An 11 year old boy with chest pain and fever
A previously well 11 year old boy was transferred to a regional hospital by his local doctor after being given an empirical dose of intramuscular ceftriaxone (25 mg/kg) because of a 24 hour history of fever (40°C), vomiting, headache, neck pain, and rash.
On arrival the patient was alert, afebrile, and seemed to be haemodynamically stable, with a heart rate of 60 beats/min, blood pressure 120/70 mm Hg, respiratory rate 18 breaths/min, and a Glasgow coma score of 14. He had pronounced neck stiffness and a widespread non-blanching petechial rash but no focal neurological signs, and examination of his precordium and lung fields was normal. A blood culture was taken, and he was given a bolus of intravenous normal saline (20 ml/kg) plus cefotaxime (50 mg/kg), dexamethasone (0.15 mg/kg), and ondansetron (0.05 mg/kg).
Initial investigations showed a haemoglobin of 132 g/l (normal range 110-150), platelet count 288×109/l (150-400), and peripheral white blood cell count 34.7×109/l (6.0-17.0) (absolute neutrophil count 24.3×109/l; bands 6.9×109/l). Sodium was 141 mmol/l (135-145) and glucose was 5.3 mmol/l (3.0-5.4). C reactive protein was 143 mg/l (normal <8 mg/l) and international normalised ratio was 2.0 (0.8-1.2).
Within 90 minutes of arrival at the regional hospital, the patint's clinical condition deteriorated greatly, with a decreasing level of consciousness (Glasgow coma score 10), and he was subsequently intubated and ventilated. Transfer to the intensive care unit was arranged, and intravenous aciclovir (16 mg/kg eight hourly) was added. A computed tomography brain scan and electroencephalogram were normal. A lumbar puncture was deferred because of the abnormal coagulation profile, but dexamethasone (0.15 mg/kg intravenously every six hours) was continued for four days on the presumptive diagnosis of meningitis. Inotrope support was not needed, and he was extubated within 24 hours of arrival.
On day three the patient was discharged from the intensive care unit. Aciclovir was stopped, and ceftriaxone (50 mg/kg intravenously every 12 hours) was continued after polymerase chain reaction (PCR) of whole blood detected Neisseria meningitidis
serogroup B DNA. Blood cultures were negative.
On the fifth day the patient had pleuritic retrosternal chest pain. There was no evidence of respiratory or haemodynamic compromise, and chest radiography and electrocardiography were normal. A repeat C reactive protein test showed a concentration of 34 mg/l, and the peripheral white blood cell count was 18×109/l.
On day six the patient had a recrudescence of his fever (38.5°C), and a persistent tachycardia (110-115/min) was noted. Clinical examination did not detect a source of his fever and he remained clinically stable. Nasopharyngeal aspirate, urine, and repeat blood cultures were negative. On day seven, C reactive protein was 167 mg/l, but the patient's peripheral white cell count was unchanged. Repeat chest radiography was performed on day eight (figure 1 below).
click image to enlarge
Chest radiograph of an 11 year old boy with fever, tachycardia, and chest pain, performed eight days after he was admitted to hospital
- 1 What two major abnormalities can be seen on the chest radiograph?
- 2 What is the most likely diagnosis?
- 3 What additional investigations can help confirm the diagnosis and what is the most appropriate management?
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