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CASE REPORT. 洪嘉蔚 醫師 / 吳維峰 主任 台北市立仁愛醫院 小兒科. General Data. Name: 李 小弟 Birth day: 85/04/24 Age: 6 y/o Chart number: 15213493 Admission day: 91/05/03 Discharge day: 91/05/20 BW: 22 Kg. Chief Complaint. Fever off and on for 8 days. Present Illness.

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CASE REPORT

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CASE REPORT

洪嘉蔚 醫師 / 吳維峰 主任

台北市立仁愛醫院 小兒科


General Data

  • Name: 李 小弟

  • Birth day: 85/04/24

  • Age: 6 y/o

  • Chart number: 15213493

  • Admission day: 91/05/03

  • Discharge day: 91/05/20

  • BW: 22 Kg


Chief Complaint

  • Fever off and on for 8 days


Present Illness

  • A 6 year-old boy suffered from fever off and on for 8 days. He also complained of cough, rhinorrhea and difficult to expectorate sputum. He was taken to LMD twice and our OPD on 91/04/30, but the symptoms persisted in spite of drugs use. So he was taken to our OPD again on 91/05/03. Physical examination revealed decreased breathing sound on right chest. CXR showed lobar pneumonia.


Brief history

  • Birth Hx: GA: 39 Wks, BBW:3050 gm, NSD

  • Previous admission: Denied

  • Vaccination: As schedule

  • Allergy Hx: Denied

  • Food exposure: Denied

  • Drug exposure: Denied

  • Recent travel: Denied

  • Family Hx: Non-contributory


Physical Examination:

  • Vital sign: BT 39.9, PR:120 bpm, RR 32/min

  • General appearance: Acute-ill looking

  • HEENT: No gross anomaly

    Conjunctiva: not injected

    Throat: mild injection

  • Chest: Symmetric expansion

    Retraction: no

    decreased breathing sound: right lung,

    fine moist rales(+)

    percussion: dullness of right chest


CBC/DC


Urinalysis


Biochemistry


Blood culture

  • 5/3 NO GROWTH

  • 5/7 NO GROWTH


Urine culture

  • 5/5 NO GROWTH


Serology

CRP

  • 5/4 163 mg/l

  • 5/7 126 mg/l

    Mycoplasma Pneumoniae Antibody

  • 5/4 NEGATIVE


Hospital Course (I)

  • Initially (5/3), empiric antibiotics with Cefuroxime 500mg IV q6h and Erythromycin 250mg PO q6h were used, but intermittent high fever up to 39C was still noted.

  • Gentamicin was added on 5/4 due to pyuria of urinalysis and suspected UTI


WHAT’S YOUR INITIAL IMPRESSION ?


Hospital Course (II)

  • On 5/5, multiple fine, discrete, rubella-like skin rashes developed on the face, trunk and extremities with itchy sensation. Vena infusion and Sinbaby lotion were used for symptom relief.


Serology

  • 5/7 IgA 126 (70-400)

    IgM 105 (40-230)

    IgG 778 (700-1600)

  • 5/8 Measles IgM (-)

    Rubella IgM (-)


Hospital Course (III)

  • On 5/7, followed CXR showed massive amount of pleural effusion, right lung. So we do chest CT, and erythromycin was changed to 220mg IV q6h

  • On 5/8, thoracocentasis was done and showed exudate effusion. So we do chest tube insertion. About 200ml of yellow-reddish fluid was drained.


Chest CT

  • Date 91/05/07

  • Impression:

    Consolidation of right lower lobe and medial segment of middle lobe, pneumonia is likely. Moderate amount of right pleural effusion and scanty amount of left pleural effusion.


Abdominal echo

  • Date 91/05/07

  • Ultrasonic Impression:

    Negative finding of abdominal ultrasonography


Pleural Effusion Study (I)

5/8 Pleural fluid

  • Appearance cloudy

  • Color reddish-yellow

  • Bloody (+)

  • Chylous (-)

  • Coagulation (+)

  • Sp. Gr. 1.025


Pleural Effusion Study (II)

  • WBC 630 cumm

    Polynuclear cells 55.0%

    Mononuclear cells 45.0%

    Abnormal cells (-)

  • Pleural, Acid-Fast Stain: Not Found

  • Pleural, Gram’s Stain: Not Found


Pleural Effusion Study (III)

Pleural Effusion

  • Glucose 71 mg/dl

  • LDH 3149 IU/L (H)

  • Protein 3.30 g/dl (L)


Pleural Effusion Study (IV)

