Chest Pain and Pulmonary Lesion in a Child With Asthma

A 16-year-old boy presented to the Emergency Department of Montreal Children's Hospital in November 2003 complaining of chest pain for 2 days. A chest radiograph revealed a right middle lobe infiltrate for which he was treated with clarithromycin for 10 days. His past medical history was significant for moderate to severe asthma, diagnosed at age 4 years, with multiple hospitalizations between 1993 and 1997, including an admission to the intensive care unit in 1995 requiring mechanical ventilation. Since then, his asthma had been well-controlled with an inhaled β-agonist and an inhaled corticosteroid. He was last treated with systemic corticosteroids in 2000. The child was also known to have anaphylactic peanut allergy, for which he carried an Epipen. In addition, he had been diagnosed with eosinophilic gastroenteritis in 1995 but was currently asymptomatic on treatment with omeprazole. He had also chronically elevated IgE concentrations, ranging from 7000 to 9956 μg/L. He lived in suburban Montreal, did not smoke and had no pets. Despite therapy for presumed community-acquired pneumonia, the child's symptoms persisted, and he was seen in the allergy clinic in December 2003 still complaining of chest pain. At that time, he was afebrile and had normal vital signs, but a weight loss of 5 kg was documented in the 6-month period between allergy clinic appointments. The patient was a thin, healthy appearing adolescent in no respiratory distress. Auscultation of the chest revealed decreased air entry over the right lung field but no adventitious sounds. There was no significant lymphadenopathy, hepatosplenomegaly or clubbing of the digits. The initial white blood cell count was 23.4 × 109/L with 71% segmented neutrophils, 16% band forms, 7% lymphocytes, 2% atypical lymphocytes and 4% eosinophils. There was no laboratory evidence of renal or hepatic dysfunction. A chest radiograph revealed a large round lesion in the right middle lobe area (Fig. 1). A computed tomography scan of the chest demonstrated a large cystic mass abutting the right anterior pleura and occupying the region of the right middle lobe (Fig. 2). There was no evidence of calcification, but there was significant right hilar and subcarinal lymphadenopathy. In addition, a small area of bronchiectasis was noted in the left lower lobe associated with smaller nodular lesions. Chest radiographs from previous years had been normal.FIGURE 1.: Chest radiograph revealing a large mass in the right middle lobe.FIGURE 2.: Computed tomography of the chest showing a large cystic mass occupying the right middle lobe and abutting the anterior pleura.At this point, the patient was admitted for further evaluation, and the infectious disease team recommended diagnostic testing. A needle aspiration of the mass was performed, and purulent fluid was aspirated. Cytology and culture revealed a causative organism, prompting further testing which identified the diagnosis.

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