Case 1: Recurrent pneumonia in a 24-month-old boy

Abstract

A 24-month-old boy was admitted to hospital with his fifth episode of pneumonia. On admission, his perinatal, growth and developmental histories were unremarkable, and his vaccinations were complete for his age. His family history revealed a father with atopy, and his history revealed eczema and occult Streptococcus pneumoniae bacteremia at nine months of age. Radiologically confirmed pneumonia had occurred in the right lower, right middle, right lower and right upper lobes at 11, 14, 18 and 22 months, respectively, with the final case of pneumonia being complicated by a 30 min atypical febrile seizure. Investigations during the hospitalization, including a complete blood count, complement and immunoglobulin levels, echocardiogram, sweat chloride test and antibody responses to vaccinations, were normal. His medications included fluticasone (250 μg twice daily) and salbutamol (two puffs four times per day as needed) started at 14 months of age, penicillin V prophylaxis (125 mg twice daily) started at 18 months of age and montelukast (4 mg at bedtime) started at 23 months of age. At 24 months of age, a chest x-ray confirmed right middle lobe pneumonia. Further questioning revealed that for a few weeks, the patient had days when he would wake up with unexplained sleepiness and no desire to play. A physical examination was positive for fever, cough and crackles in the right middle lobe. During his admission, an empirical treatment was initiated, and the response suggested the underlying diagnosis.