(1217) Tension Hydrothorax in a 3-Year-Old Patient With Community-Acquired Pneumonia

Introduction: Tension hydrothorax, an emergent condition where pleural fluid accumulation leads to significant mediastinal shift and obstructive shock, is an uncommon but critical complication of community-acquired pneumonia (CAP) in children.

Description: A 3-year-old previously healthy and fully vaccinated female with 3 days of fever, cough, and 1 day of shortness of breath presented to the pediatric emergency department via EMS after evaluation at an outpatient clinic, given albuterol with some improvement. However, upon arrival to the emergency department she was ill-appearing with heart rate 196, blood pressure 62/32, respiratory rate 41 and oxygen saturation of 93% on non-rebreather oxygen mask. Physical exam was significant for diminished breath sounds on the left chest. The patient did not improve with increased respiratory support with continuous positive airway pressure. A chest radiograph was obtained which showed large left pleural effusion and mediastinal shift. A left sided small-bore chest tube was emergently placed which drained cloudy fluid and the patient’s vital signs rapidly improved. The patient was admitted to the pediatric intensive care unit and treated with empiric antibiotics. The chest tube drained 700mL of pleural fluid and she was weaned off oxygen support in less than 24 hours. Pleural fluid analysis identified Group A Streptococcus Pyogenes. The chest tube was removed on day 3, and she was discharged on day 7. At time of discharge, she was asymptomatic with normal physical examination and clear chest X-ray.

Discussion: Tension hydrothorax secondary to CAP is rare in children and the resulting obstructive shock can easily be confused with other more common etiologies of respiratory failure and shock, such as septic shock. Previously, tension hydrothorax in children has been reported in cases of malignancy, malfunctioning ventriculopleural shunt, and foreign body ingestion. Early recognition and management are crucial to preventing cardiac and respiratory collapse. Diagnosis should be made rapidly with radiograph or point-of-care ultrasound. This case demonstrates the necessity for comprehensive diagnostics and prompt intervention in pediatric patients presenting with tension hydrothorax.