Presentation
Cough for 2 days. Spiking temperature for last 24 hours. Off food. Reduced air entry on the right.
Patient Data
Right-sided consolidation with moderate-sized effusion. Artefact over chest from clothing.
Right-sided effusion has increased significantly in size and there was deterioration in the patient's condition with increasing oxygen requirement.
US of the chest demonstrates a septated pleural effusion. There are air-bronchograms in the underlying lung confirming consolidation seen on the x-rays. Moreover, there is differential echogenicity of the lung parenchyma with areas of hypoechogenicity concerning for lung necrosis.
A right-sided US-guided chest drain was inserted. Straw-colors blood-stained fluid drained and there was a slight improvement in clinical condition after she woke up from the anesthetic.
Following chest-drain insertion and 500ml fluid drained a CT of the chest confirmed the suspicion of lung necrosis. Most of the pleural fluid has drained.
The majority of the right lower lobe is non-enhancing and necrotic with internal gas-locules.
There was slow improvement and on day 3, the chest drain was not draining very much. The chest radiograph confirms that there is only a small pleural collection remaining and that the pig-tail location is unlikely to allow much additional drainage.
The central lucency within the necrotic lobe is clearly seen on the x-ray.
Given the volume of necrosis and the fact that most of the pleural fluid had drained, no fibrinolysis was used.
The patient made a slow recovery and was switched from IV to oral antibiotics and transferred from HDU to a general ward after a week.
2 months following discharge there has been significant improvement in the appearance of the right lower lobe although there is a residual abnormality with a central lucency.
Case Discussion
Paedaitric patients with complicated pneumonia can develop parapneumonic effusions, lung necrosis, lung abscess and empyema.
Of those patients who develop lung necrosis, many do exceptionally well. They will likely have no clinical symptoms at 6 months, normal lung function by 1 year and completely normal imaging by 2 years. Given the awful imaging findings at the time of infection, that is nothing short of miraculous!
Our expectation is that this little girl will have normal respiratory function and normal imaging in a couple of years.