Acute Illness in a Patient With a Chronic Cough Since Birth

Jason M. Richerson, MD, Benjamin Estrada, MD, Michael M. Fuenfer, MD, Andrew B. Walker, MD


December 06, 2002

Case # 1

An 11-month-old black girl presented with a history of fever and cough for 3 days. Her cough had been nonproductive and associated with increased tachypnea and decreased feeding. Her mother stated that the patient has experienced chronic intermittent episodes of cough since birth, but that she has been healthy otherwise. She was born at full term by vaginal delivery, without complications. Her immunizations were current.

Findings were as follows: rectal temperature 101.6° F, pulse 163, respiratory rate 56/min, blood pressure 97/86 mm Hg, peripheral oxygen saturation/room air 88%, weight 9.52 kg.

Patient was irritable and actively coughing. She had intercostal retractions and suprasternal heave. On auscultation, breath sounds were significantly decreased in the right lower and right middle lobes, with diffuse crackles bilaterally. The physical examination was otherwise normal.

Peripheral blood examination showed hemoglobin 9.4 g/dL, total white blood cell count 17,100/mm3 with 68% polymorphonuclear leukocytes, 2% band forms, 23% lymphocytes, 7% monocytes, and platelet count of 403,000/mm3. The C-reactive protein was 17.3. Blood cultures were obtained.

The patient's respiratory status continued to deteriorate and she required progressive increments of supplemental oxygen. All blood cultures remained negative. A computerized tomography (CT) of her chest was performed.

A right thoracotomy with right lower lobectomy was performed. Findings included a bulky, multicystic right lower lobe with a venous vessel to the inferior vena cava and no communication with the tracheobronchial tree.

There were multiple areas of cysts, measuring up to 1.5 cm. Many of the cysts were filled with purulent material. Cultures were obtained from the resection but did not yield any organisms.

Examination of tissue samples revealed multiple dilated air spaces within the right lower lobe with purulent exudate and foamy macrophages. There was chronic inflammation within fibrous interstitium and fibrous obliteration of multiple alveoli. Fibrous thickening was present around the small arteries.


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