Fever, Cough, And Flank Pain In A 10-Year-Old Boy

1. Emily M. Harris, MD*\n2. Kieley Chapman, MD*\n3. Elizabeth Pingree, MD*\n4. Deanna Chieco, MD, EdM*\n\n\n \n\n1. *Boston Children’s Hospital, Boston, MA\n\nA 10-year-old previously healthy boy presents to the emergency department with a 9-day history of fever, cough, and right-sided flank pain. Eighteen months before this presentation, the patient underwent laparoscopic appendectomy for perforated appendicitis. He remained in the hospital on antibiotics for 4 days postoperatively and had a closed suction drain in place until the day of discharge. One week after the appendectomy he developed fever and shortness of breath. He was found to have a parapneumonic effusion requiring chest tube placement and a subhepatic phlegmon not amenable to drainage. He completed a course of antibiotics and recovered without any interval symptoms. The patient now presents with fever, cough, and right-sided flank pain for the past 9 days. The pain is intermittent and radiates to the right lower chest. The cough is productive of nonbloody sputum and exacerbates the pain. His maximum temperature at home was 102°F (38.9°C), with daily fevers until admission. He denies diarrhea, hematochezia, persistent vomiting, hematuria, or dysuria but reports malaise and loss of appetite. There is no history of travel or animal exposure. He was seen 2 days ago at an urgent care facility, where he was diagnosed as having pneumonia based on symptoms and findings on chest radiography. He has completed 2 days of azithromycin but his symptoms persist. Due to perceived failure of outpatient management, he is now admitted to the hospital for intravenous antibiotics and respiratory monitoring.\n\nPhysical examination reveals an alert, nontoxic-appearing boy. He is afebrile, normotensive, tachycardic to 120 beats/min, and breathing comfortably at 18 breaths/min, with oxygen saturations of 98% or greater. There are faint …