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Geronimo, Maria Angelica; Geronimo, Ralph Ernesto; Go, Camille-Marie; Go, Crystal Karen
January 24, 2011
Pulmonology Conference
General DataJ.M.3 months oldMaleRace: FilipinoBirthdaySampaloc, ManilaRoman CatholicDate of AdmissionInformant:Reliability
Chief Complaint
Difficulty of Breathing
CC: Difficulty of Breathing
Review of SystemsGeneral: (-) weight changesCutaneous: (-) rashes, (-) jaundice HEENT: (-) eye redness (-) eye discharge (-) ear
discharge (-) gum bleedingCardiovascular: (-) cyanosisRespiratory: see HPI Gastrointestinal: (-) acholic stools
Review of SystemsGenitourinary: (-) tea-colored urine (-) oliguria (-)
dischargeNervous/Behavior: (-) seizures (-) tremors (-)
mood/behavioral changesEndocrine: (-) polyuria (-) polydipsia (-) polyphagia (-)
heat/cold intoleranceMusculoskeletal: (-) edema (-) swelling (-) limitation of
motion (-) tendernessHematopoietic (-) bleeding tendencies (-) easy
bruisability
Gestational HistoryMother: 36 year-old G1P0 housewifeFather:37 year old seamanRegular prenatal checkups USTH OPD for 7 times(-) viral exanthem, radiation and any intake of illicit,
prohibited or abortifacient drugs, intake of alcohol and smoking
UTI (September 2010) - Cefalexin for 7 days and claimed to be compliant; Repeat UA - normal
OGCT and Hepatitis screening were not done
Gestational HistoryPreeclampsia (HBP 160/100; UBP is 110-10/70mmHg)
Magnesium sulfateNicardipine drip Betamethasone
Emergency CS secondary to preeclampsia
Birth HistoryLive, preterm, singleton male, delivered via “E” CS
secondary to preeclampsiaBW 1.66 kgBL 44 cmHC 31 cmCC 25 cmAC 22 cmAS 8,9MT 32-33 weeksAGA
Neonatal History1st hour of life –Bakit kinailangan mag chest xray?in
distress?panu nasabing in distress? CXR: air bronchogram with densities on the right lower lobe
Nagbigay antibiotics?Persistent respiratory distress intubated (NICU)PDA: grade II continuous murmur(ano binigay/ginawa for the pda?)
2nd day of life – hyperbilirubinemia (6.8) Phototherapy on the 5th HDNeonatal hepatitis
Neonatal History2D echocardiography: PDA, patent foramen ovale,
LVE, LAE and pulmonary arterial hypertensionBlood CS: Klebsiella pneumoniaAno meds?Assessment: sepsisDischarged at his 52nd day of life
Feeding HistoryMixed Breastfed and Milk formula
15 minutes/breast3x a day alternating with Formula S26 lactose free 1
scoop in 2 ounces every 3 hours Mother claims that there is not enough milk being
produce that’s why she started on powdered milkGood appetite with no feeding difficulties
24 Hour Food Recall
Developmental HistoryGood motor activityVisually tracks objects and looks aroundHas social smileMother do not practice him to sit with support or do
prone positionHas head lag when pulled
At par with age?
