CASE REPORT.ppt

1、CASE REPORT,洪嘉蔚 醫師 / 吳維峰 主任 台北市立仁愛醫院 小兒科,General Data,Name: 李 小弟 Birth day: 85/04/24 Age: 6 y/o Chart number: 15213493 Admission day: 91/05/03 Discharge day: 91/05/20 BW: 22 Kg,Chief Complaint,Fever off and on for 8 days,Present Illness,A 6 year-old boy suffered from fever off and on for 8 days. He

2、also complained of cough, rhinorrhea and difficult to expectorate sputum. He was taken to LMD twice and our OPD on 91/04/30, but the symptoms persisted in spite of drugs use. So he was taken to our OPD again on 91/05/03. Physical examination revealed decreased breathing sound on right chest. CXR sho

3、wed lobar pneumonia.,Brief history,Birth Hx: GA: 39 Wks, BBW:3050 gm, NSD Previous admission: Denied Vaccination: As schedule Allergy Hx: Denied Food exposure: Denied Drug exposure: Denied Recent travel: Denied Family Hx: Non-contributory,Physical Examination:,Vital sign: BT 39.9, PR:120 bpm, RR 32/

4、min General appearance: Acute-ill looking HEENT: No gross anomaly Conjunctiva: not injected Throat: mild injection Chest: Symmetric expansion Retraction: no decreased breathing sound: right lung, fine moist rales(+) percussion: dullness of right chest,CBC/DC,Urinalysis,Biochemistry,Blood culture,5/3

5、 NO GROWTH 5/7 NO GROWTH,Urine culture,5/5 NO GROWTH,Serology,CRP 5/4 163 mg/l 5/7 126 mg/l Mycoplasma Pneumoniae Antibody 5/4 NEGATIVE,Hospital Course (I),Initially (5/3), empiric antibiotics with Cefuroxime 500mg IV q6h and Erythromycin 250mg PO q6h were used, but intermittent high fever up to 39C

6、 was still noted. Gentamicin was added on 5/4 due to pyuria of urinalysis and suspected UTI,Hospital Course (II),On 5/5, multiple fine, discrete, rubella-like skin rashes developed on the face, trunk and extremities with itchy sensation. Vena infusion and Sinbaby lotion were used for symptom relief.

7、,Serology,5/7 IgA 126 (70-400) IgM 105 (40-230) IgG 778 (700-1600) 5/8 Measles IgM (-) Rubella IgM (-),Hospital Course (III),On 5/7, followed CXR showed massive amount of pleural effusion, right lung. So we do chest CT, and erythromycin was changed to 220mg IV q6h On 5/8, thoracocentasis was done an

8、d showed exudate effusion. So we do chest tube insertion. About 200ml of yellow-reddish fluid was drained.,Chest CT,Date 91/05/07 Impression: Consolidation of right lower lobe and medial segment of middle lobe, pneumonia is likely. Moderate amount of right pleural effusion and scanty amount of left

9、pleural effusion.,Abdominal echo,Date 91/05/07 Ultrasonic Impression: Negative finding of abdominal ultrasonography,Pleural Effusion Study (I),5/8 Pleural fluid Appearance cloudy Color reddish-yellow Bloody (+) Chylous (-) Coagulation (+) Sp. Gr. 1.025,Pleural Effusion Study (II),WBC 630 cumm Polynu

10、clear cells 55.0% Mononuclear cells 45.0% Abnormal cells (-) Pleural, Acid-Fast Stain: Not Found Pleural, Grams Stain: Not Found,Pleural Effusion Study (III),Pleural Effusion Glucose 71 mg/dl LDH 3149 IU/L (H) Protein 3.30 g/dl (L),Pleural Effusion Study (IV),Pleural effusion culture on 5/8 no growt

11、h on 5/13 no growth,Pleural Effusion Study (V),5/8 Pleural effusion cytology: No evidence of malignancy 5/14 Pleural PCR assay for mycobacteria result: Negative,Hospital Course (IV),On 5/10, followed CBC/DC showed leukocytosis with left shift (WBC 19570, Neu 92.9%). Persistent high fever was noted.

12、So Cefuroxime was changed to Ceftriaxone 1g IV q12h High fever up to 40C persisted in spite of Ceftriaxone + Gentamicin + Erythromycin combined use,CBC/DC,Urinalysis,Biochemistry,Blood culture,5/3 NO GROWTH 5/7 NO GROWTH 5/11 NO GROWTH,Urine culture,5/5 NO GROWTH 5/10 NO GROWTH 5/12 NO GROWTH,Serolo

13、gy (I),CRP 5/4 163 mg/l 5/7 126 mg/l 5/14 113 mg/l,Serology (II),5/13 Direct Coombs test: positive Indirect Coombs test: positive 5/14 RA 10.2 IU/ML (40.0) C3 166.0 mg/dl (90.0-180.0) C4 21.4 mg/dl (10.0- 40.0),Serology (III),5/14 Heterophil Ab: Negative ANA Negative 5/14 Legionella Ab: Negative Chl

14、amydia Ab: Negative,Ga-67 Inflammation Survey,Date 91/05/15 A patch of abnormal tracer uptake at the right lower lung field, may be inflammatory focus. Diffusely increase uptake of liver. This phenomenon can be found in iron deficiency anemia,Serology (I),Mycoplasma Pneumoniae Antibody 5/4 Negative

