A 13-year-old female with shortness of breath and pleuritic chest pain

Abstract

A 13-yr-old Caucasian female was referred to the Dept of Paediatric Diseases (Havana, Cuba) with shortness of breath and pleuritic chest pain located in her right hemithorax. The pain had occurred the day before while doing physical activity and lasted ,1 h. The patient reported a 2-month history of recurrent episodes of pleuritic chest pain, which were either self-limited or relieved by paracetamol, as well as growing fatigue in the previous few weeks. Her past history was remarkable for a diagnosis of pneumonia after exposure to fumigation during a dengue haemorrhagic fever epidemic 2 yrs earlier, which was treated with steroids and antibiotics.On admission, the patient had no weight loss, no fever or dyspnoea. Physical examination showed decreased breathing sounds in the inferior part of both hemithoraces. Cardiovascular, abdominal and neurological examination, as well as ear, nose and ophthalmologic investigations were unremarkable. The chest radiograph showed bilateral pneumonia with moderate right-sided pleural effusion. The leukocyte count was 9.8610 9 cells?L -1 with 54% neutrophils and 32% lymphocytes. The erythrocyte sedimentation rate was 85 mm?h -1 . Serum chemistry, renal and liver function tests were in the normal range. Blood cultures were negative. Antibiotic therapy with ceftriaxone and amikacin was started. During the treatment the patient reported 2 days of moderate fever and various episodes of left-sided pleuritic chest pain, which occurred especially during forceful diaphragm contractions (i.e. sneezing, laughing and coughing).Following a short stay in the Cuban hospital, the patient was transferred to an Italian hospital (Como). Amikacin was discontinued and clarithromycin added. A new chest radiograph ( fig. 1), 14 days after the previous one, and a computed tomography (CT) scan of the thorax were performed. Echocardiography and abdominal ultrasound were both negative. An increased value of the tumour marker CA-125 (220 U?mL -1 , versus a normal value ,35 U?mL -1 ) was found. Microbiological and blood testing workup results are shown in table 1.After 1 week, the patient was admitted to a hospital in Milan where a thoracic CT scan ( fig. 2) and whole-body positron emission tomography (PET; fig. 3) were performed. The latter was obtained in order to identify any possible extrapulmonary focus of the disease. Further microbiological and blood testing is shown in table 1.Pulmonary function tests showed a restrictive ventilatory pattern with a total lung capacity 76% of predicted, a vital capacity of 2.66 L (75% pred), a forced expiratory volume in one second of 2.43 L (82% pred), a transfer factor of the lung for carbon monoxide of 6.52 mmol?min -1 ?kPa -1 (71% pred) and a transfer coefficient of the lung for carbon monoxide of 1.83 mmol?min -1 ?kPa -1 ?L -1 (94% pred).Fibreoptic flexible bronchoscopy did not reveal any endobronchial lesion. Cultures of bronchoalveolar lavage (BAL) for bacteria, including Mycobacterium tuberculosis, and for fungi, and a search for malignant cells were negative...

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