Past Medical HistoryOctober 10, 2010: sepsis, neonatal hepatitis and PDA No previous surgeries doneNo allergy, eczema, asthma, food or drug sensitivities
Immunization HistoryHepatitis B – 11/22/10, 12/22/10BCG - 11/24/10DTP and OPV - 12/22/10
Table form
Family Profile
Name Age Relation Educational Attainment
Occupation Health
SG 38 Father College graduate
Seaman Healthy
CG 36 Mother College graduate
Unemployed Preeclampsia
Family History(+) Asthma – paternal grandmother(+) HPN – maternal grandmother(-) DM, blood dyscrasia, autoimmune disease,
congenital disorders, thyroid diseases, cancer, allergy
Socioeconomic and Environmental History Rented studio type made of concreteAdequate space for each household member, well-lit and
well ventilatedWater stationMeals are home-cooked prepared by his mother or
sometimes they buy cooked-mealsNo pets, no factories or other industrial establishments
within the vicinity of the residenceGarbage is not segregated and is being collected everydayNot exposed to second hand smoke
Physical ExaminationAwake, alert, in respiratory distress, ambulatory, well-
hydrated, well nourished, ill-lookingHR 135 bpm, regular, RR 48 cpm, regular, T36.7oC,
SpO2 91%Wt: 3.26 kg (z score below -3 severely underweight)Lt: 51 cm (z score below -3 severely stunted)BMI: 12.53 (z score below -2 severely wasted)Warm, moist skin, no jaundice, no visible gross skin
lesions, good skin turgor
Physical ExaminationNormocephalic head, no visible scalp lesions, patent
anterior fontanelPink palpebral conjunctivae, anicteric sclerae, pupils
2-3 mm ERTLNo tragal tenderness, intact tympanic membraneNo nasoaural discharge, nasal septum midline,
turbinates not congestedMoist buccal mucosa, nonhyperemic posterior
pharyngeal walls, tonsils not enlarged,
Physical ExaminationSupple neck, no palpable cervical lymphadenopathy,
thyroid gland not enlargedSymmetrical chest expansion, (+) subcostal
retractions, equal tactile and vocal fremiti, (+) crackles over both lung field with occasional wheezes at left lung field
Adynamic precordium, apex beat at 4th LICS MCL, no heaves/lifts, no thrills, normal rhythm, S1 louder than S2 at the apex, S2 louder than S1 at the base, (+) Grade II continuous murmur
Physical ExaminationGlobular abdomen, normoactive bowel sounds, soft,
no tenderness, no palpable masses, Traube’s space not obliterated
Genitalia: grossly male with both descended testesPulses are full and equal, no edema, no cyanosis
Neurologic ExaminationAwake, alert Cranial nerves: CNI not assessed, pupils 2-3mm equally
reactive to light, (+) direct and consensual light reflex, (+) ROR, EOM full and equal, no gross facial asymmetry, gross hearing intact (able to localize sound), CN IX, X, XI, XII not assessed
No spasticity, rigidy, flaccidity, no limitation in movementNo sensory deficitsDTR +2 No nuchal rigidity, Brudzinski’s and Kernig’s (+) Moro, grasp, plantar, sucking reflex
Salient Features3 month old maleHistory of colds, non-productive coughPE: tachypneic, (+) subcostal retractions, (+) crackles
over both lung field with occasional wheezes at left lung field
Approach to DiagnosisSymptom, sign or laboratory finding pointing to an
organ or part of an organ system
3 month old maleHistory of colds, non-productive cough, difficulty of breathingPE: tachypneic, (+) subcostal retractions, (+) crackles over both lung field with occasional wheezes at left lung field
Pulmonary Pathology
Pneumonia
Approach to the Diagnosis
Differential Diagnosis
Admitting Diagnosis
Course in the Wards
Discussion na lang ito.PPS Clinical Practice Guideline
for PCAP 2004
Complete Blood Count
Bacterial Viral
WBC 15,000 – 40,000 WBC < 20,000
Granulocytes Lymphocytes
Chest Xray (PA Lat)
Gold standard for the diagnosis of pneumoniaIndicates complications PCAP such as a pleural effusion or empyema
COURSE IN THE WARDS
ADMITTING ORDERSNPO, Hgt every 8 hoursVital signs every hourIVF? Input & Output recorded every shiftRequested:
CBC with platelets, CXR
Meds:Ampicillin 150mg/ SIVP over 30 Q6 hours (MKD?)Gentamicin 13 mg/ SIVP over 30 mins Qday(MKD?)Salbutamol nebulization (1 neb every how many hours?
In our patient...
