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

Physical Examination and Workup

Upon admission to the PICU, the boy is noted to have mild to moderate respiratory distress. Upon physical examination, he has an absence of breath sounds on the left side and diminished breath sounds with faint crackles on the right side. He is tachypneic, with a respiratory rate > 30 breaths/min. He is also tachycardic, with a heart rate > 120 beats/min. His physical examination findings are remarkable for scattered café au lait spots, conjunctival erythema, and distended veins on the neck. No lymphadenopathy or hepatosplenomegaly is noted. A chest radiograph reveals a large left pleural effusion with mediastinal shift to the right (Figure 2).

Figure 2.

A complete blood cell count (CBC) reveals a white blood cell (WBC) count of 5.7 x 103/mL, with normal WBC differential results. His hemoglobin level is 12.1 g/dL. His platelet count is 484,000/mL. His C-reactive protein level is 3.6 mg/L (reference range, < 5 mg/L). His erythrocyte sedimentation rate is elevated at 50 mm/hour (reference range, < 13 mm/hour).

A chest tube is placed in the patient for diagnostic purposes and to alleviate his symptoms. The pleural fluid is submitted for cell count and cytologic examination and reveals malignant cells. A subsequent chest CT scan reveals a large anterior mediastinal mass measuring 11.4 x 8 x 14 cm, extending to the left hemidiaphragm/chest wall and inferiorly into the retroperitoneum, with secondary mediastinal shift to the right (Figure 3).

Figure 3.


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