Investigations done at admission revealed haemoglobin of 10 g/dl, total leucocyte count (TLC) of 10.2×109/l with 55% neutrophils, and platelet count of 203×109/l. Serum electrolytes, liver function tests and renal function tests were within normal limits. The chest x-ray (posterioanterior view) was normal.
At day 4 of admission, TLC increased to 20.1×109/l with neutrophilic leucocytosis. C reactive protein (CRP) of 16.8 mg/dl (normal range 0.6–6 mg/dl) was documented and the chest x-ray showed bilateral pleural effusions with no other significant signs or findings.
Pleurocentesis was suggestive of an exudative effusion (glucose 78 mg/dl, protein 5.2 g/dl, lactate dehydrogenase 712 IU/l, leucocytes 1100 per high power field with >90% lymphocytes). The pleural fluid and blood cultures remained sterile.
The respiratory distress persisted without significant radiological findings on chest x-ray apart from minimal effusions. A contrast enhanced chest computed tomography (CT) scan was done on day 10 of hospital stay. It showed collapse and consolidation in both lower lobes with multiple well defined cavitating lesions (). There was bilateral pleural effusion and necrotic lymph nodes in the right supraclavicular region. CT guided aspiration of the right lower lobe lesion revealed thick pus which on culture grew Pseudomonas aeruginosa and Klebsiella pneumoniae sensitive to clindamycin, meropenem and ciprofloxacin.
(A) Section of computed tomography (CT) scan of chest showing bilateral lung abscesses. (B) Section from follow-up CT scan of chest showing complete healing of abscesses and normal lung parenchyma.
In view of multiple lung abscesses, the history was reviewed and the child was investigated further. There was no history of delayed cord fall at birth, consanguinity, regurgitation of feeds or foreign body aspiration. Mantoux test was negative; immunoglobulin levels were normal and ELISA for HIV 1 and 2 was negative. Mutation analysis performed for cystic fibrosis for common mutations in India was non-contributory.