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Difficulty breathing in a 3-month-old infant
Prepared by... Virat Sirisanthana, M.D.
Department of Pediatrics, Faculty of Medicine, Chiang Mai University
Chief Complaint: Difficulty breathing
History of Present Illness
A 3-month-old girl had a 1-week history of progressive difficulty in breathing. Her mother reports that her child has turned "dark" while sucking breast milk for the last three days. Today although she is
restless, there has been no reduction in oral intake. The mother is not aware of any fever.
Past Medical History
The patient was born at Maternal-child hospital in Chiang Mai. Her birth weight was 3000 kg. Her mother had history of positive VDRL at the first trimester, which was treated with penicillin injection.
The patient's birth history was uneventful. After birth she has been well until this admission.
Immunization History
She received the routine vaccinations (BCG at birth, DPT and OPV at 2 -month-old).
Family History
She is the only child. The patient’s parents are healthy.
Physical Examination
     The patient is in moderate respiratory distress. BW 5 kg.
Vital Signs
      Temperature:37.8 C   Pulse: 158 beats per minute  Respiration: 72 per minute   Blood Pressure 75/40  mmHg
HEENT
      No evidence of rhinitis, otitis, or conjunctivitis.  Oropharynx appears normal.

Chest
      Moderate intercostal retractions, no wheeze. Air exchange is fair.

Cardiovascular
      Good perfusion. Normal heart sounds without murmur
Abdomen
      Liver  5 cm below RCM. Spleen 3 cm below LCM.
Genitourinary System
      Normal
Extremities
      Moderate cyanosis, no clubbing
Skin
      Normal
Nervous System
      Normal
Laboratory
Blood gas (room air) : hypoxia (O2 saturation =59%) with normocapnia

Chest radiograph: (see below).

Figure 1 shows radiographs taken at the time of admission. The radiograph demonstrates bilaterally increased interstitial markings

Complete blood count: Hemoglobin: 10 g/dl,  hematocrit: 34 % , platelets: 88,500
WBC: 12,400  Differential: 40 % polys, 54 % lymphocytes, 5 % monocytes, 1% eosinophils,
RBC morphology: normochromic normocytic
Serology : HIV-Ab : positive
Serum Enzymes: Lactate dehydrogenase: 709 units/L
Blood culture : sent
Questions
1.Which of the following is the most likely diagnosis?
A.
Opportunistic pneumonia, particularly Pneumocystis carinii or cytomegalovirus (CMV)
B.
Pneumococcal pneumonia
C.
Asthmatic exacerbation
D.
Foreign body aspiration
E.
Viral respiratory infection

2.Which of the following is the SECOND most likely diagnosis?

A.
Opportunistic pneumonia, particularly Pneumocystis carinii or cytomegalovirus (CMV)
B.
Pneumococcal pneumonia
C.
Asthmatic exacerbation
D.
Foreign body aspiration
E.
Viral respiratory infection
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