Occult pneumonia in a child

Background

Pneumonia is a common illness and the diagnosis is generally based on clinical signs and symptoms. 1 Children present with fever and respiratory signs such as tachypnoea, breathlessness, cough, wheeze and chest pain. However, symptoms can be non-specific and include headache and abdominal pain. Routine use of a chest radiograph is not recommended since it does not favour the clinical outcome of pneumonia. 2 Moreover, guidelines advise against routinely performing chest radiographs in febrile children in the absence of respiratory symptoms. 1 This case highlights the importance of considering occult pneumonia in the differential diagnosis in febrile children without respiratory symptoms.

Case presentation

A 10-year-old boy was admitted to the hospital with an 11-day history of fever, vomiting and diarrhoea. He was previously healthy and fully vaccinated. On physical examination, we saw a moderately ill boy with a rectal temperature of 40.8°C. His respiratory rate was normal (20/min), and oxygen saturation in room air was greater than 95%. Auscultation and percussion of the lungs were normal, and examination of the abdomen and skin was unremarkable. Blood analysis showed a leucocyte count of 10.3x10⁹ /l with 8.3x10⁹ /l neutrophils and a C reactive protein of 139 mg/l. Because of fever without an apparent source, further diagnostic tests were ordered. A chest radiograph was performed and it demonstrated a rounded density projecting dorsally in the right upper lobe with a fluid level cranially. The most likely diagnosis is abscess formation in a lobar pneumonia ( figures 1 and 2 ), and empiric treatment with intravenous amoxicillin/clavulanic acid was commenced.

Outcome and follow-up

Based...