5-Year-Old Boy With Acute Illness and Chest Pain

December 20, 2010

A 5-year-old boy with a history of allergies and asthma presents with fever (temperature of 40°C [104°F]), headache, cough, vomiting, and diffuse pain in and around the chest area on the right side. The patient has never traveled and has no sick contacts. A chest radiograph is obtained (A).

THE CASE: A 5-year-old boy with a history of allergies and asthma presents with fever (temperature of 40°C [104°F]), headache, cough, vomiting, and diffuse pain in and around the chest area on the right side. The patient has never traveled and has no sick contacts. A chest radiograph is obtained (A). Laboratory studies reveal a total serum white blood cell count of 25,300/μL, with atypical lymphocytes. A CT scan of the chest is also obtained (B).

Answer and Discussion on Next Page

What empiric treatment is most reasonable?

Answer: Ceftriaxone and azithromycin

The chest radiograph revealed an opacity within the right upper lobe that was probably related to pneumonia (A). The CT scan findings confirmed the presence of an opacity in the right upper lobe (B). Empiric treatment with intravenous ceftriaxone and azithromycin is a reasonable choice to cover for community-acquired organisms. Treatment with this regimen proved to be successful. A follow-up radiograph (C) obtained the next week revealed significant improvement of the right upper lobe opacity with mild residua.

Chemotherapy agents, such as cyclophosphamide, doxorubicin, and vincristine, may be required in cases of malignancy, which can present with a chest mass. The acute presentation and radiographic findings in this case pointed away from a cancer diagnosis.

Trimethoprim/sulfamethoxazole would be appropriate for a patient with underlying immunodeficiency and diffuse bilateral interstitial or alveolar findings on the chest radiograph, consistent with a diagnosis of Pneumocystis jiroveci (formerly Pneumocystis carinii) infection.

Isoniazid, rifampicin, ethambutol, and pyrazinamide are the agents used to treat active pulmonary tuberculosis (TB). A radiograph of a patient with TB may reveal infiltrates in the upper lung fields with mediastinal or hilar lymphadenopathy. Lack of exposure made this an unlikely diagnosis. The patient’s clinical status also significantly improved within a week of treatment with antibiotics.

Case and images courtesy of Jillian Rogers and Linda S. Nield, MD, of West Virginia University School of Medicine in Morgantown.