Hot Seat #236: Short of Breath, What is the right test?
Posted on: October 7, 2024, by : Brandon Ho
18-year-old female presents with cough for the past 2 weeks now complaining of shortness of breath for the past 2 days with tactile fevers. No vomiting but feeling nauseous. Normal urine and stool output. Up to date on immunizations. Cannot lie down flat because she has trouble breathing. Endorses dizziness and denies history of wheezing. Patient up to date on immunizations, no significant personal/surgical/family history. On depo provera. No sick contact. No recent travel.
95% on RA, T 36.8C, HR 137, RR 38, BP 135/87
General: Alert, appropriate for age, cooperative
Skin: warm, dry, intact
Head: normocephalic, atraumatic
Neck: supple, trachea midline, no tenderness, no lymphadenopath
Eyes: PERRLA, EOMI, normal conjunctiva, no discharge, no jaundice
ENMT: normal TMs, oral mucosa moist, no pharyngeal erythema or exudate. Dentition intact
Cardiovascular: regular rate and rhythm, normal peripheral perfusion, extremity pulses equal
Respiratory: inspiratory and expiratory wheezing heard in the left lung fields, diminished air entry into the right lungs. Nasal flaring, substernal retractions present. Patient is able to speak in short sentences. However she gets short of breath at the end.
MSK: normal ROM, moves all extremities.
GI: soft, nontender, nondistended, normal bowel sounds
Neurologic: developmentally normal
CXR: Near complete opacification of the right lung with tracheal deviation. Large right effusion. Underlying mass or infiltrate cannot be excluded. Obliterated right mainstem bronchus with narrowed left mainstem bronchus. Left lung is clear. Differentials include right lung mass, infiltrate.
POCUS: Large R effusion with hepaticized lung, L side without effusion and normal lung sliding, small pericardial effusion but normal function.
VBG: 7.427/31.6/53.6/88.7/20.8/-2.4
CMP, Mg, phos normal.
WBC 12.70, Hgb 14.4, HCt 43.3, Plt 341, ANC 8.45, Diff unremarkable
CRP 4.77
ESR 21
Flu/RSV/Covid neg
ECG – sinus tach, RAD, nonspecific T wave abnormality
Sounds like child needs CT chest and then surgical consult for potential VATS, depending on CT results.
Wow, she is quite sick. The most common cause of a consolidation with effusion is a bacterial pneumonia and it makes sense to start antibiotics (CTX/Vanco). But it is surprising that there is no fever, no elevated wbc, and normal inflammatory markers. So it is time to pause and expand: mycoplasma, viral illness. Both can be tested for and consider adding azithromycin. Foreign body with infection– seems less likely. TB: add QuGold testing. Thinking of oncologic processes, a primary lung cancer is less common in the pediatric age range, though metastases to the lung from other primary cancers are seen. I don’t think leukemia and lymphoma present in this way, but until that is clarified would hold on steroids.
My initial thought reading the history only was a myocarditis, DCM, or other cause of heart failure. The normal function on POCUS is great, but I’d still like a formal echo just to make sure. Given the CXR findings, a chest CT and VATS for symptom relief and fluid analysis are definitely the next steps. 18-year-olds shouldn’t be aspirating foreign bodies, but stranger things have happened, and I don’t know this patient’s developmental level. The narrowing of the left bronchus as well makes me worried for bronchiolitis obliterans or other diffuse lung disease, which isn’t cool at all. Is there an organizing pneumonia (formerly called bronchiolitis obliterans organizing pneumonia)?
In the young adult age group, especially in a kid as sick as this, one also should think of things like IV drug use (significantly increases the chances of pneumonia), HIV (substantial higher risk for severe pneumonia), as well as the onset of rheumatologic/collagen vascular disease. Does she have acute lupus pneumonitis with an inflammatory instead of infectious effusion (transudate vs. exudate)? Her inflammatory markers should be elevated in this instance, so that’s doubtful.
There could be a malignancy as well, but that would be rare unless these are mets from a primary elsewhere. For her sake, I hope not.
I agree with Dewesh, CT is your first step followed closely by a VATS assuming she’s stable.