An Unusual Case of Chest Pain in a 9-Year Old Immigrant

Abstract

CASE PRESENTATION: A nine-year-old female with no past medical history presented to the emergency department with a two-week history of chest pain associated with tactile fevers and cough. One-year prior, she traveled by foot from Venezuela to the United States crossing through five countries and was detained in both Panama and the U.S. border prior to arriving in Atlanta four months ago. On physical exam, she appeared thin and emaciated, with decreased breath sounds on the right, but otherwise was in no respiratory distress with normal oxygen saturations. Initial work-up revealed leukocytosis, normocytic anemia, elevated inflammatory markers, and a normal blood smear. Chest X-Ray showed a dense opacity of the right upper lobe with mass effect of the right main stem bronchus (Image 1). Subsequent CT scan was notable for a large cavitary lesion of the right upper lobe concerning for abscess (Image 2) with hilar lymphadenopathy and a small spleen. She was empirically started on vancomycin and ceftriaxone but narrowed to clindamycin after sputum culture grew MRSA. One week into hospitalization, her anemia worsened, prompting a hemoglobin electrophoresis test, which revealed the delayed diagnosis of hemoglobin SS disease complicated by acute chest syndrome. She improved on antibiotics without blood transfusions and was discharged in stable condition to complete a four-week course of oral clindamycin. Chart review revealed multiple missed appointments, and she has been lost to follow-up. DISCUSSION: This case highlights many important takeaways healthcare providers must consider when providing care to immigrant patients. Although three-quarters of newborns with sickle cell disease (SCD) are born in sub-Saharan Africa, there is a generous and underappreciated population affected within Latin America, where many developing countries lack newborn screening programs. In the U.S., providers often rely on newborn screening results, which over time has likely decreased our index of suspicion in older children for conditions we typically diagnose prenatally or in the newborn period. Despite multiple subspecialties being involved in this patient’s care, providers failed to consider SCD as a possible etiology despite early findings of anemia and a small spleen on CT scan. Although advancements in newborn screening, genetic counseling, and prenatal ultrasound have changed the prevalence and presentations of genetic and congenital disorders, we as providers must maintain a high index of suspicion. Additionally, fear of deportation, language barriers, limited financial resources, and low health literacy are some of the many barriers immigrant patients face when seeking care in this country. In this case, the family spoke French Creole; access to a language line was crucial. Providers must ensure families have an appropriate understanding of the disease process and address socio-cultural and economic concerns to prevent at risk children from being lost to follow-up.