Swelling- Back of Chest

Case history ( whatever discussed and my impression i ll share for now)

One year old boy , previously had low grade fever followed by not  moving right lower limb.Minimal pain on moving upper limb also . immunized update , no history of fall .No past history of any bleeding manifestations during neonatal period and during immunizations. At the time of admission yesterday evening he was not sick .Not moving left lower limb,with main finding of restriction of hip joint movement .Other joints were normal , No focus of abscess , rashes or cutaneous bleeds. No signs of trauma .Fully conscious oriented .not allowing examination .Tone and deep tendon reflexes were normal .After sending blood for routine exam and culture patient was put on injection cloxacillin 200 mg /kg per day  and cefotaxime .Today morning baby was irritable and after noon fever became high grade and he developed the swelling back. Fast breathing proportionate to the fever , no grunt , chest air entry was normal , scattered crepitations left side .

Swelling on the back , skin was normal ,no discoloration  no signs of inflammation, tender ,no fluctuation , No crepitation elicited on touching the swelling or near areas .

Blood count was High with neutrophilia .

Not a good xray , rotated view ,not inspiratory under penetrated. But most important is costophrenic angles both sides seen clear , No evidence of pneumothorax.There is opacity on the left side mid and upper zone. No breaking down lesions. Soft tissue does nt show any air shadows

Liver enlarged and splenic shadow obvious in X ray

Possibilities considered at this age were 

Staphylococal pneumonia with pneumothorax and surgical emphysema as the first possibility . Yes we are justified in thinking that way as a sick child of that age with fever, painful hip movement ,next day with lung signs . But air entry equal , no mediastinal shift clinically ,swelling does nt feel like surgical emphysema and xray does nt show evidence of pneumothorax 

Other DDs , is it hematoma , battered baby syndrome ? any possibility of bites and stings responsible for swelling . 

In this context pneumothorax is not there , surgical emphysema not visible ,then what is the reason for swelling ? is it abscess. Possible 

As the child is sick , we planned to make it CP and taxime and Vancomycin .

Shall update tomorrow 

18/04

Baby is sick ,toxic. Pyoderma on scalp and legs .Swelling on the back is tender ,extended upwards behind neck .Skin over swelling is now shiny and red .Not moving left limb.Irritable ,deep tendon  reflexes normal .

USG hip done did nt show collection.

Inj .CP &Vanco continuing 

Other discussions and arguments .

Why stop Cloxacillin early and step up to vancomycin ? Yes partly there is logic for this argument . We all consider Vancomycin superior to Clox in staph infections . It is not .Vancomycin has superiority only in MRSA , otherwise spectrum is small , and clox ll work better in sensitive strains. Then one more argument . Why CP ? CP to have better gram positive cover.  Cloxacillin and vanco both have very narrow range. CP have good coverage including anaerobic , but not gram negative spectrum . Then another question , why should you give third generation cephalosporins ? Right ..Here almost sure that we are dealing with an infection , and staph or gram positive organism is most likely . Here we are yet to get the culture proof. The child is ill nourished , we have send the test for HIV. In a sick child we cant take risk without giving gram negative spectrum