St. Louis Children’s Hospital

The following case study was used by James P. Keating, MD, MSc, medical director, St. Louis Children’s Hospital Diagnostic Center, and his co-editor, Andrew J. White, MD, division director of pediatric rheumatology/immunology, as part of the “Patient of the Week” (POW) series. Many of the POW case studies cover uncommon illnesses, or common illnesses with unusual symptoms that can be overlooked. If you would like to be added to the POW e-mail distribution list, send an e-mail message to jkeating@wustl.edu or white_a@wustl.edu.

PL1: Nisren Soufi

PL2: Doug Moeckel

Ped Surg: Pat Dillon/Angela Dietrich-Kusch

PICU: Matt Goldsmith

Ped: Jim Kemp

Neuro: Doug Larsen

A 9-year-old male was admitted with CC: tachypnea and fever for two days.

Course: Admitted to PICU. Rx: ceftriaxone, vancomycin and azithromycin, and intravenous fluids.

PE: T 36.5 RR 80 HR 120 SAO2 98% (O2 by nasal catheter). Difficulty speaking due to SOB. Intercostal and supraclavicular retractions. Decreased breath sounds in R lower thorax. Films showed a large R pleural effusion, and video-assisted thoracoscopy (VATS) drained a large volume (>200ml) of yellow turbid fluid from the R pleural cavity. Extensive fibrinous exudate was removed from the visceral and parietal pleura with Yankhauer (tonsil suction) device and a ring forceps to free the lung. A chest tube was placed under direct vision with the tip toward the apex. The fluid contained neutrophils and gram positive cocci (no growth at this point).

Diagnosis:

1. Pneumonia with empyema, candidate organisms include staphylococcus aureus, group A beta hemolytic streptococcus and pneumococcus.

Course: On HD #4 he was stable and moved to the floor (1500 hrs). His chest tube was changed to water seal. The intern was called to his bedside (2300 hrs) because he was dizzy and nauseous (resolved with reassurance) and noted that the R pupil was 2 mm and the L pupil was 3 mm. She asked her resident to verify her finding. With the lights lowered, the anisocoria was even more striking and slight ptosis was also noted. The pupils both constricted to light. The chest tube was pulled back.

Their initial thoughts included:

1. Temporal lobe herniation on L. Unlikely with normal LOC, intact light reflex and no long tract signs, nor focal signs, headache, hypertension, bradycardia.
2. Residual atropine effect. He had sedation a few hours previously (PICC placement) but had not received atropine.
3. An otherwise subclinical seizure can cause anisocoria. Unlikely with no evidence of seizure and the presence of new ptosis.
4. Horner’s syndrome (HS).

Horner’s syndrome due to local changes in the area of the superior cervical (stellate) ganglion, which lies beneath the parietal pleura near the apex of the lung, is the probable explanation for the anisocoria and ptosis. We cannot easily determine if he has anhidrosis on the R cheek but it is likely. The oral cavity showed no evidence of contusion in the area of the R tonsil or pharynx, which would be an alternative explanation of acquired Horner’s syndrome. If the HS were due to an intra-oral injury, anhidrosis would be absent since the sudomotor fibers follow the external carotid at the bifurcation and would not be affected by an injury to the plexus as it courses with the internal carotid artery behind the tonsils and pharyngeal muscle layer. Happily, children, are not likely to suffer from the malignancies that lead to HS in adults, although there are reports of neuroblastoma presenting with HS in childhood.

Nice pick-up and management by a busy intern-resident pair.

References

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3. Liu GT, Deskin RW, Bienfang DC. Horner’s syndrome caused by intra-oral trauma. Journal of Clinical Neuro-Ophthalmology 1992; 12(2):110-115.
4. Pitner SE. Carotid thrombosis due to intraoral trauma: An unusual complication of a common childhood accident. New Eng J Med 274, 764-767. 1966.
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8. Vijayan N. Pneumothorax and Horner’s syndrome. N Eng J Med 1973; 288(11):583-584.
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