Visual Diagnosis: Respiratory Distress: A Great Masquerader

Catherine Kier; Rula Balluz; Vikash Modi; Latha Chandran

doi:10.1542/pir.32-10-e95

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Catherine Kier, MD*
Rula Balluz, MD*
Vikash Modi, MD^†
Latha Chandran, MD, MPH^§

^*Department of Pediatrics, Stony Brook University Medical Center, Stony Brook, NY.
^†Department of Otorhinolaryngology, Weill Cornell Medical College, New York, NY.
^§Office of the Dean, Stony Brook University School of Medicine, Stony Brook, NY.

Author Disclosure

Drs Kier, Balluz, Modi, and Chandran have disclosed no financial relationships relevant to this case. This commentary does contain a discussion of an unapproved/investigative use of a commercial product/device

Case 1 Presentation: Persistent Pulmonary Infiltrate

A 2-year-old boy has had several hospitalizations for right upper lobe (RUL) pneumonia associated with reactive airway disease. During this episode, he presents with a low-grade fever, cough, wheezing, and an oxygen saturation of 90% to 91% on room air. His temperature is 37.9°C (axillary), respiratory rate is 38 breaths/min, heart rate is 129 beats/min, and blood pressure is 92/60 mm Hg. Posteroanterior and lateral radiographic views of the chest obtained in the emergency department (ED) show a density in the RUL area (Fig. 1). On admission, he is given intravenous hydration, intravenous ceftriaxone, albuterol nebulizer treatments, oral corticosteroids, and supplemental oxygen.

Figure 1.

Chest radiograph taken on day 1 of admission showing a right upper lobe density.

Within 24 hours, the patient responds with improved work of breathing and resolution of hypoxia and fever. A follow-up radiograph shows persistence of the right upper lobe infiltrate. Initial and repeat blood cultures are negative. The patient is discharged after 6 days on a 10-day course of oral antibiotics, with a 2-week follow-up evaluation scheduled.

Two weeks later, the patient has improved further and does not have fever, tachypnea, or respiratory distress. Due to the recurrent nature of the RUL infiltrate, a chest radiograph is repeated to document radiologic resolution of the pneumonia. Surprisingly, the chest radiograph shows a persistent RUL density and mediastinal shift to the right (Fig. 2). Subsequent computed tomography (CT) scan of the chest reveals the underlying diagnosis.

Figure 2.

Chest radiograph taken 2 weeks later showing persistent right upper lobe density, with right mediastinal and tracheal shift.