdominal distension with significant right upper quadrant tenderness and guarding. Labs were remarkable for a blood glucose of 40 mg/dL, a venous pH of 7.15, a lactate of 8.2 mmol/L, an AST of 789 IU/L and an ALT of 301 IU/L An abdominal ultrasound showed gallbladder wall thickening without evidence of biliary dilatation or cholelithiasis. She was admitted with an initial diagnosis of cholecystitis and given piperacillin/tazobactam. Repeat abdominal ultrasound the following morning was unremarkable with interval resolution of the gallbladder findings. She was noted to have worsening transaminitis with coagulopathy (INR of 2.3) and was given phytonadione. Her transaminitis continued to peak for 32 hours. Further laboratory investigation revealed a normal ammonia level, a urinalysis negative for ketones, and a normalized lactate making a metabolic etiology less likely. Evaluation for ingestion, given potential access to multiple high‐risk medications including antiepileptics, was negative. Her viral studies returned positive for respiratory syncytial virus (RSV). With the assistance of a pediatric gastroenterology consult, RSV‐induced hepatitis was diagnosed. A liver biopsy was not performed given her improved clinical status along with the resolution of her transaminitis and coagulopathy.


RSV is a common cause of pediatric hospitalization, with most children experiencing an infection by 2 years of age. RSV can cause infection in the lower respiratory tract resulting in bronchiolitis. Systemic complications are rare. Extrapulmonary manifestations of RSV can occur in severe cases, particularly in children requiring extensive respiratory support including mechanical ventilation. These systemic symptoms are thought to arise from inflammatory triggers rather than the viral infection itself; however, RSV has been isolated from liver and cardiac tissue. It is well known that hepatitis is seen with several viral infections, but it is not commonly associated with RSV. Despite its rarity, this case demonstrates that RSV‐induced hepatitis should be considered in the differential for hepatitis in the setting of respiratory tract symptoms


RSV induced hepatitis should be considered in the differential diagnosis of abdominal pain in patients with upper respiratory tract symptoms consistent with bronchiolitis.

To cite this abstract:

Ney G, Lesage‐Horton H, Northway C, Stojan J. Respiratory Distress and Abdominal Pain: Are They Linked?. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 314. Journal of Hospital Medicine. 2013; 8 (suppl 2). Accessed January 22, 2020.

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