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A previously healthy, fully immunized 7-year-old boy was taken to the emergency department in Colorado in June for headache, photosensitivity, irritability, and fevers up to 38.5 C, all lasting 6 days. He had no relevant sick contacts, travel, food and/or water or animal and/or vector exposures.

On arrival, he was afebrile, alert, and appropriately interactive, with abdominal tenderness. Pertinent laboratory results included a peripheral white blood cell count of 12.7 103/lL and a sodium level of 125 mmol/L, with values for the remainder of electrolytes, transaminases, C-reactive protein, and lactate all within normal limits. A computed tomography scan of the abdomen and pelvis with contrast and a computed tomography scan of the head without contrast were unremarkable. He received an intravenous (IV) normal saline bolus of 20 mL/kg. Eighteen hours later, he was transferred to our PICU because of increasing irritability …