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Community-acquired pneumonia in children: what to do when there is no response to standard empirical treatment?
  1. Shivanthan Shanthikumar1,3,4,
  2. Amelia Clifford2,
  3. John Massie1,3,4,
  4. Theresa Cole4,5,
  5. Andrew Steer2,3,4,
  6. Michael Marks2,3,
  7. Amanda Gwee2,3,4
  1. 1Respiratory Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
  2. 2Department of General Medicine, Royal Children's Hospital, Melbourne, Australia
  3. 3Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
  4. 4Murdoch Children's Research Institute, Parkville, Victoria, Australia
  5. 5Department of Immunology, Royal Children's Hospital, Melbourne, Australia
  1. Correspondence to Dr Shivanthan Shanthikumar, Department of Respiratory Medicine, Royal Children's Hospital, 50 Flemington Road, Parkville, Melbourne, VIC, 3052, Australia; shivanthan.shanthikumar{at}rch.org.au

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SS (registrar) and AC (resident)

A 5-year-old female presents to a tertiary paediatric hospital in Australia with a 2-day history of fever, vomiting and abdominal pain. Her past history consists of three episodes of otitis media in the preceding 12 months, all resulting in tympanic membrane perforation. Her parents report an ‘innocent heart murmur’ diagnosed by a paediatric cardiologist. There is no history of travel or animal exposure. With regard to family history, she is the child of non-consanguineous Caucasian parents, and her father has Crohn's disease. On examination, she is febrile (40.0°C) and tachypnoeic (45 breaths/min) with normal oxygen saturations (99% room air). Bronchial breath sounds are auscultated posteriorly in the left lower zone. She has a 3/6 systolic murmur heard at the apex and lower left sternal edge with no radiation. Her first full blood examination showed a neutrophilia (13.9×109/L, normal <8.5×109/L) and mild lymphopenia (1.9×109/L, normal >2.0×109/L) which resolved. Her C-reactive protein (CRP) is elevated at 157 mg/L (normal <8 mg/L). A chest radiograph (CXR) shows left lower lobe consolidation with an irregular area of radiolucency suggestive of an evolving abscess (see figure 1A). The patient is commenced on intravenous flucloxacillin (50 mg/kg, 6 hourly) and ceftriaxone (50 mg/kg, 12 hourly). Despite this, she continues to spike high-grade fevers (>39.0°C). Blood cultures on two occasions are negative.

Figure 1

(A) A chest radiograph (CXR) showing left lower lobe consolidation with suggestion of abscess; (B). Repeat CXR showing worsening left lower lobe consolidation and tracheal deviation; (C). CT scan showing left lower lobe consolidation, bilateral lung nodules and some areas of ground-glass opacification.

AS (general paediatrician and paediatric infectious diseases physician)

The initial presentation with fever and abdominal pain is not uncommon in patients with pneumonia. Tachypnoea is a sensitive and specific sign of pneumonia, and CXR is the most appropriate initial diagnostic investigation.1 The presence of fever, …

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