Imaging description

This previously healthy seven-month-old boy was brought to a local community hospital with acute fever and cough. A chest radiograph demonstrated extensive opacification of the right upper lung. Pneumonia was diagnosed and the child was admitted and given intravenous antibiotics for 24 hours. However, respiratory symptoms persisted and the child remained febrile with subsequent hypothermia and some lethargy. Because of concern for sepsis or meningitis, the child was transferred to an academic medical center children’s hospital. A chest radiograph on admission demonstrated dense bulging right upper lobe consolidation with a medial area of cavitation or pneumatocele formation as well as a diffuse macronodular and micronodular pattern elsewhere throughout both lungs (Fig. 18.1a). There also appeared to be prominent paratracheal as well as subcarinal adenopathy with mild mass effect on the airway (Fig. 18.1a). The radiographic appearance raised concern for an unusual infection including tuberculosis (TB) or fungal disease such as Cocidioidiomycosis or Cryptococcus, less likely an unusual viral or pyogenic bacterial infection. A lumbar puncture demonstrated findings of subacute meningitis (lymphocytic predominance of cells).