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New diagnosis of common variable immunodeficiency in a 12-year-old with pneumonia: an illustrative case.

Case: The patient was a 12-year-old African American male who presented to our hospital from a community hospital for further care of a worsening left-sided pneumonia. His mother reported a 3-week history of intermittent cough and fever at home before his community hospital admission. She had been treating these symptoms with over-the-counter cough remedies at home but became concerned because his symptoms were not improving. The patient also had diagnoses of idiopathic bronchiectasis and selective immunoglobulin (Ig) A deficiency (reported according to history). He had required hospital admission for bacterial pneumonia several times during his life, and he was well below the 1% mark for height, weight, and BMI for his age. At the community hospital, he was treated aggressively with weight-appropriate doses of ceftriaxone and vancomycin. Despite treatment, the patient’s symptoms had not improved. Repeat imaging at the community hospital demonstrated worsening status of his pneumonia. On admission to our hospital, he was not in marked respiratory distress requiring invasive respiratory support. However, it was noted that he was extremely thin, had decreased to no air movement at the left lung base, had severe digital clubbing, and was coughing frequently with dyspnea on minimal exertion. His chest radiograph (Fig 1) and chest computed tomography scan (Fig 2) from the community hospital were interpreted by our pediatric radiologists to show a left-sided necrotizing pneumonia with concern for empyema.



FIGURE 1 
Chest radiograph at admission to the community hospital showing opacification of much of the left hemithorax with areas of cystic lucency that were thought to represent necrotizing pneumonia.





FIGURE 2 
Chest radiograph from the community hospital showing evidence of severe necrotizing pneumonia on left with multiple fluid collections and gas collections throughout the consolidated left lung. A large, complex pleural fluid collection is also seen with areas of gas and enhancing septations concerning for …