Endgames Picture Quiz

A teenager with a cough, fever, and poor appetite

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2821 (Published 26 April 2012) Cite this as: BMJ 2012;344:e2821
  1. Simona Turcu, respiratory fellow,
  2. Samatha Sonnappa, paediatric respiratory consultant
  1. 1Great Ormond Street Hospital, London WC1N 3JH, UK
  1. Correspondence to: S Turcu sfturcu{at}googlemail.com

A 14 year old girl presented to her local hospital with a three week history of progressively worsening cough, fever, and poor appetite, which had not responded to a week of oral antibiotics.

On examination she had a temperature of 38°C, was pale, not clubbed, and her oxygen saturations were 95% in air. There was a dull note on percussion, with reduced air entry on auscultation in the right upper zone of the chest, and no added sounds. The rest of the systemic examination was normal. At admission, blood tests showed haemoglobin 109 g/L (reference range 105-135), white blood cell count 12.7×106 cells/L (6.0-18), neutrophils 7.65×106 cells/L (2.0-6.0), C reactive protein 33 mg/L (0-5), erythrocyte sedimentation rate 116 mm in the first hour (10). Chest radiography and computed tomography were performed (figs 1 and 2). She was started on intravenous antibiotics and transferred to a tertiary centre for further management.

Fig 1 Chest radiograph

Fig 2 Chest computed tomogram

Questions

  • 1 What abnormality do the figures show and what is the most likely diagnosis?

  • 2 What other investigations would you perform and what differential diagnoses would you consider?

  • 3 What is the appropriate management?

  • 4 What are the possible complications of this condition?

Answers

1 What abnormality do the figures show and what is the most likely diagnosis?

Short answer

There is a round opacity with air fluid level in the right upper zone on the chest radiograph, which can be localised to the right upper lobe on the computed tomogram. The appearance suggests a lung abscess.

Long answer

A large circular mass can be seen in the right upper to mid zone on the chest radiograph with air fluid level within …

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