A 13-year-old girl is admitted for fever, cough, and malaise for the past two days. She has no history of sick contacts and all her immunizations are up to date. Her leukocyte count is 21,000/mm³ with 7% band forms. Upright chest x-ray findings are shown in the image below: Which of the following is the most likely location of the pathologic process in this patient?

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11ec160b_35d9_f381_9249_e3c96159f7eb_MD0001_00 This patient has fever, productive cough, leukocytosis with left shift, and an area of consolidation on chest x-ray that is consistent with lobar pneumonia. Pulmonary consolidation occurs when the air in alveoli is replaced with a substance (eg, edema, pus, blood, cellular debris) that results in a region of opacification on radiographs. The borders of a consolidation tend to be indistinct as the alveoli become more sporadically involved at the peripheral portions of the disease process. However, if the consolidation abuts a fissure (eg, oblique, horizontal), it can be sharply defined because the consolidation cannot directly spread across the fissure to another lobe. This patient's consolidation is sharply defined inferiorly by the horizontal fissure, which is present only in the right lung and separates the right upper lobe from the right middle lobe. Although multiple radiographic views are usually required for localization of a lung lesion, this patient's findings on lateral radiograph are consistent with right upper lobe pneumonia. Other features that can help localize a lobar pneumonia include: (Choices B and D) In an upright chest x-ray, large accumulations of fluid in the pleural space (eg, pleural effusion) can blunt the costophrenic angles and spread across lung fissures to involve the area around more than one lung lobe. Educational objective: Pulmonary consolidation is caused by the accumulation of material (eg, fluid, cellular debris) in the alveoli, which can be visualized on radiographs as an area of opacification with indistinct borders. A sharply defined horizontal or oblique line indicates that the consolidation abuts one of the lung fissures. Consolidation that is sharply defined inferiorly by the horizontal fissure is consistent with right upper lobe pneumonia.

A 13-Year-Old Girl Is Admitted for Fever, Cough, and Malaise