Abstract Background Diaphragmatic paralysis (DP) is an uncommon but clinically significant complication of thoracic disease and intervention in children. It may arise from phrenic nerve injury secondary to infection, inflammation, or mechanical trauma. We present a case of reversible right-sided diaphragmatic paralysis following complicated pneumonia and chest tube drainage in a child with isovaleric acidemia. Case Presentation An 8-year-old girl with well-controlled isovaleric acidemia presented after three hospitalizations within one month for recurrent right-sided pneumonia. Initial admission revealed rhinovirus/enterovirus infection and right lower lobe pneumonia treated with ceftriaxone and amoxicillin. After transient improvement, she was re-hospitalized twice for recurrent symptoms and progressive pleural effusion despite antibiotics. Computed tomography demonstrated right lower lobe consolidation, a large effusion, and hilar lymphadenopathy. A chest tube placed by interventional radiology drained approximately 500 mL of serous fluid. Extensive infectious workup including aerobic, anaerobic, fungal, and mycoplasma cultures, broad-range bacterial PCR, and serologic testing for Histoplasma and Legionella was negative. She completed a 10-day course of amoxicillin-clavulanate after tube removal, with resolution of infection.At outpatient follow-up, persistent elevation of the right hemidiaphragm was noted. Ultrasound confirmed right diaphragmatic paresis with paradoxical movement. Pulmonary function testing demonstrated impaired cough (peak cough flow = 130 L/min; normal ≥ 270 L/min). She completed a 13-session cardiopulmonary rehabilitation program, achieving clinical stability without dyspnea. At six months, imaging confirmed full recovery of diaphragmatic motion and improved cough flow (209 L/min). Discussion This case illustrates an acquired, reversible phrenic nerve palsy likely related to apicomedial chest tube placement. Potential mechanisms include mechanical compression, stretch, or ischemic neuropathy of the phrenic nerve along its pericardial course. Similar complications have been described following mediastinal drain insertion or thoracic surgery but rarely in otherwise healthy school-aged children.Diagnostic evaluation of suspected DP should include radiography and ultrasound, the latter offering 90% sensitivity and specificity with excellent safety and bedside feasibility. Management is typically conservative in non-ventilator-dependent patients, emphasizing respiratory physiotherapy and close monitoring, as spontaneous recovery occurs in up to 80% within one year. Surgical options such as diaphragmatic plication are reserved for persistent symptomatic cases. Conclusion Acquired diaphragmatic paralysis is an uncommon complication of chest tube drainage in pediatric pneumonia. Awareness of the phrenic “danger zone” near the mediastinum is essential to reduce risk. Prompt recognition with ultrasound and supportive rehabilitation can lead to full recovery and avert unnecessary surgical intervention. This abstract is funded by: None
Mull et al. (Fri,) studied this question.