Visual Diagnosis: A 7-week-old Boy with Tachypnea and Poor Feeding

Zainul S. Hasanali; Christopher O’Hara

doi:10.1542/pir.2016-00003

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Zainul S. Hasanali, PhD*
Christopher O’Hara, MD*

^*Division of Pediatric Hospital Medicine, Penn State Hershey Medical Center, Hershey, PA

AUTHOR DISCLOSURE
Drs Hasanali and O’Hara have disclosed no financial relationships relevant to this article. This commentary does contain a discussion of an unapproved/investigative use of a commercial product/device.

Presentation

A 7-week-old boy presents to the emergency department with a 2- to 3-day history of worsening tachypnea, poor feeding, and decreased urine output. His mother states that he has been hungry and eager to eat but only takes 1 oz of formula that he then vomits. The emesis is nonbloody, nonbilious, and looks like undigested formula. He was born at 34 weeks’ gestation and has had a baseline cough and tachypnea since birth, although his cough has worsened as his tachypnea has increased. His caregivers deny fevers, cyanosis, diaphoresis or tiring with feedings, rhinorrhea, nasal congestion, diarrhea, constipation, or increased fussiness. Upon physical examination, he is afebrile. He has a II/VI systolic ejection murmur due to mild-to-moderate pulmonary stenosis. His breath sounds are diminished, and he is tachypneic, with subcostal retractions and the need for 0.5 L/min oxygen. Chest radiograph (Fig) and computed tomography (CT) scan both show right lower lobe consolidation with right-greater-than-left pleural effusions. A respiratory panel documents parainfluenza virus type 1 reactivity. Over the span of several days, the infant tolerates feedings through a nasojejunal tube and completes a 7-day course of antibiotics but is unable to be weaned off of oxygen without desaturating to 80%. His respiratory rate returns to his previous baseline on hospital day 2, but he is still tachypneic. Pleurocentesis reveals the cause of the oxygen requirement, poor feeding, and tachypnea.

Figure.

Chest radiograph showing bilateral pleural effusions.

Diagnosis

After multiple radiographs demonstrated persistent effusions, clinicians performed pleurocentesis of the right chest cavity. The cloudy fluid was sent for analysis. It contained 18,000 nucleated cells/μL, more than 90% of which were lymphocytes. Triglyceride values were elevated …