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Lung Abscess - the answer is in the chest radiograph

Sara Todo Bom Costa^1,2, Ana Sofia Vilardouro^1,2, Mafalda Casinhas², Vanessa Albino², Florbela Cunha^2
1Pediatrics Department, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal, ²Pediatric Service, Hospital Vila Franca de Xira, Lisboa, Portugal

Address for Correspondence: Sara Todo Bom Ferreira da Costa, Av. Prof. Egas Moniz MB, 1649-028 Lisboa
Email: sara.tbferreiracosta@gmail.com
Keywords : Lung Abscess, Infant, Fever
Question:
An 18-month-old male child, with a history of recurrent wheezing, was brought to the pediatric emergency department with a 3-week history of cough, nasal congestion and intermittent fever. The clinical examination on admission showed unaltered general status, hyperemic pharynx and tonsils, normal cardiopulmonary auscultation and absence of respiratory distress. Laboratory tests revealed elevated infection parameters (leukocyte count of 27600/uL with 76% neutrophils and C-reactive protein of 10.27 mg/dL) and the rapid strep test was negative. The chest radiograph revealed a round image, 45 mm in diameter, with an air-fluid level and well-defined margins, which was compatible with a lung abscess (Figure 1) The patient was admitted and started on clindamycin and cefotaxime. A chest computer tomography (CT) scan confirmed the lesion (Figure 2). The length of hospital stay was 18 days, but the child was afebrile since day 2 and remained asymptomatic with adequate oxygen saturation on room air. He was then discharged with an oral amoxicillin clavulanate for 10 more days and referred to a pediatric consultation. During his follow up, a primary immunodeficiency (PID) screening revealed only reduced IgA levels.
Ten months after his admission, a follow up CT scan still showed a small pneumatocele that was 22 mm in diameter.

Figure 1. Chest radiograph: on the left, there is round image, 45 mm in diameter, with an air-fluid level and well-defined margins compatible with a lung abscess.


Figure 2. Chest Computed Tomography of the chest: this exam confirms the large cavitary lesion in the left lower lobe with a relatively thick wall.

What is the Diagnosis?