Pediatric Case Challenge: An 8-Year-Old Boy With Autism, Lupus, Fever, and Chest Pain

Agnes Reschke, MD; Liora Schultz, MD; Catherine Aftandilian, MD; Norman Lacayo, MD


May 03, 2023

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.


An 8-year-old boy presented to his pediatrician with congestion, cough, low-grade fever, and ear pain. His past medical history is significant for diagnoses of autism spectrum disorder and systemic lupus erythematosus (SLE). He routinely takes azathioprine, hydroxychloroquine, and prednisolone. He also received a course of azithromycin for acute otitis media. After completing his course of azithromycin with some improvement, his fever returned. He then went to an urgent care center. A chest radiograph revealed left-sided pneumonia (Figure 1).

Figure 1.

The patient was given one dose of ceftriaxone and discharged home, with instructions to follow up with his pediatrician. His pediatrician had him begin taking oral cefdinir the following day; however, that evening, he developed chest pain, orthopnea, and shortness of breath, for which he went to the emergency department.

He was admitted to the hospital for 4 days, during which time he received intravenous (IV) ceftriaxone and IV clindamycin. After his fever, chest pain, and difficulty breathing improved, he was discharged home receiving high-dose amoxicillin and clindamycin. The next day, his increased work of breathing returned, and he was readmitted to the hospital. Shortly after admission, he was transferred to the pediatric intensive care unit (PICU) for acute respiratory distress.


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