A
6-month-old infant with second attack of pneumonia
Prepared
by...
Virat Sirisanthana, M.D.
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Department
of Pediatrics, Faculty of Medicine, Chiang Mai
University
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Patient:
A 5.5-month-old Thai infant
Address: Chiang Mai |
CC
: difficulty breathing, cough 7 days prior to admission |
PI
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- At
age 1.5 month he was refered to CMU hospital
because of fever, convulsion and dyspnea. The
LP revealed: wbc 10 mono 100% protein 57 sugar
47/71 ,latex agglutination negative, culture
no growth. He was treated as "sepsis"
with Cefotaxime 200 MKD. During admission he
developed respiratory failure. CXR : Perihilar
- peribronchial infiltration (click
for CXR) . He was intubated. Suction
obtained secretion which was positive for AFB
4+ (click for sputum
smear),. Antit-tuberculous drugs were
added (2IRZS /4IR). His serum HIV-Ab was positive.
Trimetroprim/sulfamethoxazole was also added
for Pnemocytis carinii pneumonia prophylaxis.
He slowly recovered and was discharged from
the hospital at the age of 2.5 months.
- At
3 and 4 month old he was followed up at the
OPD. He was continued on anti-tuberculous drugs,
but did not have the refill of trimetroprim/sulfamethoxazole
prophylaxis.
- At
5 month old he was followed up at the OPD. He
was continued on anti-tuberculous drugs and
trimetroprim/sulfamethoxazole was restarted
for PCP prophylaxis.
- At
5 month and 7 days old (ie. 7 days prior to
this admission) he started having low grage
fever with dry cough and progressive difficult
breathing. A few days prior to admission his
symptoms got worse. He became "blue"
while sucking or crying. He took less feeding,
so his mother brought him to the OPD
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PAST
HISTORY |
- PRENATAL
: He is the only child. Both mother and father
are HIV-infected persons. His mother is healthy
looking.
- NATAL
: He was born at a primary care hospital without
complication. (birth weight of 2,300 gm)
- POSTNATAL:
normal
- FEEDING
: infant formular
- IMMUNIZATION
: as schedule
- FAMILY
HISTORY: his father died of pulmonary tuberculosis
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PHYSICAL
EXAMINATION |
- VITAL
SIGN : T 37.8 c PR 140 / min RR : 60 /min BP:
90/50 mmHg OXYGEN SATURATION AT ROOM AIR 60%
- GA
: Thai boy, good conciousness, dyspnea, cyanosis,
flaring ala nasi
- HEENT
:mild pale conjunctivae, no icteric sclera,
AF 1x2 cm, not tense, oral thrush
- CHEST
: subcostal retraction, LUNG : creppitation
at both lower lung with occational rhonchi HEART
:regular rythm, tachycardia, no murmur
- ABDOMEN
:normal contour, active bowel sound, soft. Liver:
2 cm below RCM , SPLEEN: not palpable
- EXTRIEMITIES
: wnl
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INVESTIATION |
- CBC
:Hb 9.2 Hct 30 WBC 14,900 N 72 L 28 PLATELET
207,000 U/A : NO CELL pH 6 Sp. Gr.1.017 BUN
:28 Cr : 0.5 ELECTROLYTE : N a 138 K 4.5 C l
107 CO2 21
- ABG
:ON CANNULAR O2 4 LPM pH 7.255 PaO2 37 Paco2
50.6 HCO3 21.7 BE -0.4 O2 SAT 89.7 ON BOX O2
10 LPM pH 7.352 PaO2 77.2 Paco2 47.5 HCO3 27.3
BE 0 O2 SAT 94.4 A-a gradient 576
- CXR
: There are patchy infiltration at left perihilar
region and both lower lung fields (click
for CXR).
- SERUM
LDH : 788
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PROBLEM
LIST
- HIV
exposed infant with history of pulmonary tuberculosis
-
another attack of pneumonia (tachypnea, low grade
fever, hypoxia, creppitation both lower lungs, abnormal
CXR)
TREATMENT
- OXYGENATION
- ANTI
TB DRUG : INH + RIFAMPIN
- CEFOTAXIME
100 MKD IV
- BACTRIM
20 MKD IV
COURSE
IN THE HOSPITAL
The
patient deteriolated and was intubated. He expired
on the 6th day of admission. Lung necropsy was done.
HISTOPATHOLOGY
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