Monica Prieto MD, Children’s National Medical Center

The Case
A 16 yo old otherwise healthy male presented with 2d of chest pain and fever found to have an abnormal EKG and pulmonary nodules bilaterally on CXR. This case asked readers to determine how urgent and aggressive the patient’s workup and treatment should be given his relatively common complaints, but rarer findings on diagnostic workup.

Here’s How You Answered Our Questions:

EKG: biphasic T-wave in V3, and flipped T-waves in V4, V5.
CXR: nodular opacities in the RUL and LUL.
CBC shows WBC count 10.33, 76% PMNs, and an ESR/CRP of 50 and 21.69, respectively.

Discussion:
This was a great case that showed how en sync the attendings and fellows were. As our discussion proved as well, given this is a common complaint in any pediatric emergency department, there were red flags in the history that clued us into doing “more” than usual.

We all agreed that naturally many things occur at once in the ED including pain medication and diagnostic workup. Dr. Guse mentioned that given the pleuritic nature of chest pain and high fever, she would be inclined to obtain chest imaging. Dr. Champman also astutely mentioned not to forget the abdomen because this could easily be referred chest pain from intra-abdominal pathology.

Our group spent quite a bit of time discussing the use of radiation in obtaining a CT, but ultimately agreed this patient warranted such imaging. It was also brought up that the amount of radiation that our institutions CT scanner emits has much improved over the last decade. The roll for urgent imaging here would be to assess for an underlying primary malignancy that has resulted in seeding to the lungs as pulmonary nodules. But our group quickly admitted to the vast differential of nodules and preferred to obtain expertise from our ID colleagues prior to further imaging.

Denouement:
Cardiology was consulted and performed an echocardiogram which showed no evidence of myocardial dysfunction, thrombi, or endocarditis.
ID was also consulted and concerned for septic emboli to the lungs. The patient was started on IV antibiotics and admitted for further work-up and management.
The patient had a neck ultrasound with doppler to evaluate for Lemierre’s disease (thrombophlebitis of the internal jugular vein), which was negative.  His blood culture grew staphylococcus aureus, and he had a chest CT which was consistent with pulmonary emboli. He continued to complain of groin pain, so he had an MRI of her left groin which was consistent with an adductus magnus muscle tear and superimposed pyomyositis. He had a PICC placed and was discharged home to complete a 3 week course of IV antibiotics.

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