  • Pleural effusion culture

    on 5/8 no growth

    on 5/13 no growth


Pleural Effusion Study (V)

  • 5/8 Pleural effusion cytology:

    No evidence of malignancy

  • 5/14 Pleural PCR assay for mycobacteria

    result: Negative


Hospital Course (IV)

  • On 5/10, followed CBC/DC showed leukocytosis with left shift (WBC 19570, Neu 92.9%). Persistent high fever was noted. So Cefuroxime was changed to Ceftriaxone 1g IV q12h

  • High fever up to 40C persisted in spite of Ceftriaxone + Gentamicin + Erythromycin combined use


CBC/DC


Urinalysis


Biochemistry


Blood culture

  • 5/3 NO GROWTH

  • 5/7 NO GROWTH

  • 5/11 NO GROWTH


Urine culture

  • 5/5 NO GROWTH

  • 5/10 NO GROWTH

  • 5/12 NO GROWTH


Serology (I)

CRP

  • 5/4 163 mg/l

  • 5/7 126 mg/l

  • 5/14 113 mg/l


Serology (II)

5/13 Direct Coombs’ test: positive

Indirect Coombs’ test: positive

5/14 RA< 10.2 IU/ML (<40.0)

C3 166.0 mg/dl (90.0-180.0)

C4 21.4 mg/dl (10.0- 40.0)


Serology (III)

  • 5/14 Heterophil Ab: Negative

    ANA Negative

  • 5/14 Legionella Ab: Negative

    Chlamydia Ab: Negative


Ga-67 Inflammation Survey

  • Date 91/05/15

  • A patch of abnormal tracer uptake at the right lower lung field, may be inflammatory focus.

  • Diffusely increase uptake of liver. This phenomenon can be found in iron deficiency anemia


WHAT’S YOUR DIAGNOSIS ?


Serology (I)

Mycoplasma Pneumoniae Antibody

  • 5/4 Negative

  • 5/7 160X

  • 5/14 320X


Pleural Effusion Study (II)

  • 5/8 Pleural fluid for Mycoplasmal

    pneumonia antibody: 80X


Serology (III)

  • 5/16 Cold hemaglutination: 512 X (<32X)


Hospital Course (V)

  • Chest tube was removed on 5/13

  • We used prednisolone (2mg/kg/day in 4 divided doses) on 5/14. Fever subsided on the night of 5/14.

  • Steroid was tapered gradually

  • On 5/20, patient was discharged under stable condition.


CBC/DC


Biochemistry


Serology (I)

CRP

  • 5/4 163 mg/l

  • 5/7 126 mg/l

  • 5/14 113 mg/l

  • 5/30 5.2 mg/l


Final Diagnosis

  • Mycoplasmal lobar pneumonia, complicated with prolonged fever, skin rashes, right lung pleural effusion, and hemolytic anemia


DISCUSSION


Mycoplasma Pneumoniae

  • In 1944, M. pneumoniae was reported by Monroe Eaton, originally called the Eaton agent.

  • Smallest free-living microorganism, belongs to the class Mollicutes.

  • Mycoplasmas lack a cell wall, so tend to be pleomorphic.


Clinical Manifestations

  • M. pneumoniae causes approximately 20% of all cases of pneumonia.

  • Peak incidence at 6-21 years of age.

  • Incubation period of 2-3 weeks.

  • Transmission by inhalation of infected droplet aerosols.


  • Pneumonia is the most important clinical manifestation of M. pneumoniae infection.

    * Bronchopneumonia pattern mostly.

    Lobar pneumonia and large amount

    pleural fluid are unusual.

    Pediat Radiol 1989;19(8):499-503

    * Respiratory disease other than

    pneumonia: unspecific URI, pharyngitis,

    AOM, croup, sinusitis, bronchitis,

    bronchiolitis, asthma.


  • Cutaneous manifestations : common.

    * Exanthem and enanthem of Mycoplasma

    pneumoniae infection are observed in 5 to

    24% of cases

    AAP, Report of Committee on Infectious Diseases, 1994:333-5

    * Most common with an erythematous

    maculopapular rash on the trunk and back;

    discrete (rubelliform) or confluent

    (morbilliform).

    * Most serious presentation: Erythema

    multiforme and Stevens-Johnson syndrome.

    Clini Pediatrics 1991:30(1),42-9


  • Hematologic manifestations:

    * Hemolytic anemia: usually mild,

    however, it may become severe and

    result in 50% reduction in hemoglobin

    concentration.

