Refractory pneumonia and high fever.

In June, 2008, a previously healthy and fully immunised 30-month-old girl was seen by her GP with a 7-day history of fever (temperature up to 40°C). Physical examination was consistent with pharyngitis, and amoxicillin was prescribed. The fever persisted and the child developed a produc tive cough, so she was admitted to our emergency department. On presentation, she was febrile, irritable, tachypnoeic, and tachycardic with a blood pressure of 110/60 mm Hg. Lung auscultation showed reduced breath sounds on the right side. Oxygen saturation was 97% on room air. Medical history was unremarkable. Blood test results showed: erythrocyte sedimentation rate (ESR) 99 mm/h, C-reactive protein (CRP) 278 mg/L, white blood cell count 13·7×109/L (neutrophils 86%), haemoglobin 110 g/L, platelets 31·2×109/L, and total proteins 48 g/L (serum albumin 37%). Liver function tests, creatinine, IgG, IgA, IgM, and urine analysis were normal. Chest radio graph showed a mild pleural eff usion in the right lung. Tests for common viral and bacterial infections were nega tive. Intravenous ceftriaxone and oral clarithromycin, fl u ids, and other supportive measures were administered.