Assembly

Snap Crackle Pop: Respiratory Failure in a Term Infant

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Author
Megan Craig, MD. John Naheedy, MD. Daniel Lesser, MD.
Divisions of Respiratory Medicine and Radiology.
University of California San Diego, Rady Children’s Hospital San Diego


Case

A previously healthy term 3-month-old male presented to his pediatrician’s office with one day of worsening tachypnea and grunting. Initial chest radiograph revealed severe bilateral patchy alveolar opacification, prompting his pediatrician to refer him to the emergency department. On arrival, he was in extremis with respiratory rate of 60 breaths per minute and SpO2 of 58% in room air. Physical exam noted an ashen, pale, listless and minimally responsive infant with severe retractions, coarse breath sounds bilaterally, and crepitus over the anterior chest wall and neck. Repeat chest radiograph performed prior to the infant receiving any positive pressure ventilation revealed extensive pneumomediastinum. He was transferred to the pediatric intensive care unit where he further decompensated, requiring intubation and mechanical ventilation within 12 hours of admission. Chest CT was obtained with findings below.

Figure 1. Axial image of CT chest
Figure 1. Axial image of CT chest
Figure 2. Coronal image of CT chest
Figure 2. Coronal image of CT chest

Question

What is the underlying pathophysiology leading to the pulmonary disease seen in the infant’s chest CT?

A. Abnormal bronchial dilation caused by infection and inflammation
B. Altered embryologic airway branching morphogenesis causing cystic malformation
C. Rupture of terminal airways distal to termination of fascial sheath
D. Pulmonary vascular occlusion due to thrombotic events

Answer