A 13-yr-old male with fever, malaise, body pains and dry cough

A previously healthy 13‐yr‐old male was evaluated at La Spezia Hospital, La Spezia, Italy, because of a 15‐day history of fever, malaise, body aches and dry cough, which were not modified by treatment with amoxicillin. A summary of the first admission blood tests is shown in table 1⇓. The chest radiograph and the high-resolution computed tomography (HRCT) scans performed at that time are shown in figure 1a–c⇓. Treatment with ampicillin, teicoplanin and netilmycin was administered for 7 days followed (as a result of no significant clinical response) by 12 days i.v. therapy with ciprofloxacine and imipenem-cilastatine. The apyretic patient was discharged on oral ciprofloxacin. However, 2 weeks later, he was referred to the Giannina Gaslini Institute, Genoa, Italy, for further evaluations due to the recurrence of fever and dry cough. Fig. 1.— Chest radiograph (a) and high resolution computed tomography scans at two different levels (b and c) taken at the first admission. View this table: Table 1— Blood test results for the patient's first and second admission On second admission, the patient's body temperature was 37.8°C, his respiratory rate was 28 breaths·min−1 and transcutaneous O2 saturation in room air was 98%. Blood test results are shown in table 1⇑. Chest radiograph and HRCT scans are shown in figure 2a–c⇓. Fibreoptic bronchoscopy did not demonstrate any airway abnormality. Bronchoalveolar lavage (BAL) analysis showed as follows: 1) increased neutrophil percentage (35%); b) no acid-fast bacilli, viruses, fungi or malignant cells; and 3) positive cultures for Streptococcus mitis and S. milleri . Microscopic examination of transbronchial-biopsy specimens obtained from the right lower lobe showed interstitial nonspecific lymphocyte infiltration. Treatment with ampicillin-tazobactam and vancomycin was prescribed for 10 days, with only slight improvement of the clinical and laboratory parameters but no further changes in the chest radiographs. A diagnostic surgical procedure was performed and …