Radiological Case of the Month FREE

AN 11-MONTH-OLD, previously healthy boy, was admitted after a 3-day history of daily fevers up to 38.8°C. The patient was otherwise active and playful and had no history of rhinorrhea, cough, vomiting, or diarrhea. On admission, his temperature was 38.8°C, but he was alert, well nourished, and in no respiratory distress. His chest was clear on auscultation, and the findings from the remainder of his examination showed no abnormalities. The white blood cell count was 20.7×10⁹/L, with 0.61 segments, 0.06 band forms, and 0.29 lymphocytes, and 0.04 basophils. The hemoglobin level was 98 g/L (reference range, 140-175 g/L); hematocrit 0.28 (reference range, 0.41-0.50); and a platelet count of 0.001×10⁹/L. A chest radiograph done on admission, with the patient in the right lateral decubitus position, is shown (Figure 1). Blood culture showed no growth of organisms after 72 hours, and purified protein derivative for tuberculin was nonreactive with a positive control.

The patient was treated with intravenous cefuroxime, but continued to have fevers, even though the antibiotics were changed to a combination of nafcillin sodium and cefotaxime sodium. On day 6, he developed tachypnea and a fever of 40°C. Another chest radiographic scan (Figure 2) and a thoracentesis was performed, which removed 100 mL of cloudy, bloody fluid. Fluid analysis showed protein at 43 g/L (reference range, 60-80 g/L); lactate dehydrogenase, 3133 U/L; and a pH of 7.1. Gram stain was negative, and culture showed no growth of organisms after 72 hours. Acid-fast bacilli stain and culture were also negative for organisms.

The patient underwent a video-assisted minithoracotomy, lung decortication, and pleural drainage. Findings are shown in Figure 3. After surgery, he was afebrile while he was being treated with intravenous antibiotics and was given oral antibiotics when he was discharged from the hospital 10 days later. Evaluation results for immunodeficiency status was negative, but a swallowing study showed significant aspiration of formula when mixed with contrast material given by bottle.