A 2-year-old male with a history of solitary kidney presented with greater than one month of daily coughing, wheezing, and decreased appetite. The patient was previously seen by his primary care physician after three weeks of symptoms where he was prescribed albuterol as needed for viral bronchospasm. The patient’s wheezing did not improve after two weeks of albuterol treatment so a chest x-ray was ordered. The patient’s mother denied any fevers, vomiting, diarrhea, weight changes, or night sweats.
Vitals: BP 131/60; Pulse 148; Temp 36.7 °C (98.1 °F) (Axillary); Resp 28; Wt 15.7 kg (34 lb 9.8 oz); SpO2 95% General: Alert; well appearing HEENT: Pupils equally reactive to light; moist mucous membranes; nares with normal mucosa without discharge Cardiovascular: Regular rate; regular rhythm; normal S1, S2; no murmur noted; distal pulses 2+ Pulmonary: Good aeration throughout all lung fields; clear breath sounds bilaterally; prolonged expiratory phase; stridor with agitation Abdomen: Soft; non-tender; non-distended White blood cell (WBC) count: 56.1/uL (Blasts 58%) Platelets: 288/uL Uric acid: 8.3 mg/dL LDH: 2231 iU/LD D-Dimer: 3.22 ug/mL Fibrinogen: 463 mg/dL Bronchospasm, bronchiolitis, viral infection, pneumonia, foreign body aspiration, space-occupying lesion, vocal cord dysfunction, cardiac dysfunction, and acute chest in patients with sickle cell disease. The radiograph shown demonstrates a mediastinal mass. This patient was ultimately diagnosed with T-cell acute lymphoblastic leukemia. T-ALL can present with fatigue, fevers, weight loss, easy bleeding/bruising, paleness, or a mediastinal mass. Mediastinal masses found on chest x-ray require further evaluation to determine the diagnosis, location, and treatment. If malignancy is suspected, an oncology referral and bone marrow sample will be necessary.Take-Home Points
Copyright
Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

Jane Rivas, MD
Medical College of Wisconsin

Latest posts by Jane Rivas, MD (see all)
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Christine Fernandez, MD
Department of Pediatrics
Medical College of Wisconsin

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- SAEM Clinical Images Series: ‘Tis Not the Season to be Wheezing - November 21, 2022

Wendy Wendt, MD
Medical College of Wisconsin

Latest posts by Wendy Wendt, MD (see all)
- SAEM Clinical Images Series: A Rare Pediatric Scalp Rash - April 10, 2023
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- SAEM Clinical Images Series: ‘Tis Not the Season to be Wheezing - November 21, 2022