(Figure 2) Image A is a plain film radiograph of the chest, which demonstrates a left sided pleural effusion (red arrow). Additionally, there are multiple airspace opacities (blue arrows) including cavitation in the left upper lobe. These findings are concerning for multifocal pneumonia with pleural effusion and cavitary necrosis. Images B (axial) and C (coronal) are CT scans of the neck with intravenous contrast which demonstrate enlargement of the right palatine tonsil with area of low attenuation centrally with mild peripheral rim enhancement with foci of air (green arrow). This represents a tonsillar abscess.
At the BMSCH, she was transferred to the pediatric intensive care unit immediately. Her PICU admission vitals were temperature 99.0 °F, pulse 100 bpm, BP 111/55, RR 31 bpm, SpO2 95% on room air. Physical exam showed pertinent findings of mild acute distress, tachypnea, rashes along ulnar side of L hand, dressing along L upper lateral thoracic region s/p thoracentesis, diminished breath sounds along bases bilaterally with no wheezing, crackles, or rhonchi, and suprasternal retractions present bilaterally.
Her further evaluation and management included almost daily imaging which included almost daily chest radiographs and CT scan of the chest which showed bilateral multifocal, necrotizing pneumonia characterized by pleural effusions with loculations, cavitary abscess, left empyema, and mediastinal lymphadenopathy (figure 3). Her initial admission CXR to BMSCH showed worsening multifocal pneumonia compared to outside hospital CXR.
Due to significant hypoxemia, she was initially on high-flow nasal cannula 20L at FiO2 30% but was changed to synchronized intermittent mandatory ventilation (SIMV). Due to septic shock, she required inotropes. Her antibiotic regime included cefepime and vancomycin. A CT scan of her chest including the neck on day 3 at BMSCH revealed right palatine tonsil and thyroid abscesses. Otolaryngology evaluated her with no recommendations to drain the thyroid abscess.
For further management of her pneumonia, she underwent video-assisted bilateral thoracoscopic surgery (VATS) along with insertion of bilateral chest tubes for pleural effusion, lung abscess, and empyema. After drainage of significant amount of fluid, she was weaned to HFLNC to maintain oxygen saturations above 92%.
Of note, all three blood cultures including anaerobic cultures of pleural fluid during her stay in the PICU was unremarkable. She was administered an 11-day course of vancomycin, and 28-day course of cefepime and metronidazole for anerobic coverage. The patient’s pleural fluid also showed cell count within normal limits, elevated RBC count 46,906 #/cubic mm, and total nucleated cells BF 6,156 #/cubic mm. Her polysegmented neutrophils were 81%, lymphocyte 8%, monocyte 4%, and histiocyte 7%.
Slowly, her labs showed improvement: procalcitonin and C-reactive protein initially elevated at 98.01 ng/mL and 46.12 mg/dL, respectively, ultimately trended down to 0.33 ng/mL and 4.32 mg/dL 27 days later.
Patient’s hemodynamic stability improved with chest tube draining after three TPA flushes into the left lung area of complex loculations, and continued antibiotics. Her chest tubes continued to drain her pleural fluid. Her right chest tube was then removed after draining a total of 422 mL. When her blood culture on admission was identified asFusobacterium nucleatum on day 6 at BMSCH, her antibiotic coverage was altered to ceftriaxone, and metronidazole was continued. Patient was then transferred to hospital floor on 1liter nasal cannula. Her 24 French chest tube became clogged after draining a total of 4,020 mL, and a second 8 French pigtail catheter was inserted posterolaterally on her left side that drained an additional 3,260 mL in 7 days. Total fluid drained and recorded from all three tubes during her hospital course was 7,702 mL.
Due to concerns for any cardiac vegetation, echocardiogram showed tissue near tricuspid valve, small pericardial effusion, and no vegetations. Initial echocardiogram in the PICU showed fractional shortening of 38.5%, LVIDd of 5.6 cm, and LVIDs of 3.5 cm, which approximates an ejection fraction of 63% using the Teichholz formula.
Our patient needed prolonged hospitalization for continued fevers and oxygen dependence. Due to back pain localized at the left scapular area, further imaging, including MR studies of left upper extremity revealed musculoskeletal edema and proximal humeral osteomyelitis and T12 vertebral body emphysematous osteomyelitis (figure 4), which was an incidental finding.
Her bilateral duplex venous ultrasounds of the upper extremities and bilateral neck showed no thromboses, and duplex ultrasound of the carotids bilaterally was unremarkable, which is quite different from the other cases of LS.