A 3-WEEK-OLD Hispanic boy was seen in the emergency department with a 2-day history of cough and rhinorrhea. This breast-fed infant was the 3.1-kg product of a 36-week gestation to a 20-year-old, Spanish-speaking primigravida woman. There had been exposure to a 16-year-old relative with an upper respiratory tract infection who was newly arrived from Mexico. In the emergency department the infant had a temperature of 38.2°C. Physical examination results were within normal limits and he was discharged.
On the third day, the infant was seen in the clinic with cough and rhinorrhea. Examination revealed bilateral rhonchi, occasional substernal retractions with grunting, and a 2/6 systolic ejection murmur. The infant was admitted and a chest x-ray film was interpreted as being within normal limits (Figure 1, A). The white blood cell count (WBC) was 24.7×109/L with 0.42 neutrophils and 0.45 lymphocytes. The infant appeared to be doing well and was discharged for 2 days.
The day after discharge (day 6 of illness), he was readmitted with lethargy, decreased oral intake, and diminished urine output. Tachycardia (180-200 beats/min), tachypnea, and temperature to 38.7°C were noted. Chest film showed a right upper lobe infiltrate (Figure 1, B). The WBC was 55.1×109/L with 0.48 neutrophils and 0.41 lymphocytes. Ampicillin, gentamicin, and erythromycin therapy was started. Paroxysms of coughing continued and oxygen by nasal cannula was administered. On day 7 of illness, the WBC was 65.6×109/L. Deterioration of his respiratory status necessitated endotracheal intubation. Chest film demonstrated an opaque right lung (Figure 1, C). An acute decrease in blood pressure to 27/13 mm Hg was unresponsive to boluses of albumin and epinephrine. Ventricular fibrillation developed and the child could not be resuscitated.
Autopsy findings included consolidation of the right lung and around the interlobar fissure on the left side (Figure 2). Combined heart-lung weight was 135 g. Clear serous pleural effusions were present (15 mL right lung, 5 mL left). The spleen weight was normal at 9.8 g. A sterile culture from the right lung showed no growth of bacterial or viral organisms.
A diffuse lobar pneumonia with alveoli filled by macrophages, proteinaceous material, and necrotic cell debris is seen in Figure 3. Multiple aggregates of gram-negative coccobacilli associated with the cilia of the respiratory epithelium were seen within bronchiole lumens.
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