LAUSR

A 19-year-old woman with a history of trisomy 21, obesity, and atopic dermatitis presented to the emergency department (ED) with 48 hours of epigastric pain and vomiting. Prior to presentation, her family reported that the patient had more than 20 episodes of nonbloody, nonbilious emesis and had been unable to tolerate any oral intake without emesis. On arrival to the ED, vital signs were notable for tachycardia and intermittent tachypnea. Her lungs were clear and equal bilaterally and abdominal examination was described as soft and nontender. Lab work was notable for an elevated lipase (5946 U/L) and mild leukocytosis (white blood cell count 14.6 103/μL). Serum hemoglobin, calcium, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total bilirubin, and triglyceride levels were all within normal range. An abdominal plain film was obtained demonstrating a normal bowel gas pattern and elevated left hemidiaphragm of uncertain etiology, considered by the radiologist to be due to possible left diaphragm dysfunction (Figure 1). She was subsequently admitted to the hospital pediatrics (HP) service for supportive management of pancreatitis. On arrival to the HP service, she was started on 1.5× maintenance intravenous fluids and antiemetics with the goal of early and aggressive fluid resuscitation, per the most recent pediatric pancreatitis management recommendations.1-3 On the morning of hospital day 1, the patient developed worsening tachycardia, which was attributed to a combination of pain and dehydration in the context of persistent emesis. Oxygen saturations ranged between high 80s and mid 90s and initially improved with changes in neck position. Pain control was optimized, and she was given a 1 L normal saline bolus, resulting in a transient improvement in her heart rate. Thyroid studies were obtained to rule out other possible causes of tachycardia given known trisomy 21 and were within normal limits. Later in the day she developed persistent retching and dark, guaiac-positive emesis. She was subsequently started on intravenous pantoprazole for presumed gastritis. Overnight, the patient became febrile to 38.2°C and tachypneic with desaturations to the high 80s requiring oxygen via nasal cannula. A chest radiograph was obtained and re-demonstrated left diaphragm elevation, but additionally showed rightward shift of the heart and mediastinum. This was read as likely due to mass effect from a large left pleural effusion, secondary to either pancreatitis or a new left-sided pneumonia. Additional imaging was quickly obtained including an abdominal ultrasound which showed echogenicity of the pancreatic head, consistent with the working diagnosis of pancreatitis. Chest ultrasound showed a large left pleural effusion with possible lingular and left lower lobe pneumonia, including multiple areas of necrosis and pneumatoceles. The patient’s chest radiograph also showed a large gastric bubble, so a nasogastric tube was placed to decompress the stomach. A chest radiograph was repeated 8 hours later showing opacification and air fluid levels in the left hemithorax supportive of a diagnosis of necrotic pneumonia, but also raising the possibility of an unusual presentation of diaphragmatic hernia. Therefore, a computed tomographic (CT) scan of her chest, abdomen, and pelvis ultimately revealed the unifying diagnosis (Figure 2).