Severe acute kidney injury in a 3-year-old boy with fever and pleural effusion: Questions
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CLINICAL QUIZ
Severe acute kidney injury in a 3-year-old boy with fever and pleural effusion: Questions Aakash Chandran Chidambaram 1 & Sriram Krishnamurthy 1 & Bobbity Deepthi 1 & Pediredla Karunakar 1 & Kaushik Maulik 1 & Sreeram Chandra Murthy Peela 2 & Sujatha Sistla 2 & Sree Rekha Jinkala 3 Received: 14 April 2020 / Revised: 15 April 2020 / Accepted: 22 April 2020 # IPNA 2020
Case report A 3-year-old boy presented with a history of fever and cough for 6 days, which was associated with anorexia. There was no past history of lower respiratory tract infections or hospitalizations. The family history was unremarkable for any infections, hospitalizations, or major illnesses. There was no history of any drug intake for the child other than paracetamol for fever. The boy had received vaccines as per the national immunization program of India, but not the pneumococcal vaccine, varicella, or influenza vaccines. The child was conscious but had increased work of breathing at presentation to our hospital. He was developmentally normal for age, and the weight (14 kg; − 0.24 z) and height (95 cm; − 0.38 z) were within acceptable limits. Physical examination revealed axillary temperature 38.5 °C, heart rate 140/min, respiratory rate 51/min (with significant subcostal and intercostal retractions), blood pressure 90/55 mmHg, and capillary refill time 3 s. The oxygen saturation by pulse oximetry was 85% on room air. Reduced air entry in the left infra-mammary, infra-scapular, and infra-axillary areas, with reduced vocal fremitus and reduced vocal resonance, were noted. Fine crepitations were also noted in these areas. The central nervous system examination was also normal, with no neck rigidity, and Kernig’s The answers to these questions can be found at https://doi.org/10.1007/ s00467-020-04591-7. * Sriram Krishnamurthy [email protected] 1
Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry 605006, India
2
Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
3
Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
sign and Brudzinski’s sign were negative. There were no focal neurological deficits. The other systemic examinations were unremarkable. Supplemental oxygen by mask and intravenous (IV) fluids were administered, and he was admitted to the pediatric intensive care unit (PICU). The chest X-ray revealed left-sided pleural effusion (Fig. 1). He was started on intravenous ceftriaxone and vancomycin, after obtaining necessary blood samples for investigations (Table 1). Blood investigations revealed neutrophilic leukocytosis. Serum creatinine was 0.41 mg/dL at this juncture. A diagnostic pleural tap was done after which intercostal drainage tube was inserted (Fig. 1). The pleural fluid was sent for gram stain, bacterial culture, and molecular diagnostic tests. Nasopharyngeal swabs for influenza A (including H1N1) an
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