If the Boy Had Pneumonia, Why Did He Have Odd Sores on His Body?
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Version 0 of 1. “Is he a healthy kid?” Dr. Ingrid Polcari asked the boy’s father. He certainly looked healthy to the young dermatologist, except for the ugly, nickel-size sore that marred his otherwise smooth, plump cheek. The 5-year-old’s father had taken him in because of three awful-looking sores that appeared out of nowhere. The first one, near the right elbow, erupted a few weeks earlier; the second, on the left calf, a few days after; and the third one, on the face, just after that. His pediatrician had tried a couple of different antibiotic pills and creams, but the lesions just kept getting bigger and uglier. Other than that, the father said, his son was healthy, happy, active. “Has he ever been hospitalized?” the doctor continued. Well, the father answered a little more slowly, a couple of months earlier he was in the hospital with pneumonia. It had been a terrible experience for them all. ↓ Unrelenting Fever It started when the father was out of town. The child woke up in the middle of the night, crying hysterically, his wife told him the next day. The little boy sobbed that his tummy wouldn’t let him breathe. She wasn’t sure what to make of it, and he really seemed O.K. — he didn’t have a fever, and he was breathing fine — so she rubbed his head until he fell asleep and wrote it off as a nightmare. But then it happened again the very next night. As soon as the pediatrician’s office opened, she called to make an appointment. When the school contacted her late that morning to say her son had a high fever, she took him straight to the doctor’s office. He had a cough, so the doctor thought it might be pneumonia and ordered a chest X-ray. When the imaging proved him right, he started the boy on antibiotics. It was early in the year for pneumonia, he told the mother, but things happen. Even with the antibiotics, the child’s high fever persisted. And he was breathing fast, as if he’d been running rather than just lying in bed. His parents took turns going to the pediatrician, to the local urgent-care center and to the emergency room at Children’s Minnesota Minneapolis Hospital. He got one antibiotic after another, each covering a broader spectrum of bacteria. Still, he didn’t get better. Finally a new X-ray showed that the boy had fluid in the sac around his right lung, and he was given intravenous antibiotics. When he didn’t improve after 24 hours, the pulmonologist recommended draining the fluid. It would make the boy feel better and might reveal the bug that was causing the infection. But getting the fluid out was the real nightmare, the boy’s father recalled. A long plastic tube about the width of a pencil was inserted into the child’s side, between two of his ribs, into the sac around his right lung. This tube had to stay in place so that the fluid could be removed. And it had to be repositioned every six hours. It was heartbreaking to hear his little boy whimper when he saw the technicians coming. I don’t want to, he would say softly. But he let them do what needed to be done. He was so brave, the father recalled. ↓ His Mood Improves Just over a cup of a thick, bloody yellow fluid drained out that first day. After four days, the fluid was gone and the tube was removed. Free of the tube and the fluid compressing his lung, the boy reverted to the child his parents knew. A Nerf gun given by a friend was rediscovered, and he ran around firing at windows and walls. He still had a fever, but he was much better. He was sent home on antibiotics. Though they never knew which bug made him so sick, he had been fine for the last few weeks — until he started getting these sores, the father added. Could the sores be something he picked up in the hospital? Maybe, Polcari acknowledged. She looked carefully at each of the wounds. The one on his face was red, raised and scaly, with little spots of dried pus. The sore on his elbow looked much the same but larger — maybe the size of a quarter. The one on his leg was the smallest, less than the size of a dime. The rest of his exam was normal. Polcari thought it was some kind of infection. But the boy had already been treated for the usual suspects: streptococcus and Staphylococcus aureus. One medicine he’d been given would have treated antibiotic-resistant staph aureus (MRSA). Maybe it was some kind of fungus — they often infect the lung before moving on to other parts of the body, like the skin. Or perhaps it was a relative of the bacterium that causes tuberculosis. Those can result in strange-looking skin infections, and they definitely wouldn’t get better with the antibiotics he had taken. To find out, she told the father, they would need to biopsy the sores. ↓ Fungus at the Root It was exactly a week later when Polcari got the first clue. The pathologist identified a strange invader lurking among the child’s skin cells. It did look, he thought, like some type of fungus. They would have to wait for more testing to find out exactly which one. In the meantime, Polcari wanted to send the child to see an infectious-disease specialist, Dr. Bazak Sharon, a colleague at the University of Minnesota Masonic Children’s Hospital. There are two common types of fungus that cause both lung and skin infections. Each is endemic to a different part of the country. Coccidioidomycosis (frequently called cocci) is most commonly seen in patients living in a band that stretches from West Texas to Southern California. Blastomycosis (often called blasto) is most common in the Ohio and Mississippi River valleys. There had been a few cases of it right there in Minneapolis. These organisms live in soil, but they are usually more of a problem for dogs than for humans. Infection in humans tends to be asymptomatic or mild enough that patients rarely seek medical attention. When Sharon heard the boy’s story from Polcari, he arranged to see the child the same afternoon. He was most concerned about the possibility that the child had a fungal infection severe enough to cause a bad pneumonia and then spread throughout the body. Each of these bugs could spread to skin, bones, even brain. And they could be deadly if left untreated. The resident working with Sharon, Mollika Sajady, was in her second year of training in pediatrics. She saw the patient and his parents first. Then she presented the child’s story to Sharon. The boy was exposed to many different soils and animals over the past year or so. He had been to Texas the summer before — coccidioidomycosis territory. More recently, he visited petting zoos, orchards and farms in Minnesota. They were all sources of fungi. But Sajady was convinced that the child’s most significant exposure occurred during a family visit to his grandparents’ country home in northern Minnesota that summer. It was in a new lakeside development with lots of places to run and lots of dirt to dig up. Most notable, over the past year or so, the family told her, three dogs at the development, including one belonging to the boy’s grandparents, had been infected with blastomycosis. The grandparents’ dog and another had died. ↓ Not Just A Dog Killer When Sharon heard that, he knew they had the diagnosis. He told the boy’s parents. They were stunned. They had heard of blasto, of course, but thought it was something only dogs could get. And they knew how serious it was in dogs. Once the blasto diagnosis was confirmed, the boy started on a six-month course of treatment, which was completed a year and a half ago. Just days after starting the antifungal, the lesions on his skin started clearing up. They all healed without scarring. Today the boy enjoys telling his story — relishing his mastery of the big words that describe his infection and ordeal. Although the boy seems to have come through without scars, his parents have not. They are reluctant to take the boy back to his grandparents’ lakeside home. The father had to deliver the bad news: If they wanted to see their only grandson, they would have to come down to Minneapolis. Which, of course, they do. |