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Special Feature
August 1999

Radiological Case of the Month

Author Affiliations

From Emory University School of Medicine, Egleston Children's Hospital, Atlanta, Ga.



Arch Pediatr Adolesc Med. 1999;153(8):887-888. doi:10.1001/archpedi.153.8.887

A 9-MONTH-OLD previously healthy infant presented with a history of a fever (temperature to 39.5°C) daily for 32 days. At the onset of the fever, she had several small bumps around her mouth and cold symptoms consisting of a nonproductive cough and rhinorrhea. Her primary care physician diagnosed a viral illness. The physician reevaluated her persistent fever 2 weeks later, diagnosed otitis media, and started treatment with an antibiotic. After completion of the antibiotic course, she was still febrile and was given a second antibiotic with no improvement of her condition. The parents reported she was weaker and her activity level had decreased. She no longer pulled herself to a standing position. She had no noticeable decrease in appetite or weight and no change in behavior.

The infant had achieved developmental milestones appropriately and had been immunized. Her medical and family history were unremarkable. There was no history of recent travel or ill contacts. She lived with her mother, father, and brother, who were all healthy. During the day the patient stayed with her grandmother and aunt.

Physical examination showed her vital signs to be normal except for a temperature of 38.9°C. She was ill-appearing but well nourished and well developed. Her conjuctiva and mucosa were pink. She had no cough, tachypnea, or retractions, and her lung auscultations were clear. The liver, spleen, and lymph nodes were not enlarged. Physical examination results included normal tympanic membranes, normal cardiovascular findings, normal joints, normal neurological findings, and no rashes.

Initial laboratory evaluation included a serum leukocyte count of 15 × 109/L, with a differential cell count of 0.01 cellbands, 0.63 segmented neutrophils, 0.27 lymphocytes, and 0.06 monocytes; a hemoglobin level of 73 g/L with normal indices; a platelet count of 7.2×109/L; and an erythrocyte sedimentation rate of 114 mm/h. The remainder of her serum chemistry test results and urinalysis were normal. A chest radiograph (Figure 1 and Figure 2) was performed because of the history of persistent fever. A lumber puncture was performed and the cerebrospinal fluid revealed a leukocyte count of 12.2×109/L with a differential cell count of 0.55 segmented neutrophils, 0.26 lymphocytes, and 0.16 monocytes; glucose and protein values of 2.4 mmol/L (44 mg/dL) and 63 g/L, respectively; and a negative Gram stain. Cerebrospinal fluid, blood, and urine cultures were performed.