An Infant with Failure to Thrive and Persistent Tachypnea (Answers)

Winner of the Clinical Quiz Dr. Ayushi Verma, 3rd year Postgraduate Resident Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi.Question 1: Describe the findings indicated by the red, blue and green arrows in Image 1aImage 1: (a) Chest X-ray AP view: Red arrow showing overdistension of the left upper lobe. Blue arrow: Mediastinal shift to the right. White arrow: Collapse of ipsilateral remaining lung field. Green arrow: Infiltrates in the right lung. (b) Chest X-ray repeated after 10 days of admission showing resolution of infiltrates in the right lung and persistence of overdistension of the left upper lobe with mediastinal shift to the right, collapse of the ipsilateral lungAnswer:Image 1a is a chest X-ray anteroposterior view in which red arrow shows overdistension of the left upper lobe (increased translucency of the left hemithorax with flattening of the diaphragm); blue arrow shows mediastinal shift to the right; green arrow shows infiltrates in right lung (patchy opacities in right upper, middle and lower lung zones). Question 2: Describe two major findings in Image 1b Answer:Image 1b is chest X-ray repeated after 10 days of admission showing resolution of infiltrates in the right lung and persistence of (i) overdistension of the left upper lobe with (ii) mediastinal shift to the right and collapse of ipsilateral lung. Question 3: Describe the findings indicated by red, blue, yellow, and white arrows in Image 2Image 2: Computed tomography thorax: Blue arrow: hyperinflation of left upper lobe. Red arrow: Mediastinal shift toward the right side. Yellow arrow: Collapse of the underlying lung on the left side. White arrow: Consolidation in the right upper, middle, and lower lobe of the lungAnswer:Image 2 is computed tomography of thorax, with blue arrow showing hyperinflation of left upper lobe; red arrow showing mediastinal shift toward the right side; yellow arrow showing collapse of the underlying lung on the left side; white arrow showing consolidation in the right upper, middle, and lower lobe of the lung. Question 4: What is the final diagnosis based on the clinical picture and radiological imaging? Answer: The final diagnosis is congenital lobar emphysema of the left upper lobe with significant mediastinal shift to the right with right lung pneumonia. This diagnosis was made based on the history of failure to thrive, persistence of baseline respiratory distress in the form of tachypnea, and retractions despite adequate course of antibiotics and resolution of crepitations in chest, confirmed by radiological findings.Comments by Dr. Ankita Patel (Section Editor) Thank you to everyone who participated in our latest quiz. It seems many are caught up in the festivities, as we received a smaller participation than usual. The quiz provided a great learning opportunity, demonstrating how a proper combination of investigations and clinical history can simplify the diagnostic process. We hope to see greater participation in our next quiz. Wishing u all a happy Diwali along with continued learning.Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.