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This is the x ray of a 2½‐month‐old boy who presented with a 2‐week history of cough and recent onset of breathlessness and decreased feeding. He had no previous illnesses and his ante‐natal scans were normal. Soon after admission, he developed an oxygen requirement of 0.75 l/min. He was pale and feverish with bilateral wheeze on auscultation. Four hours later, he became mottled and developed reduced skin perfusion. Blood gases showed severe metabolic acidosis (pH 6.9, Pco2 11, base excess 12.8) and he required multiple fluid boluses to correct this. A chest x ray showed a large hyperlucent area in the left hemi‐thorax with mediastinal shift to the right—probably congenital cystic adenomatoid malformation/pneumothorax. Six‐slice CT showed a large air‐ and fluid‐filled cavity in the left hemithorax with a thin soft‐tissue rim. He continued to be acidotic and developed renal compromise. He was ventilated, stabilised and transferred to a tertiary centre. He had full spiral CT with contrast through a nasogastric tube, which showed a diaphragmatic hernial defect with stomach in the left hemithorax. He was operated on the same day and had an uneventful stay later.
Late presentation of congenital diaphragmatic hernia poses considerable diagnostic challenge, often leading to misdiagnosis and risk of inappropriate chest drain insertion.1 Clinical pathology is due to a mediastinal shift and pulmonary collapse as opposed to pulmonary hypoplasia and hypertension in newborns. Its possibility should be suspected in every child presenting with unusual respiratory symptoms and abnormal chest x ray findings.2,3
Competing interests: None.