(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.