2nd HDAmpicillin dose was increased to 160 mg/ SIVP over
30 mins, Q6Hgt monitoring was discontinuedFeeding was resumed
Nebulization was discontinued
3rd HD
6th HDDecreased monitoring to Q4IVF consumed
7th HDLast dose of antibiotics givenDischarged stable and improved
Pneumonia
Discussion
• Inflammation of parenchyma of the lungs
• Etiologic agent vary with the age and immune status of the child, as well as with some environmental conditions
Signs and Symptoms• Symptoms of pneumonia vary, depending on the age of the
child and the cause of the pneumonia. Common symptoms include:– fever– chills– cough– tachypnea– breathing with grunting or wheezing sounds– labored breathing leading to retractions– vomiting– chest pain– abdominal pain– decreased activity– loss of appetite (in older kids) or poor feeding (in infants)– in extreme cases, cyanosis
Pathophysiologyresults from inflammation of the alveolar space and may
compromise air exchangeMost commonly, this inflammation is the result of
invasion by bacteria, viruses, or fungi, but it can occur as a result of chemical injury or may follow direct lung injury (eg, near drowning).
Four stages of lobar pneumonia have been described. The first stage, occurring within 24 hours of infection
the lung is characterized microscopically by vascular congestion and alveolar edema
Many bacteria and few neutrophils are present The stage of red hepatization (2-3 d)
similarity to the consistency of liver, is characterized by the presence of many erythrocytes, neutrophils, desquamated epithelial cells, and fibrin within the alveoli
In the stage of gray hepatization (2-3 d)the lung is gray-brown to yellow because of
fibrinopurulent exudate, disintegration of red cells, and hemosiderin
The final stage of resolution is characterized by resorption and restoration of the pulmonary architectureFibrinous inflammation may extend into the
pleural space, causing a rub heard by auscultation, and it may lead to resolution or to organization and pleural adhesions.
Bronchopneumonia, a patchy consolidation involving one or more lobes, usually involves the dependent lung zonesThe neutrophilic exudate is centered in bronchi
and bronchioles, with centrifugal spread to the adjacent alveoli
* Bacterial superinfection of viral pneumonia : mixed pattern of interstitial and alveolar airspace inflammation
In interstitial pneumonia, patchy or diffuse inflammation involving the interstitium is characterized by infiltration of lymphocytes and macrophages The alveoli do not contain a significant exudate,
but protein-rich hyaline membranes similar to those found in adult respiratory distress syndrome (ARDS) may line the alveolar spaces
Miliary pneumonia is a term applied to multiple, discrete lesions resulting from the spread of the pathogen to the lungs via the bloodstream. miliary tuberculosis, histoplasmosis,
and coccidioidomycosis may manifest as granulomas with caseous necrosis
to foci of necrosisFactors that bypass or inactivate local defenses (eg,
tracheostomy tubes, immotile cilia syndrome) predispose the child to pneumonia The result is loss of surfactant activity with local
collapse and consolidation.
Pathogens implicated in pneumonia vary with the age of the child, the underlying patient-specific risk factors, immunization status, and seasonality.
Newborns and infantsvia the maternal genital tract group B streptococci, Escherichia coli and other
fecal coliforms, and C trachomatis. Group B streptococci most often is transmitted to
the fetus in utero, usually as a result of colonization of the mother's vagina and cervix by the organism.
However, most pneumonia in this age group is community acquired and involves Streptococcus pneumoniae, Staphylococcus aureus, and non-typeable Haemophilus influenzae.
Young childrenViruses are a common cause of pneumonia among
toddlers and preschoolersStreptococcus pneumoniae is by far the most common
bacterial cause of pneumoniaChildren in this age group are also at risk for infection by M
pneumoniae
Older children and adolescentsM pneumoniae is a frequent cause of pneumonia
among older children and adolescentsOlder adolescents may have lost their immunity to
pertussis and may become infected by this organism
Bacterial pneumonia in this age group most often is caused by Streptococcus pneumoniae.
