Case 52

Michael P. D'Alessandro, M.D.
Peer Review Status: Internally Peer Reviewed

Clinical History:
The patient was an 8 year old male who had a sore throat, cough and fever for 8 days. On presentation to the outside hospital he also had chest and abdominal pain, moderate respiratory distress, and fever to 99.7 degrees F. On the day of admission to the outside hospital, the patient had a chest film (not provided) which showed right upper lobe consolidation. He was placed on intravenous ampicillin with a slight improvement of his clinical symptoms, but a chest film the next day showed complete opacification of the right hemithorax and he was transferred to our institution.

Clinical Physical Exam:
Anxious child, in respiratory distress, febrile to 38.2 degrees C. The right chest was dull to percussion.

Clinical Labs:
Elevated white count

Clinical Differential Diagnosis:
Pneumonia

Imaging Findings:
Chest films from the 2nd hospital day showed an opacified right hemithorax with a cavity in the right upper lobe. Chest CT exam from the same day better delineated the extent of the disease.

Image 1

Images 2 and 3

Imaging Differential Diagnosis:
Lung abscess, pneumatocele

Operative Findings:
A thoracentesis was performed, and 200 cc of clear yellow fluid was aspirated that was shown in the laboratory to be an exudate. Under fluoroscopic guidance, 3 cc of pus was aspirated out of the cavity in the right upper lobe. A chest tube was placed into the right pleural space.

Pathological Findings:
The pleural fluid was sterile. Beta-hemolytic Group A Streptococci was cultured from the pus.

Final Diagnosis:
Pneumonia, Lung Abscess

Follow-up and Prognosis:
The patient had an uncomplicated post-operative course. The patient was switch to intravenous oxacillin and cefuroxime. A fistulogram performed during a repeat fluid drainage from the right upper lobe abscess cavity from the 6th hospital day showed the abscess cavity communicated with the bronchial tree. The patient became afebrile on the 6th hospital day. Follow-up films obtained several months later showed complete resolution of the disease.

Similar Cases:
Case 5, Case 28

References:

• Paediapedia
• WebPath
• WebPath
• WebPath
• WebPath
• WebPath
• WebPath
• WebPath

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