A 5-Year-Old Girl With Fever and Cough

Nicholas J. Bennett, MB BChir, PhD

Disclosures

October 11, 2016

Discussion

CT revealed a large (7 × 7 × 6 cm), multiloculated cystic lesion in the upper lobe of the right lung, with what appeared to be an air-fluid level. This is consistent with a lung abscess. The girl was admitted to the hospital for intravenous antibiotics and surgical consultation. Laboratory tests obtained on admission showed a white blood cell count of 19 × 103 cells/µL, with a differential of 70% neutrophils, 22% lymphocytes, and 8% monocytes. Upon admission, her hemoglobin level was 9.3 g/dL and platelet count was 67.2 × 103 cells/µL. Her erythrocyte sedimentation rate was 100 mm/h.

The patient underwent video-assisted thoracoscopic surgery (VATS), and green, purulent fluid was drained from the cyst. During the VATS, she had an episode of bradycardia and hypotension associated with an air leak and possible tension pneumothorax, which resolved when the air leak was sealed. She was admitted to the pediatric intensive care unit postoperatively. Intravenous piperacillin/tazobactam and vancomycin were started for broad antimicrobial coverage pending culture results. A blood transfusion was given for moderate anemia (hemoglobin level, 6 g/dL).

On day 2 of hospitalization, the fluid from the patient's abscess grew Streptococcus pneumoniae that was resistant to penicillin, cefotaxime, erythromycin, trimethoprim/sulfamethoxazole, and ceftriaxone and was sensitive to vancomycin, levofloxacin, and linezolid. She was switched to linezolid after difficulty obtaining therapeutic levels of vancomycin.

Biphasic febrile respiratory illness should always raise the possibility of a secondary bacterial infection after a viral illness. Although not documented, this young girl's initial illness was consistent with influenza, which is associated with a high rate of secondary invasive staphylococcal and streptococcal infection. The impressive abscess and subsequent hospital course were unexpected given the benign physical examination findings, and highlight the usefulness of imaging studies in the appropriate context.

The patient's condition may have been diagnosed at her second visit with a prolonged viral illness, but the period of wellness was a clue to this being a secondary infection. The normal pulse oximetry findings and respiratory rate were consistent with a normal ventilation/perfusion ratio, because her lung parenchyma was relatively spared around the abscess itself.

The most surprising factor was the lack of lung findings on examination. An area of decreased breath sounds is the typical finding in pediatric pneumonia, but in this case, the clinician can hypothesize that the cyst acted to transmit the surrounding breath sounds effectively.

Studies looking at predictive factors for positive chest radiograph findings have identified several clinical signs that correlate with abnormal radiographic findings. Fever was found to be a sensitive predictor of radiographic abnormalities among children for whom chest radiographs were ordered in one study, although fever is of course not a specific finding for pneumonia. Tachypnea seems to be a helpful indicator, as is decreased air entry on auscultation, but other findings are less predictive of radiographic abnormalities.[1]

The Ghon focus is a radiographic finding seen in primary pulmonary TB. First described by Anton Ghon, it is a calcified inflammatory lesion that is classically seen toward the periphery of the lung fields, especially in the upper lobes. Tuberculous disease may cause lung destruction and cyst formation but typically does not cause fluid-filled lesions (as seen in this patient). In addition, she had no risk factors for acquiring TB, such as family contacts in the prison or healthcare systems, and no recent immigration from or travel to areas of high TB endemicity.

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