A 5-Year-Old Girl With High Fever and Nonproductive Cough

Nicholas J. Bennett, MB BChir, PhD

Disclosures

May 08, 2020

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A normally well 5-year-old girl presents with a 2- to 3-week history of fever, cough, and occasional posttussive emesis. She was seen one week ago and was diagnosed with a viral upper respiratory infection after an unremarkable physical examination. Testing for respiratory viral infections was not performed at that time, and symptomatic care was recommended.

After that visit, the patient improved, and 5 days ago, she was afebrile and well enough to return to school. Two days ago, however, the fever and cough returned worse than before. She is now experiencing pain in her right shoulder. Her mother reports that she "just isn't herself" and has brought her back for reevaluation.

The patient had one episode of vomiting with coughing 2 days ago, with no diarrhea. She has had decreased appetite and activity when febrile. Her fevers have been as high as 104°F (40°C) at home. Her cough is nonproductive. Her mother has given her acetaminophen two or three times to control the fever, but otherwise she takes no medications.

The patient is a normally healthy child with no significant medical history, and her immunizations are up to date, including a seasonal influenza vaccine last month. She has no siblings and lives with her parents, who do not smoke. No known contact with people exposed to tuberculosis (TB) and no significant travel history are noted.

Physical Examination and Workup

Upon physical examination, the patient is a slightly ill-appearing young girl in no acute distress. Her temperature is 102.6°F (39.2°C), respiratory rate is 28 breaths/min, heart rate is 152 beats/min, and blood pressure is 103/62 mm Hg. The pulse oximetry reading is 98% while she is breathing room air. Her lungs sound clear bilaterally, with normal percussion and no areas of decreased breath sounds, rales, or wheezing.

The patient has normal heart sounds without any murmur, a soft abdomen without organomegaly, mild cervical adenopathy, and no rashes. Her extremities are warm and well-perfused, with a capillary refill time of 2 seconds. No other lymph nodes are palpable in her axillae or groin.

Because of the recurrent fever and cough, a chest radiograph is obtained (Figure 1), which reveals a right upper-lobe opacification and an area of increased lucency. CT of the chest clarifies the diagnosis (Figures 2 and 3).

Figure 1.

Figure 2.

Figure 3.

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