    Pediat Infec Dis J 1998;17(2):173-7

    * Direct Coombs test usually positive.

    * Steroid administration may be

    beneficial.

    South Med J 1990;83(9):1106-8


Hemolytic anemia is presumably related to the presence of cold agglutinins in serum which at high concentration, may agglutinate erythrocytes at 37℃

Rev Pneumol Clin 1990,46(2),83-4


  • Gastrointestinal findings are nonspecific with nausea, vomiting, abdominal pain, and/or diarrhea.

  • Neurologic disease association was reported 2.6-4.8%.

    * Encephalitis, meningitis, transverse

    myelitis, psychosis, Bell palsy and

    Guillain-Barre` syndrome.

  • Arthritis in association with M.pneumoniae

    infection have not been established.


  • Hepatitis was once thought to be unusual, but recent studies suggest that liver dysfunction may be present in up to 30% of M. pneumoniae infection.

    Pediatr Pulmonol 1990;8:182-7


  • Liver dysfunction was observed more frequently in patients with pleuropneumonia than in simple pneumonia cases.

    Pediatr Pulmonol 1990;8:182-7


Radiographic Manifestation (I)

Interstitial infiltration was more commonly seen in pediatric than adult patients (46% vs 20%)

Unilateral lesions 80%

Single lobe lesions 77%

Lower lobe predominant 69%

Pleural effusion 7%

高雄醫學科學雜誌 1993;9(4):204-11


Radiographic Manifestation (II)

  • Unilateral infiltration 84%

  • Lower lobe predominance 60%

  • Confluent consolidation 56%

  • Patchy consolidation 33%

  • Pleural effusion 24%

    長庚醫學雜誌 1991;14(3):156-62


Diagnosis (I)

  • WBC, CRP, ESR are non-specific, may be normal or elevated.

  • Growth of the organism takes weeks, generally only in expertise laboratories.

  • PCR is sensitive and specific.

  • Serologic testing : Cold agglutinins, titer of >1:64 is suggestive of infection; Anti-mycoplasmal Ab detection, fourfold or greater rise are considered diagnostic.


Diagnosis (II)

  • Imaging : Interstitial infiltrate or bronchopneumonia pattern. Lobar consolidation and pleural effusion are uncommon but may occur.


Treatment

  • Erythromycin is the drug of choice.

    (40-50mg/kg/24hr q6h for 10-14 days).

  • Newer macrolides:

    Azithromycin (10mg/kg on day 1, and

    5mg/kg/24hr on days 2-5) or

    Clarithromycin (15mg/kg/24hr given in two

    divided doses for 10 days).


Empiric Therapy for Lobar Pneumonia

  • Clinically moderate to severely toxic, treat empirically for S. pneumonia, S. pyogens ( and H. influenzae type b in unimmunized children)

  • In toxic children, tests for Mycoplasma should be considered because focal pneumonia is a rare presentation


  • Cefuroxime intravenously, ceftriaxone or cefotaxime intravenously

  • For anti-staphylococcal coverage, add to the above, either: nafcillin, oxacillin, or clindamycin

  • For Mycoplasma: intravenous erythromycin or azithromycin; or oral erythromycin, azithromycin, or clarithromycin.


Pneumonia, with pleural fluid or empyema

  • Treat empirically for S. pneumonia, S. pyogenes, and S. aureus ( and H. influenzae type b in unimmunized children)

  • Consider aspiration pneumonia with anaerobic oral flora as pathogens; needle or catheter aspiration of pleural fluid, with drainage, is often required for clinical cure.


  • Ceftriaxone or cefotaxime

  • For antistaphylococcal covarage, add to the above either: nafcillin, oxacillin, or clindamycin (also covers anaerobes found in aspiration pneumonia as well as most pneumoncocci)

  • Single agent therapy with meropenem, or ticarcillin/clavulanate (Timentin) both of which cover both aerobic and anaerobic pathogens


CONCLUSION


  • Presence of pleuropneumonia appears to be associated with more severe and prolonged course of illness

    Pediatr Pulmonol 1990;8:182-7


  • Even in patients with clinically mild pneumonia, Mycoplasma pneumoniae may be the cause of severe anemia

    Ann of Hematol 2001;80(3):180-2


  • Association of exanthem and pneumonia or of hemolytic anemia and pneumonia are considered to be strongly suggestive for the diagnosis of M. pneumonia infection

    Clin Infec Dis 1993;17(Suppl 1):S47-51


THANKS FOR YOUR ATTENTION !

THE END


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