A 4-month-old infant with cough and fever.

Healio.com/Pediatrics | 139 Editor’s note: Each month, this department features a discussion of an unusual diagnosis in areas including genetics, radiology, or dermatology. A description and images are presented, followed by the diagnosis and an explanation of how the diagnosis was determined. As always, your comments are welcome via email at [email protected]. A4-month-old boy was referred to our clinic with a diagnosis of pneumonia. When he was 2 months old, he was treated for pulmonary infection for 20 days. A few days after being discharged, he was referred to our clinic with the symptoms of cough, fever, and respiratory distress. His natal and prenatal history were unremarkable. His one sibling had died due to pneumonia at the age of 1 month, but his parents were healthy. There was no history of vomiting or seizure. At admission, his temperature was 39°C and he was in respiratory distress. Breath sounds were decreased in his right hemithorax. He was in the third percentile for his weight and the tenth percentile for his length. Chest radiograph showed that his right lung was totally infiltrative, and there was a cavitary lesion in the right upper lobe (Figure 1). Ultrasound was performed to exclude the possibility of pleural effusion, and no effusion was detected. His white blood cell count was 28,100 mm3, hemoglobin level was 10.6 g/dL, platelet count was 660,000 mm3, and Creactive protein was 2.3 mg/dL. Liver and renal function tests were normal. Treatment with intravenous (IV) teicoplanin and meropenem was started. For respiratory distress, he was given IV methylprednisolone, nebulized salbutamol, and ipratropium bromide. His respiratory distress was resolved, but there was not marked response to treatment. His thorax computerized tomography (CT) showed consolidation in the right upper lobe with cavitation and air bronchogram (Figure 2). Gastric aspirates were negative for Mycobacterium tuberculosis. His tuberculin skin test was also negative, but mycobacterium PCR was positive. Due to the positive PCR test for tuberculosis, chest radiographs for his parents were also evaluated. The child’s mother’s test was negative, but a cavitary lesion was detected on his father’s chest radiograph. Bronchoalveolar lavage results showed acid-fast bacilli positivity. Sputum culture was done, and antituberculosis treatment was started for his father. The patient’s tuberculosis treatment is still ongoing.