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Pulmonary puzzles
An extra piece of grey
  1. Rajashree Ravindran1,
  2. Simon Jordan2,
  3. Andrew Bush3
  1. 1Paediatrics Emergency Medicine, Chelsea and Westminster Hospital NHS Trust, London, UK
  2. 2Thoracic Surgery Department, Royal Brompton Hospital NHS Trust, London, UK
  3. 3Paediatric Respiratory Medicine, Royal Brompton Hospital NHS Trust, London, UK
  1. Correspondence to Dr Rajashree Ravindran, Paediatrics Emergency Department, Chelsea and Westminster Hospital NHS Trust, 369 Fulham Road, London SW10 9NH, UK; Rajashree.Ravindran1{at}nhs.net

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A 14-year-old boy presented to the paediatric accident and emergency with a 2-week history of right-sided pleuritic chest pain, cough and intermittent fevers. A chest radiograph (CXR) was performed (figure 1A), and he was discharged home with advice to return if symptoms did not resolve.

Figure 1

(A) Initial chest X-ray. (B) Repeat chest X-ray.

He re-presented a week later with increased work of breathing, chest pain and temperature spikes up to 38.5°C. On clinical examination, there was dullness on percussion and reduced breath sounds on the right side. The repeat CXR is shown in figure 1B.

The initial blood investigations showed a normal white cell count and raised C-reactive protein of 303 mg/L (0–10). He was tachypnoeic, requiring 1–2 L of oxygen, and was commenced on intravenous co-amoxiclav and clarithromycin. A chest ultrasound demonstrated a large pleural effusion, and he was transferred …

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