Efficacy of an 11-Valent Pneumococcal Conjugate Vaccine against Radiologically Confirmed Pneumonia Among Children Less Than 2
Years of Age in the PhilippinesA Randomized, Double-Blind, Placebo- Controlled Trial
Lucero et alThe Pediatric Infectious Disease Journal
Volume 28 Number 6, June 2009Lippincott Williams and Wilkins
PneumococcusLeading cause of childhood pneumonia worldwidePneumococcal conjugate vaccines (PCV) have
demonstrated efficacy against childhood invasive pneumococcal disease (IPD) and pneumonia in the US and Africa
No information is available from Asia on the impact of PCV on childhood pneumonia
Study Setting6 municipalities in Bohol province in central
Philippines3 seasons: hot, rainy, coldNo HIV and no malariaInfant mortality rate in Bohol: 28/1000 live birthsMajor cause of death: pneumonia and diarrheaStudy monitored by RITM and KTL
Study DesignRandomized, placebo-controlled, double blind trialCollaboration with government and private health
services in Bohol3 doses of 11PCV or a saline placebo given at 4 weeks
interval to determine Vaccine Efficiency
ParticipantsInformed consent of the motherInclusion criteria
Children age <6 weeks to 6 monthsThe family was expected to remain in the study area for 2
years or until the end of December 2004Infant was healthy
Exclusion criteriaFirst dose DTwPRectal temperature of 38°CNeurologic diseaseHistory of hospitalization or treatment for immune
suppressionEnrolment in another clinical trial
Vaccine
11 PCV 1 μg S. pneumoniae capsular
polysaccharide conjugated to tetanus toxoid for types 1, 4, 5, 7F, 9V, 19F, and 23F
3μg of polysaccharide of types 3, 14, and 18C conjugated to dipththeria toxoid
10μg pf polysaccharide of type 6B conjugated to diptheria toxoid
Manufactured by Sanofi pasteur
PlaceboSaline
Vaccines were given intramuscularly in the anterolateral aspect of right thigh
Routine vaccines given in left thigh
Definition of termsCommunity acquired pneumonia
Pneumonia with onset either in the community or in hospital but less than 72 hours after admission
IPDBacteremia or culture proven meningitis
Trial end point: Radiologically defined CAP using WHO vaccine trialists’ standard guidelinesPresence of a dense opacity that could be a fluffy
consolidation of a portion of a lobe, a whole lobe or the entire lung, often containing air bronchograms and sometimes associated with pleural effusion in the lateral pleural space
Associated with a pulmonary infiltrate or an effusion large enough to obscure such an opacity
Secondary end pointsHospitalized or not hospitalizedCulture proven invasive disease with a vaccine type-
specific pneumococcusSerious adverse events
Clinical Pneumonia (WHO Severity Grade)History of cough and/or difficulty of breathingIncreased respiratory rate according to ageLower chest wall indrawing (severe)Cyanosis and/or inability to drink (very severe)
Surveillance for Clinical EpisodesBlood cultureChest x-rayCSF culture when indicatedAntibiotic treatment
ResultsJuly 2000-December 18, 200312,194 enrolled children98.7% subjects received 3 doses of study vaccineMedian age was 1.8, 2.9, and 3.9 months for
vaccination
DiscussionPrevention of 22.9% of radiologically defined
pneumonia among children 2 years of ageAge stratified analysis of Vaccine Efficacy:
<12 months = 34.0%12-23 months = 2.7%
Vaccine had no effect against clinical pneumonia
Conclusions11 PCV show similar efficacy as the available 7PCV in other
epidemiological and geographic settingsUse of WHO-PEP as feasible end point in clinical trials and
good proxy for measuring pneumococcal pneumonia1/5 of radiologically confirmed pneumonia is caused by
pneumococcus in a low income, low mortality developing country such as the Philippines, and thus preventable by PCV
Inclusion in national program on immunization depends on specific disease burden measurement and cost-effectiveness calculation