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Case of the Month - October 2014

Harhsa Lochan and Brian Eley, Paediatric Infectious Diseases Unit, Red Cross War Memorial Children’s Hospital, and the Department of Paediatrics and Child Health, University of Cape Town

A 2-month old boy presented with a 2-week history of cough, fever and respiratory distress requiring admission to a level 2 hospital. He was born at term and there no complications in the immediate post-natal period.

Past medical history included 2 previous episodes of bronchiolitis, the most recent 11 days prior to this admission. There was no history of TB or HIV exposure, failure to thrive or dysmorphic features noticed.

On presentation, he was hypoxic with oxygen saturation of 91% in room air. There was also extensive oral candidiasis. The chest radiograph showed right upper lobe consolidation (Figure 1). He was transferred to a level 1 facility on day 1 of the current illness where he completed 7 days of antibiotics (ampicillin and gentamicin initially). Blood culture was negative after 5 days of incubation and there were no viruses detected on the nasopharyngeal aspirate PCR.

Figure 1

Despite antimicrobial and oxygen therapy, there was minimal clinical improvement. Ten days into the current illness, he was transferred to a level 3 hospital from the level 1 facility. Continuous positive airway pressure (CPAP) ventilation was commenced. Ertapenem was also initiated for a presumed nosocomial infection.

He continued to have ongoing respiratory distress with a respiratory rate up to 100 breaths/min, marked subcostal and intercostal recession and persistently high temperatures up to 38.1°. The chest radiograph showed persistent RUL consolidation (Figure 2) despite appropriate antibiotics which included clarithromycin to treat for possible mycoplasma or chlamydial infection. There was no history of aspiration during the admission.

The following were relevant investigations performed during the course of the infant’s admission to hospital:

Days into admissionDay 0Day 10Day 19Day 27
White cell count (5.5-18 x 109/l)14.2931.313.088.56
Neutrophils (2–8 x 109/l)11.4926.302.217.19
Lymphocytes (2-17x 109/l)1.660.630.491.03

Bocavirus was detected on a repeat nasophayngeal aspirate PCR. The HIV rapid test was negative. The patient was screened for tuberculosis and induced sputum specimens were Xpert MTB/RIF and culture positive for Mycobacterium tuberculosis complex, rifampicin susceptible. The CMV viral load was raised at 7561900 copies/ml (log >6.70).

Figure 2

Question 1: What is the differential diagnosis for a child with a persistent pneumonia at a single site and unremitting fever?

Continue to Answer 1