A child with acute lymphocytic leukaemia

The patient was a child aged 5 years who had been diagnosed to have acute lymphocytic leukemia (ALL). Chemotherapy was given with wysolone, vincristine, daunomycin, l-asparaginase, and intrathecal methotrexate. In addition he was given fluconazole and co-trimoxazole to cover infections during the induction period of the chemotherapy). During the second week after the start of treatment he complained of pain on the right lower chest. On examination, there was tenderness in the right 6th and 7th intercostal spaces. Breath sounds there were normal and there were no adventitious sounds. The following day he had cough and fever and continuing chest pain, and now a right basal pleural rub could be heard on auscultation. Over the next few days his condition worsened and he developed tachypnoea and dullness to percussion with crackles over the right lower chest. Chemotherapy drugs were temporarily discontinued. The following test results were available: [Hb]6.8 g/dl; total lymphocyte count 500/ul; platelets 24,000/ul; blood taken for culture and sensitivity: initially this yielded no growth, and a further blood sample was taken for culture. Throat swab culture showed growth with Klebsiella pneumoniae resistant to all antibiotics except tigicycline. The second blood culture yielded a methicillin-resistant Staphylococcus aureus (MRSA). Treatment over the next few days included oxygen and a variety of antibiotics. Blood products were transfused. He continued to have fever spikes.