Cough with fever and resp...

A child was born by caesarean section at the postmenstrual age of 38 weeks. At the age of nine months, he was admitted to a regional hospital with cough, high fever and moderate tachypnoea. Chest X-ray revealed bilateral pulmonary infiltrates, and the child was treated with intravenous antibiotics. Ten days later, he was referred to the university hospital because of persistent cough, increasing respiratory distress and atelectasis of the right lower and middle lobes on chest X-ray.

Examination

At referral, we saw a pale and dystrophic child in moderate respiratory distress. Weight was on the third percentile for a height on the 75th percentile. The child was afebrile. He had chest hyperinflation, tachypnea (60 per minute) and intercostal retractions. Fine rales were heard over the right hemithorax. Transcutaneous oxygen saturation was 92% when awake but dropped below 90% during sleep. White blood cell count was 22900 per microliter (42% neutrophils), C-reactive protein was slightly elevated at 25 mg/L (normal value below 5 mg/L). Bronchoscopy demonstrated patent central airways: no mucus plug, no foreign body, no external airway compression. There was some erythema of the mucosa and scanty secretions in the right bronchial tree.