Visual Diagnosis: An Adolescent Girl Who Has Fever, Cough, and Chronic Chest Pain

Presentation

A 15-year-old girl presents to the emergency department with the complaint of 4 days of fever to 101°F (38.3°C) and worsening cough. The cough is nonproductive. For the past 10 months, she has had persistent, gradually increasing right-sided chest pain that worsens with deep inspiration. She has noted enlargement of her right chest for several months. Review of systems reveals increased fatigue and difficulty sleeping, but no weight loss, vomiting, diarrhea, rash, pain on urination, night sweats, trauma, bruising, or enlarged lymph nodes. Past medical history is significant for two episodes of pneumonia as a young child. She is receiving no medications. Approximately 10 months ago, she and her immediate family immigrated to the United States from Kazakhstan, traveling through Moscow and Florida before settling in rural southern Washington. Immunizations are up to date for United States immigration, and purified protein derivative testing for tuberculosis was negative. The family history is negative for respiratory disease and childhood cancers. The social history is significant for being a native of Kazakhstan and living in a rural farming community where she had been exposed to sheep, cattle, and chickens. Her father is a dog breeder. She has had no known contact with sick individuals or anyone who has tuberculosis. She does not smoke.

Physical examination reveals an oral temperature of 101.4°F (38.6°C), respiratory rate of 45 breaths/min, heart rate of 96 beats/min, blood pressure of 106/76 mm Hg, and an oxygen saturation of 98% in room air. She is uncomfortable and demonstrates minimal right-sided chest retractions and splinting toward the right side (Fig. 1⇓). Expansion of her right chest is visibly larger than her left, but both sides appear to move symmetrically with respirations. Auscultation reveals …