Un unexpected pleural effusion in a pediatric patient in apparently good health

ABSTRACT

We are describing the case of a 9-year-old male child who was first admitted to the Emergency Room of another hospital due to hip pain, shortness of breath and loss of appetite, following a four-day-history of tachycardia associated with right hip pain and no fever. The biochemical analyses and the chest X-ray (performed in this hospital) showed increased phlogosis indexes (C-reactive protein (CRP) 106.3 mg/L 21xN; lactate dehydrogenase (LDH) 373 U/L, white blood cells (WBC) 11800 mmc, neutrophils(N) 44%, lymphocytes(L) 51%, platelets (PLT) 297000 mmc; D-dimer 2.82 mg/L) and lung consolidation with right pleural effusion. The patient was therefore moved to our hospital for further study. At the time of admission, the child was eupneic. Although his condition was normal, the thoracic auscultation showed a respiratory silence in the right hemithorax.
Moreover, laboratory tests confirmed the persistence of incremented phlogosis indexes (CRP 10.20 mg/Dl 21 x N, LDH 428 U/L, WBC 11780 mmc N50% L 45% PLT 288000 mmc); thus, an antibiotic therapy with amikacin and meropenem was started. The patient’s past medical history was unremarkable. In consideration of his clinical presentation, we performed microbiological tests to exclude infectious diseases (serological tests for Mycoplasma pneumoniae and Chlamydiapneumoniae; Quantiferon-TB Gold test for Mycobacterium tuberculosis). The exams came out negative, with absence of significant microbiological evidence supporting the radiological findings. His clinical conditions worsened within the first 24 hours. The patient became tachypneic, so oxygen support was required. After performing a thoracic ultrasound which showed the presence of massive pleural effusion in the right pleura with right lung atelectasis, a thoracentesis was performed, and 1000 cc of serum-haematic pleural fluid was drained and sent to laboratory for cytologic, microbiologic and microbacterium testing. The cytological analysis of pleural effusions showed cells compatible with T-lymphoma; accordingly, a chest computed tomography (CT) was performed, showing a voluminous “bulky” mass in the anterior mediastinum, so a neoplastic aetiology was suspected. Finally, the bone marrow aspiration allowed us to diagnose T-cell acute lymphoblastic leukaemia (ALL).
Hence, according to the International Protocol for Children and Adolescents With Acute Lymphoblastic Leukemia, chemiotherapy was started and the patient’s symptoms significantly improved as he responded well to the treatment.

IMPACT STATEMENT
This case presents a singular experience manifested in a pediatric patient with ALL who initially presented with a large and unilateral pleural effusion with the aim to highlight the importance of never underestimating the possibility of an unusual underlying cause.

Received: May 22, 2023
Accepted: Aug 21, 2023