An extra piece of grey

A 14-year-old boy presented to the paediatric accident and emergency with a 2-week history of right-sided pleuritic chest pain, cough and intermittent fevers. A chest radiograph (CXR) was performed (figure 1A), and he was discharged home with advice to return if symptoms did not resolve. Figure 1 (A) Initial chest X-ray. (B) Repeat chest X-ray. He re-presented a week later with increased work of breathing, chest pain and temperature spikes up to 38.5°C. On clinical examination, there was dullness on percussion and reduced breath sounds on the right side. The repeat CXR is shown in figure 1B. The initial blood investigations showed a normal white cell count and raised C-reactive protein of 303 mg/L (0–10). He was tachypnoeic, requiring 1–2 L of oxygen, and was commenced on intravenous co-amoxiclav and clarithromycin. A chest ultrasound demonstrated a large pleural effusion, and he was transferred …