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A previously healthy 2½12 year old boy with varicella infection presented five days later with high fever, productive cough, and dyspnoea.
On admission, he had signs of respiratory distress and poor perfusion. He was pale and dyspnoeic, with a temperature of 41.2°C and 96% saturation in room air. Lung auscultation revealed bronchial breath sounds in the right upper field. Resolving lesions typical of varicella were seen on skin examination. The rest of the physical and neurological examination was normal. Chest x ray showed consolidation in the right upper lobe with air bronchogram. A diagnosis of lobar bronchopneumonia was made and IV ceftriaxone was started.
On day 5, chest x ray showed an airspace cavity with air fluid level at the anterior segment of the right upper lobe. On lateral decubitus a shifting of the same level was noted, indicating a free fluid containing cavity (figs 1 and 2). Antibiotic treatment was continued for four weeks, leading to complete clinical resolution. No invasive procedure was performed. Chest x ray performed three months after admission was unremarkable.
Lung abscesses are circumscribed, thick walled cavities in the lung containing purulent material. Diagnosis is usually made on the basis of characteristic roentgenographic findings. The abscess cavity becomes visible when air entering from the bronchus creates an air–fluid level over the pus and may be missed if only a supine film is taken.
Asher and Levershe1 noted that the roentgenographic appearance of a lung abscess is often dramatic and may therefore cause considerable alarm and lead to overtreatment. They argue that “children with a lung abscess usually do well with antibiotic therapy alone, and it is unusual to require other therapy”.
In our patient, the lung abscess followed a varicella infection. Conservative treatment with intravenous antibiotics for four weeks led to a complete recovery.