Column Editor: Joe Julian, MD, MPHTM, FAAP | Hospitalist, Internal Medicine - Pediatrics | Clinical Associate Professor, Internal Medicine and Pediatrics, UMKC School of Medicine
A 16-year-old female is directly admitted from a referring hospital for further evaluation and management of an abnormal chest radiograph. The patient has had fevers for the past two weeks with associated productive cough (yellow sputum without blood), chills, night sweats and headache. She has an unintentional weight loss of 8 pounds during this time. No associated sore throat, rhinorrhea or rashes.
She has not had any travel outside of her metro-based location in Kansas for the past two years. She has not spent any time in a juvenile detention center, group home, or with anyone from a tuberculosis-endemic country. Several extended family members with a history of incarceration have spent time around the patient but have no history of active coughing or febrile illness. She does not use intravenous drugs or have unprotected sexual intercourse.
Approximately six weeks prior, the patient took a significant amount of sleeping pills and a friend “pumped her stomach” with their hands. She is unsure if she vomited and did not seek medical attention after this episode. She did spend a short time in a behavioral health hospital after this incident. She has no known sick contacts. She does not have any other medical conditions and does not take any medications on a regular basis. She has no family history of rheumatologic or pulmonary diseases.
Vital Signs and Physical Exam
Vitals: Temperature 37°C | Pulse 90 | Respiratory rate 20 | Blood pressure 102/66 | Oxygen saturation 97% on room air
- Comfortable, no acute distress
- Mucous membranes moist, no oral ulcerations
- Normal work of breathing, diminished lung sounds on right side
- Regular rate and rhythm without murmur, normal S1/S2
- No hepatosplenomegaly, no palpable lymphadenopathy
Pertinent Labs and Imaging
||Value w/ Units
|% Immature Gran
|C Reactive Prot
Chest radiograph from referring facility
1) Which of the following is the next best diagnostic step?
A. CT scan of chest with contrast
B. Transthoracic echocardiogram (TTE)
C. Doppler ultrasound of neck
D. Flexible bronchoscopy
Answer: A. CT scan of chest with contrast
This patient has a very large cavitary lesion that is concerning for an infectious process. A CT scan would provide more information on the extent of parenchymal involvement, additional areas of cavitation, and the presence of empyema. Embolic, rheumatologic and oncologic etiologies, although lower on the differential, are still possibilities and a CT scan would help with further differentiation.
A transthoracic echocardiogram and Doppler ultrasound of neck are helpful if there is a very high suspicion of an embolic source. However, the patient has no risk factors or clinical findings concerning for endocarditis or septic thrombophlebitis. A flexible bronchoscopy is generally not needed unless the patient does not respond to empiric antimicrobial therapy.
View the patient's CT scan: