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A 2 year old with fever and cough

BMJ 2009; 339 doi: (Published 08 July 2009) Cite this as: BMJ 2009;339:b2150
  1. A Gupta, specialist registrar1,
  2. D S Urquhart, specialist registrar1,
  3. A Devaraj, specialist registrar2,
  4. I M Balfour-Lynn, consultant1
  1. 1Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London SW3 6NP
  2. 2Department of Radiology, Royal Brompton Hospital, London SW3 6NP
  1. atulgupta{at}

    A previously well, fully immunised 2 year old boy presented to his general practitioner with a five day history of cough and fever. He was initially prescribed oral amoxicillin, which did not improve his condition. On examination, the patient was febrile, tachycardic, and tachypnoeic; he was also in respiratory distress and had markedly reduced air entry on the right side of the chest with stony dullness on percussion. Cardiovascular and abdominal examinations were unremarkable. Inflammatory markers were raised (white cell count 28×109/l−1 and C reactive protein 340 mg/l−1). A chest radiograph was taken (fig 1).

    Chest radiograph (posteroanterior view)


    • 1 What abnormalities are shown in the chest radiograph?

    • 2 What further investigations are indicated in this case?

    • 3 What is the likely diagnosis?

    • 4 What is the most likely pathogen?

    • 5 What specific treatment plan would be most suitable for this patient?


    Short answers

    • 1 The chest radiograph shows near complete opacification of the right hemithorax, with preservation of lung volumes and absence of air bronchograms. These signs are in keeping with a large right pleural effusion with no mediastinal shift. The patient had no significant secondary scoliosis.

    • 2 Ultrasound scan of the chest, blood culture, and a full blood count should all be performed. In addition, electrolytes, serum albumin, and C reactive protein concentrations should be measured.

    • 3 This patient has a parapneumonic effusion/empyema (thick fluid with loculations/overt pus).

    • 4 Streptococcus pneumoniae is the most common isolated cause for a parapneumonic effusion in developed countries.

    • 5 The specific treatment a child currently receives is dependent on unit expertise and local practice. Approaches include:

    • Chest drain with or without fibrinolytics—the preferred initial approach for most paediatric centres in the United Kingdom

    • Mini-thoracotomy—preferred by only a few centres in the United Kingdom

    • Video assisted thoracoscopic surgery with drain …

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