Pneumonai after submersion injury

A RARE CASE OF PNEUMONIA

DR. P. REVATHI DCH PG

PROF. DR.S.SUNDARI & PROF.DR.JEYACHANDRAN

G7 WARD & IMCUICH & HC

7y / F7y / F H/O fall with facedown into pool of stagnant H/O fall with facedown into pool of stagnant

dirty water ,which the child aspirateddirty water ,which the child aspirated Admitted for Scalp laceration, Admitted for Scalp laceration,

breathlessness – Rx in private Hospital breathlessness – Rx in private Hospital CT Brain / CT ChestCT Brain / CT Chest Head injury conservatively managedHead injury conservatively managed

3 days later3 days later Cough , Fever, Breathlessness, Cough , Fever, Breathlessness,

Right Chest Pain – 4 daysRight Chest Pain – 4 days Conscious, Dyspneic, Tachypneic Conscious, Dyspneic, Tachypneic

HR – 120 / minHR – 120 / minRR – 44 / minRR – 44 / minBP – 80 / 60 mmHgBP – 80 / 60 mmHgRS - Air entry in Rt RS - Air entry in Rt Inframammary, axillary, Inframammary, axillary, infraaxillary areasinfraaxillary areas

CBC – WBC 20 x 10CBC – WBC 20 x 103 3

Hb – 10.7Hb – 10.7Platelet – 4 lakhsPlatelet – 4 lakhs

DC – PDC – P7979 L L 1313 E E88

RFT / LFT / Sr. electrolytes, Urine R/E – NRFT / LFT / Sr. electrolytes, Urine R/E – NNEC – Klebsiella growthNEC – Klebsiella growthMSAT / Widal - NegativeMSAT / Widal - Negative

TB Workup – NegativeTB Workup – Negative Throatswab for HThroatswab for H11NN11 – Negative – Negative HIV Screening – NegativeHIV Screening – Negative NBT- NegativeNBT- Negative Immunoglobin profile - NormalImmunoglobin profile - Normal

COURSE IN HOSPITALCOURSE IN HOSPITALRx Inj . Ceftriaxone, Inj cloxacillin, Inj AmikacinRx Inj . Ceftriaxone, Inj cloxacillin, Inj Amikacin

BAL on 10BAL on 10thth day – negative day – negative

Inj. Piperacillin & Tazobactam, Inj. Metronidazole T. AzithromycinInj. Piperacillin & Tazobactam, Inj. Metronidazole T. Azithromycin

T. FluconazoleT. Fluconazole

COURSE IN IMCUCOURSE IN IMCUFever , Respiratory DistressFever , Respiratory Distress

SPOSPO22 – 96% with Mask – 96% with Mask

Wet Mount – Scanty fungal filamentsWet Mount – Scanty fungal filamentsSputumSputum C/S – No growthC/S – No growth

BAL on 18BAL on 18thth day dayAspergillus & Nocardia grownAspergillus & Nocardia grown

Nocardia sensitive to linezolid, cipro, cotrimoxazole, Nocardia sensitive to linezolid, cipro, cotrimoxazole, imipenem, amikacin, gentamycinimipenem, amikacin, gentamycin

NOCARDIANOCARDIA

SDAGRAMS STAIN

ASPERGILLUS

Lacto phenol cotton Blue

LJ MEDIUM -BAL

CHALKY WHITE COLONY

SDA – water sample

BLACKFUNGALCOLONY

Recovery after RxRecovery after Rx X – ray – 4X – ray – 4thth day day Respiratory distressRespiratory distress Fever Fever

NOCARDIANOCARDIA- Gram +ve filamentous bacteria – Gram +ve filamentous bacteria –

saprophytesaprophyte- Opportunistic infection – Localized & Opportunistic infection – Localized &

DisseminatedDisseminated- Inhalation, direct inoculation, Nosocomial.Inhalation, direct inoculation, Nosocomial.

ASPERGILLUSASPERGILLUS- Monomorphic Mycelial fungi – A . Monomorphic Mycelial fungi – A .

fumigatusfumigatus- Route – Hematogenous, Inhalation, Route – Hematogenous, Inhalation,

Ingestion Skin woundIngestion Skin wound Hypersenstivity Syndrome Hypersenstivity Syndrome Saprophytic non invasive syndrome Saprophytic non invasive syndrome Invasive SyndromeInvasive Syndrome

Special thanks to EKAM Foundation Dept of pulmonology Dept of Microbiology IBMS – Taramani

Take Home Message

Mixed pneumonia should be considered with h/o aspiration or near drowning

Characteristic Radiological picture of fungal pneumonia seen in adults may not be seen in pediatric age group.

Early diagnosis & prolonged treatment improves outcome………