Hot Seat #81: 15 mo M with URI symptoms and leukocytosis
Posted on: September 26, 2016, by : Jaclyn Kline
Jaclyn Kline, Children’s National Medical Center
with Pavan Zaveri, Children’s National Medical Center
The Case
A 15 month old boy presents to the ED with cough, congestion and subjective fever for the past 2 days. His mother states he has seemed more tired, but is eating and drinking normally, and making a normal number of wet diapers.
He was seen earlier that day by his pediatrician, and was found to have a fever to 102°F. The PCP checked a CBC which showed WBC of 21,000, so he referred the child and his mother to the ED for further evaluation.
ROS: Denies vomiting, diarrhea, decreased PO, decreased urine output.
PMH: Born at 39 weeks by C-Section for maternal pre-eclampsia, immunizations up to date, no other medical problems
PE:
VS T 38.5, HR 128, RR 32, BP 103/79, S 99% on room air
General – Child playful, smiling at examiner
HEENT – oral mucosa moist, no pharyngeal erythema, exudate or petechiae, TMs clear bilaterally
Neck – supple, no lymphadenopathy
CV – regular rate and rhythm, no murmur, no gallop, 2+ dorsalis pedis pulses bilaterally
Resp – no retractions, no crackles, no wheezes, symmetric chest expansion, decreased air entry on right
GI – abdomen soft, nontender, not distended, normoactive bowel sounds throughout, no hepatosplenomegaly or masses
GU – circumcised male, testes descended bilaterally
You give a dose of ibuprofen, and the fever resolves.
Question 1:
You decide to obtain a chest x-ray:
You also repeat the CBC, which shows:
WBC-20.2 (differential pending), Hgb-12, Hct-32.8, Plt-198
He remains afebrile with stable VS and no signs of respiratory distress or hypoxia.
Question 2:
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
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I think there is something wrong in the mediastinum — with the thoracic trachea demonstrating an abrupt curvature to the patient’s right. I think this is real, despite the slightly rotated view. Off the top of my head, in the differential are anterior mediastinal masses (remember the terrible T’s!), TB (which might be one of those T’s?), and abnormal vascular rings/slings. I think chest CT is the way to go, at least initially. Depending on what that showed (or didn’t show!), maybe an ECHO would be warranted. Also, there is probably some air-space disease on the right c/w pneumonia, but I’d want to make sure this is secondary to a bronchial/mediastinal compression. CT would be most helpful with this latter question.
So, a 15 month old fever with high fever and overall reassuring picture with just decreased BS on right.
The options provided gave us a nice variety of options. Just to review, the older rule out SBI data had indicated this concept of an “occult pneumonia” defined as normal exam/sats with a WBC > 20K, which this patient fits except the focal findings that are present. What this was/is would be that when all infants were getting blood, urine, CXR and CSFs done for their fever evaluation as immunizations were developing, there were a number found with pneumonia on CXR despite no other findings, whose prevalence was increased when the WBC >20K. The most recent article on this concept I find is from 2007 (http://onlinelibrary.wiley.com/doi/10.1197/j.aem.2006.08.022/epdf) from a study at Boston Children’s I believe, finding “Occult pneumonia was found in 5.3% of patients with fever and no lower respiratory tractfindings, tachypnea, or respiratory distress.”
Anyhow, so getting the CXR was definitely my first step. The only other option I would have preferred in the dispo would be discussing with the radiologist about the findings on the CXR. The right side looks wonky and with the small image it’s hard to clearly say what’s what. And I’ll defer to Dewesh’s excellent differential above about what to be concerned about.
While a CT Chest can give us definite answers, it takes me back to fellowship when I had a patient with a “white-out” on the left so proceeded to CT to better define the likely empyema or the such, only to find out, we had just performed a radiation-expensive echo to find a huge heart filling most of the L hemithorax. You can only guess at the ultimate underlying disease this patient had…..
More tomorrow….