We report two interesting cases highlighting the value of repeat chest radiograph in a child presenting with pneumonia. First is a case of hereditary haemorrhagic telangiectasia in the chest presenting as pneumonia in 4 year old child. He presented to the children's hospital with cough and fever, and a chest radiograph showed rounded opacity in the left lower lobe, presumed to be a round pneumonia. He had persistent symptoms despite antibiotic treatment. A repeat chest x ray (figure 1) showed the rounded opacity to be persistent. A subsequent CT scan of the chest revealed a pulmonary arteriovenous malformation in left lower lobe for which he underwent percutaneous embolisation. Revisiting the family history revealed hereditary haemorrhagic telangiectasia on the paternal side.
Second is a case of anterior mediastinal cystic hygroma which became apparent on a repeat chest x ray. She presented with a similar history of cough and fever, and a chest radiograph (figure 2) showing bilateral pneumonia with minimal effusion on the left. A repeat chest radiograph (figure 3) after a course of antibiotics showed widened upper mediastinum with suspicion of a mass on the left side. A CT scan showed an abnormal left anterior mediastinal mass which was initially suspected to be teratoma. A percutaneous biopsy of the mass was inconclusive. She then underwent resection of the mass which revealed to be mediastinal cystic hygroma. She also had a history of cystic hygroma removed from the neck at the age of 2 years.
Pneumonia is one of the most common infections in children, with an annual incidence of 34 to 40 cases per 1,000 children. As per nice guidelines, follow-up radiography is not required in those who are previously healthy and who are recovering well, but should be considered in those with a round pneumonia, collapse or persisting symptoms. These two cases reinforce the value of repeat chest radiograph while treating children with pneumonia.