15、5/7 160X 5/14 320X,Pleural Effusion Study (II),5/8 Pleural fluid for Mycoplasmal pneumonia antibody: 80X,Serology (III),5/16 Cold hemaglutination: 512 X (32X),Hospital Course (V),Chest tube was removed on 5/13 We used prednisolone (2mg/kg/day in 4 divided doses) on 5/14. Fever subsided on the night

16、of 5/14. Steroid was tapered gradually On 5/20, patient was discharged under stable condition.,CBC/DC,Biochemistry,Serology (I),CRP 5/4 163 mg/l 5/7 126 mg/l 5/14 113 mg/l 5/30 5.2 mg/l,Final Diagnosis,Mycoplasmal lobar pneumonia, complicated with prolonged fever, skin rashes, right lung pleural eff

17、usion, and hemolytic anemia,DISCUSSION,Mycoplasma Pneumoniae,In 1944, M. pneumoniae was reported by Monroe Eaton, originally called the Eaton agent. Smallest free-living microorganism, belongs to the class Mollicutes. Mycoplasmas lack a cell wall, so tend to be pleomorphic.,Clinical Manifestations,M

18、. pneumoniae causes approximately 20% of all cases of pneumonia. Peak incidence at 6-21 years of age. Incubation period of 2-3 weeks. Transmission by inhalation of infected droplet aerosols.,Pneumonia is the most important clinical manifestation of M. pneumoniae infection. * Bronchopneumonia pattern

19、 mostly. Lobar pneumonia and large amount pleural fluid are unusual. Pediat Radiol 1989;19(8):499-503 * Respiratory disease other than pneumonia: unspecific URI, pharyngitis, AOM, croup, sinusitis, bronchitis, bronchiolitis, asthma.,Cutaneous manifestations : common. * Exanthem and enanthem of Mycop

20、lasma pneumoniae infection are observed in 5 to 24% of cases AAP, Report of Committee on Infectious Diseases, 1994:333-5 * Most common with an erythematous maculopapular rash on the trunk and back; discrete (rubelliform) or confluent (morbilliform). * Most serious presentation: Erythema multiforme a

21、nd Stevens-Johnson syndrome. Clini Pediatrics 1991:30(1),42-9,Hematologic manifestations: * Hemolytic anemia: usually mild, however, it may become severe and result in 50% reduction in hemoglobin concentration. Pediat Infec Dis J 1998;17(2):173-7 * Direct Coombs test usually positive. * Steroid admi

22、nistration may be beneficial. South Med J 1990;83(9):1106-8,Hemolytic anemia is presumably related to the presence of cold agglutinins in serum which at high concentration, may agglutinate erythrocytes at 37 Rev Pneumol Clin 1990,46(2),83-4,Gastrointestinal findings are nonspecific with nausea, vomi

23、ting, abdominal pain, and/or diarrhea. Neurologic disease association was reported 2.6-4.8%. * Encephalitis, meningitis, transverse myelitis, psychosis, Bell palsy and Guillain-Barre syndrome. Arthritis in association with M.pneumoniae infection have not been established.,Hepatitis was once thought

24、to be unusual, but recent studies suggest that liver dysfunction may be present in up to 30% of M. pneumoniae infection. Pediatr Pulmonol 1990;8:182-7,Liver dysfunction was observed more frequently in patients with pleuropneumonia than in simple pneumonia cases. Pediatr Pulmonol 1990;8:182-7,Radiogr

25、aphic Manifestation (I),Interstitial infiltration was more commonly seen in pediatric than adult patients (46% vs 20%) Unilateral lesions 80% Single lobe lesions 77% Lower lobe predominant 69% Pleural effusion 7% 高雄醫學科學雜誌 1993;9(4):204-11,Radiographic Manifestation (II),Unilateral infiltration 84% L

26、ower lobe predominance 60% Confluent consolidation 56% Patchy consolidation 33% Pleural effusion 24% 長庚醫學雜誌 1991;14(3):156-62,Diagnosis (I),WBC, CRP, ESR are non-specific, may be normal or elevated. Growth of the organism takes weeks, generally only in expertise laboratories. PCR is sensitive and sp

27、ecific. Serologic testing : Cold agglutinins, titer of 1:64 is suggestive of infection; Anti-mycoplasmal Ab detection, fourfold or greater rise are considered diagnostic.,Diagnosis (II),Imaging : Interstitial infiltrate or bronchopneumonia pattern. Lobar consolidation and pleural effusion are uncomm

28、on but may occur.,Treatment,Erythromycin is the drug of choice. (40-50mg/kg/24hr q6h for 10-14 days). Newer macrolides: Azithromycin (10mg/kg on day 1, and 5mg/kg/24hr on days 2-5) or Clarithromycin (15mg/kg/24hr given in two divided doses for 10 days).,Empiric Therapy for Lobar Pneumonia,Clinically

29、 moderate to severely toxic, treat empirically for S. pneumonia, S. pyogens ( and H. influenzae type b in unimmunized children) In toxic children, tests for Mycoplasma should be considered because focal pneumonia is a rare presentation,Cefuroxime intravenously, ceftriaxone or cefotaxime intravenousl

30、y For anti-staphylococcal coverage, add to the above, either: nafcillin, oxacillin, or clindamycin For Mycoplasma: intravenous erythromycin or azithromycin; or oral erythromycin, azithromycin, or clarithromycin.,Pneumonia, with pleural fluid or empyema,Treat empirically for S. pneumonia, S. pyogenes, and S. aureus ( and H. influenzae type b in unimmunized children) Consider aspi