Chest Wall Swelling in a Child With Pneumonia

A 2-year-old male, previously healthy aside from a recent admission for croup, presented to the emergency department with a chief complaint of fever, difficulty breathing, and diffuse erythematous rash. The mother described a rapid onset of a bright red, swollen rash that started in the middle of the chest and progressed to the face and the extremities. The child had completed a 5-day course of oseltamivir for suspected influenza infection 6 days prior. On presentation, he was febrile with a rectal temperature of 38.6°C, a respiratory rate of 40 breaths per minute, a heart rate of 180 beats per minute, and blood pressure of 101/81 mm Hg. On physical examination, he was ill-appearing and in mild respiratory distress with a confluent erythematous rash resembling a sunburn on his trunk and extremities. Laboratory evaluation was significant for a white blood cell count of 24.2 × 10/L (reference range 5.0-15.5 × 10/L) with 81% segmented neutrophils, a C-reactive protein of 20.3 mg/dL (reference range <1.0 mg/dL), and an erythrocyte sedimentation rate of 24 mm/h (reference range 0-15 mm/h). Chest radiograph showed bibasilar opacities consistent with multi-lobar pneumonia (Figure 1). A blood culture was obtained, and he was started on broadspectrum coverage with vancomycin, clindamycin, and ceftriaxone for multi-lobar pneumonia with suspected toxic shock syndrome (TSS). The patient was placed on high-flow nasal cannula at 5 L/min, and given his hemodynamic stability admitted to the pediatric ward/floor. The Biofire Filmarray Blood Culture Identification Panel (Biomérieux) revealed Staphylococcus aureus without the presence of the mecA gene in his blood culture. Based on these results, his vancomycin was replaced with cefazolin and he was continued on ceftriaxone. The clindamycin was also continued for antitoxin properties for suspected TSS. On hospital day 2, the patient developed a shock-like state with poor perfusion, and despite aggressive fluid resuscitation, he was transferred to the pediatric intensive care unit. At transfer, he was noted to have tenderness, swelling, and erythroderma over his anterior chest wall (Figure 2A). Further imaging revealed the diagnosis.