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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
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
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
Chief Complaint
  • Fever off and on for 8 days
present illness
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
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
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

blood culture
Blood culture
  • 5/3 NO GROWTH
  • 5/7 NO GROWTH
urine culture
Urine culture
  • 5/5 NO GROWTH
serology
Serology

CRP

  • 5/4 163 mg/l
  • 5/7 126 mg/l

Mycoplasma Pneumoniae Antibody

  • 5/4 NEGATIVE
hospital course i
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
hospital course ii
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.
serology1
Serology
  • 5/7 IgA 126 (70-400)

IgM 105 (40-230)

IgG 778 (700-1600)

  • 5/8 Measles IgM (-)

Rubella IgM (-)

hospital course iii
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
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
Abdominal echo
  • Date 91/05/07
  • Ultrasonic Impression:

Negative finding of abdominal ultrasonography

pleural effusion study i
Pleural Effusion Study (I)

5/8 Pleural fluid

  • Appearance cloudy
  • Color reddish-yellow
  • Bloody (+)
  • Chylous (-)
  • Coagulation (+)
  • Sp. Gr. 1.025
pleural effusion study ii
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 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 Study (IV)
  • Pleural effusion culture

on 5/8 no growth

on 5/13 no growth

pleural effusion study v
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
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
blood culture1
Blood culture
  • 5/3 NO GROWTH
  • 5/7 NO GROWTH
  • 5/11 NO GROWTH
urine culture1
Urine culture
  • 5/5 NO GROWTH
  • 5/10 NO GROWTH
  • 5/12 NO GROWTH
serology i
Serology (I)

CRP

  • 5/4 163 mg/l
  • 5/7 126 mg/l
  • 5/14 113 mg/l
serology ii
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
Serology (III)
  • 5/14 Heterophil Ab: Negative

ANA Negative

  • 5/14 Legionella Ab: Negative

Chlamydia Ab: Negative

ga 67 inflammation survey
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
serology i1
Serology (I)

Mycoplasma Pneumoniae Antibody

  • 5/4 Negative
  • 5/7 160X
  • 5/14 320X
pleural effusion study ii1
Pleural Effusion Study (II)
  • 5/8 Pleural fluid for Mycoplasmal

pneumonia antibody: 80X

serology iii1
Serology (III)
  • 5/16 Cold hemaglutination: 512 X (<32X)
hospital course v
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.
serology i2
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
Final Diagnosis
  • Mycoplasmal lobar pneumonia, complicated with prolonged fever, skin rashes, right lung pleural effusion, and hemolytic anemia
mycoplasma pneumoniae
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
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.
slide60
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.

slide61
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

slide62
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

slide63
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

slide64
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.

slide65
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

slide66
Liver dysfunction was observed more frequently in patients with pleuropneumonia than in simple pneumonia cases.

Pediatr Pulmonol 1990;8:182-7

radiographic manifestation i
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
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
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
Diagnosis (II)
  • Imaging : Interstitial infiltrate or bronchopneumonia pattern. Lobar consolidation and pleural effusion are uncommon but may occur.
treatment
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
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
slide73
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
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.
slide75
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
slide77
Presence of pleuropneumonia appears to be associated with more severe and prolonged course of illness

Pediatr Pulmonol 1990;8:182-7

slide78
Even in patients with clinically mild pneumonia, Mycoplasma pneumoniae may be the cause of severe anemia

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

slide79
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

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