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Endgames Picture Quiz

An infant with respiratory distress

BMJ 2010; 340 doi: (Published 19 May 2010) Cite this as: BMJ 2010;340:c2155
  1. Johnny Canlas, paediatric specialty registrar 1,
  2. Anwar Ayubi, staff grade paediatrician2,
  3. Fatima Kagalwala, paediatric specialist registrar2,
  4. Raghavan Prasad, consultant paediatrician12,
  5. Jeewan Rawal, consultant paediatrician12
  1. 1Queen’s Hospital, Romford, Essex RM7 0AG
  2. 2King George Hospital, Goodmayes, Essex IG3 8YB
  1. Correspondence to: J Rawal jeewan.rawal{at}

    A 4 month old African girl presented to the accident and emergency department with a two day history of fever, cough, and poor feeding. She was born full term at a weight of 3000 g. She had no neonatal complications. She was exclusively breast fed and her mother had no history of serious illness. On examination, she had fever, tachypnoea, and tachycardia. Her oxygen saturation was 96% on air. Fine crepitations were heard at the bases of her lungs. A gallop rhythm was detected on cardiac auscultation. Her liver was 2 cm palpable. She had swollen but non-tender wrists. Her full blood count and liver function tests were normal except for an alkaline phosphatase of 942 U/l. Her calcium was 1.5 mmol/l and phosphate 2.16 mmol/l. Radiography of the chest and right wrist was performed (fig 1).

    Fig 1 Chest radiograph (left) and radiograph of the right wrist (right)

    • 1 What are the radiological findings?

    • 2 What additional investigations should be requested?

    • 3 What is the most likely diagnosis in this patient?

    • 4 How should the condition be treated?


    1 What are the radiological findings?

    Short answer

    The chest radiograph (fig 2) shows cardiomegaly and pulmonary plethora. The wrist radiograph (fig 2) shows widening, cupping, and fraying of the epiphysis of the right radius and ulna suggestive …

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