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A 6-month-old infant with second attack of pneumonia

Prepared by...
Virat Sirisanthana, M.D.
Department of Pediatrics, Faculty of Medicine, Chiang Mai University
Patient: A 5.5-month-old Thai infant
Address: Chiang Mai
CC : difficulty breathing, cough 7 days prior to admission
PI :
  • 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
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
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
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

PROBLEM LIST

  1. HIV exposed infant with history of pulmonary tuberculosis
  2. another attack of pneumonia (tachypnea, low grade fever, hypoxia, creppitation both lower lungs, abnormal CXR)

TREATMENT

  1. OXYGENATION
  2. ANTI TB DRUG : INH + RIFAMPIN
  3. CEFOTAXIME 100 MKD IV
  4. 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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