An 8 year old boy of Indian origin presented to his local hospital with a three week history of worsening respiratory symptoms. He was previously fit and well, had not been febrile, and his only medical history was a recent visit to his general practitioner because he “found it hard to catch his breath at night.” He was becoming increasingly scared of going to bed at night and his mother was also concerned about some bumps that she could feel on his scalp while stroking his head in bed.

A chest radiograph was performed (fig 1⇓).

The decision was made to drain in theatre under general anaesthetic what was assumed to be a right sided pleural effusion. Upon induction, the patient became apnoeic and was difficult to ventilate. He then became asystolic and cardiopulmonary resuscitation was commenced. Emergency bronchoscopy was required to establish an airway and cardiac output was restored after 20 minutes of cardiopulmonary resuscitation.

The patient was transferred to his regional paediatric intensive care unit for further investigation and management.

Blood tests were undertaken and his initial blood results were as follows (normal ranges in brackets):

• Haemoglobin 117 g/l (115-155)

• White blood cell count 6.35×10⁹/l (6.0-18.0)

• Platelet count 125×10⁹/l (150-450)

• Lactate dehydrogenase 3406 U/l (432-700)

• Uric acid 1170 μmol/l (135-320)

• Urea 8.9 mmol/l (2.5-6.0)

• Creatinine 95 μmol/l (35-80)

• Calcium 2.12 mmol/l (2.19-2.66)

• Magnesium 0.83 mmol/l (0.7-0.95)

• Phosphate 4.34 mmol/l (1.1-1.75)

• Albumin 25 g/l (37-56)

• Alkaline phosphatase 50 U/l (200-495)

• C reactive protein 80 …