Clinical Pediatrics 50(9) 882–884 © The Author(s) 2011 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922811408591 http://cpj.sagepub.com Resident Rounds Introduction “A wolf in sheep’s clothing” would be an apt description for these 2 cases of suspected pneumonia that presented to 2 rural hospital emergency rooms. Pediatric cancer can present in atypical fashion in unusual sites and mimic less serious illness. We present a case of Ewing’s sarcoma of the rib that was initially diagnosed as lobar pneumonia until review by a radiologist. The second case of paraspi- nal ganglioneuroma was thought to be recurrent pneu- monia until a computed tomography (CT) scan was done for suspected appendicitis. Primary care providers and emergency room doctors should be aware of the unusual manifestations of cancer in children as early diagnosis with initiation of therapy is a major factor in improving outcome. Case 1 A 6-year-old African American male presented to the emergency room at a rural hospital with complaints of fever, chest pain localized to the right side, and difficulty breathing for 1 month. He was a known asthmatic with multiple visits to the emergency room and hospitaliza- tions. Parents reported a recent increase in frequency of exacerbations while on Singulair and albuterol. He had a nonproductive cough and denied any bruising, petechiae, vomiting, loss of weight, or bone pains. Review of other systems was negative. Surgical history was significant for tonsillectomy and adenoidectomy. Physical exam revealed that he was afebrile, alert, and active. Vital signs and cardiovascular exam were within normal limits. Chest movements were diminished on the right side, and he was noted to have tenderness on palpation of the chest wall with decreased breath sounds over right infra-axillary and infra-mammary regions. No rales, rhonchi, or wheezing were evident. His abdominal, central nervous system, and rest of the exams were nor- mal. His chest X-ray showed a dense opacity in the right mid lung zone and was initially interpreted as possible right middle lobe pneumonia (Figure 1). On radiology review, a destructive lesion was noted on the third rib (Figure 1) and he was referred to pediatric oncology. Biopsy of the mass and histological, immunohistochemical, and molecular markers (EWS-FL1) confirmed a diagnosis of Ewing’s sarcoma. Positron emission tomography/ computed tomography (PET/CT) scan showed hypermet- abolic soft tissue mass centered on the right chest wall involving the right third rib and bilateral pulmonary nodules and mildly increased uptake over the sacrum (Figure 2). 1 Manipal University, Manipal, India 2 Tulane University School of Medicine, New Orleans, LA, USA 3 Ochsner Hospital, New Orleans, LA, USA Corresponding Author: Raj Warrier, Pediatric Hematology/ Oncology, Ochsner Hospital, 1315 Jefferson Highway, New Orleans, LA 70121, USA Email: rwarrier@ochsner.org Thoracic Tumor Mimicking Pneumonia Aman Chauhan, MBBS 1 , Tyler Clark, BA 2 , Craig Lotterman, MD 3 , Daniel J. Bourgeois, BSc 2 , Ankit Pansara, MD 3 , and Raj Warrier, MD 3 Figure 1. Portable anteroposterior chest radiograph shows a large mass in mid lung zone of the right hemithorax in this skeletally immature patient. There is blunting of the right costophrenic angle indicating a pleural effusion. Presence of an effusion is worrisome of pleural involvement with the disease process. The right third rib shows cortical destruction medially, which indicates osseous invasion