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CASE REPORT

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.

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CASE REPORT

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  1. CASE REPORT 洪嘉蔚 醫師 / 吳維峰 主任 台北市立仁愛醫院 小兒科

  2. 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

  3. Chief Complaint • Fever off and on for 8 days

  4. Present Illness • A 6 year-old boy suffered from fever off and on for 8 days. He 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 showed lobar pneumonia.

  5. 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

  6. Physical Examination: • Vital sign: BT 39.9, PR:120 bpm, RR 32/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

  7. CBC/DC

  8. Urinalysis

  9. Biochemistry

  10. Blood culture • 5/3 NO GROWTH • 5/7 NO GROWTH

  11. Urine culture • 5/5 NO GROWTH

  12. Serology CRP • 5/4 163 mg/l • 5/7 126 mg/l Mycoplasma Pneumoniae Antibody • 5/4 NEGATIVE

  13. 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 was still noted. • Gentamicin was added on 5/4 due to pyuria of urinalysis and suspected UTI

  14. 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.

  15. Serology • 5/7 IgA 126 (70-400) IgM 105 (40-230) IgG 778 (700-1600) • 5/8 Measles IgM (-) Rubella IgM (-)

  16. 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 and showed exudate effusion. So we do chest tube insertion. About 200ml of yellow-reddish fluid was drained.

  17. 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 pleural effusion.

  18. Abdominal echo • Date 91/05/07 • Ultrasonic Impression: Negative finding of abdominal ultrasonography

  19. Pleural Effusion Study (I) 5/8 Pleural fluid • Appearance cloudy • Color reddish-yellow • Bloody (+) • Chylous (-) • Coagulation (+) • Sp. Gr. 1.025

  20. Pleural Effusion Study (II) • WBC 630 cumm Polynuclear cells 55.0% Mononuclear cells 45.0% Abnormal cells (-) • Pleural, Acid-Fast Stain: Not Found • Pleural, Gram’s Stain: Not Found

  21. Pleural Effusion Study (III) Pleural Effusion • Glucose 71 mg/dl • LDH 3149 IU/L (H) • Protein 3.30 g/dl (L)

  22. Pleural Effusion Study (IV) • Pleural effusion culture on 5/8 no growth on 5/13 no growth

  23. Pleural Effusion Study (V) • 5/8 Pleural effusion cytology: No evidence of malignancy • 5/14 Pleural PCR assay for mycobacteria result: Negative

  24. Hospital Course (IV) • On 5/10, followed CBC/DC showed leukocytosis with left shift (WBC 19570, Neu 92.9%). Persistent high fever was noted. So Cefuroxime was changed to Ceftriaxone 1g IV q12h • High fever up to 40C persisted in spite of Ceftriaxone + Gentamicin + Erythromycin combined use

  25. CBC/DC

  26. Urinalysis

  27. Biochemistry

  28. Blood culture • 5/3 NO GROWTH • 5/7 NO GROWTH • 5/11 NO GROWTH

  29. Urine culture • 5/5 NO GROWTH • 5/10 NO GROWTH • 5/12 NO GROWTH

  30. Serology (I) CRP • 5/4 163 mg/l • 5/7 126 mg/l • 5/14 113 mg/l

  31. 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)

  32. Serology (III) • 5/14 Heterophil Ab: Negative ANA Negative • 5/14 Legionella Ab: Negative Chlamydia Ab: Negative

  33. 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

  34. Serology (I) Mycoplasma Pneumoniae Antibody • 5/4 Negative • 5/7 160X • 5/14 320X

  35. Pleural Effusion Study (II) • 5/8 Pleural fluid for Mycoplasmal pneumonia antibody: 80X

  36. Serology (III) • 5/16 Cold hemaglutination: 512 X (<32X)

  37. 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 of 5/14. • Steroid was tapered gradually • On 5/20, patient was discharged under stable condition.

  38. CBC/DC

  39. Biochemistry

  40. Serology (I) CRP • 5/4 163 mg/l • 5/7 126 mg/l • 5/14 113 mg/l • 5/30 5.2 mg/l

  41. Final Diagnosis • Mycoplasmal lobar pneumonia, complicated with prolonged fever, skin rashes, right lung pleural effusion, and hemolytic anemia

  42. DISCUSSION

  43. 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.

  44. Clinical Manifestations • M. 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.

  45. Pneumonia is the most important clinical manifestation of M. pneumoniae infection. * Bronchopneumonia pattern 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.

  46. Cutaneous manifestations : common. * Exanthem and enanthem of Mycoplasma 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 and Stevens-Johnson syndrome. Clini Pediatrics 1991:30(1),42-9

  47. 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 administration may be beneficial. South Med J 1990;83(9):1106-8

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