CASE REPORT

1
CASE REPORT

• ??? ?? / ??? ??
• ???????? ???

2
General Data

• Name ? ??
• 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

3
Chief Complaint

• Fever off and on for 8 days

4
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.

5
Brief history

• Birth Hx GA 39 Wks, BBW3050 gm, NSD
• Previous admission Denied
• Vaccination As schedule
• Allergy Hx Denied
• Food exposure Denied
• Drug exposure Denied
• Recent travel Denied
• Family Hx Non-contributory

6
Physical Examination

• Vital sign BT 39.9, PR120 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

7
CBC/DC
5/3 5/7
WBC 9100 10110
Hgb 11.9 10.6
Hct 32.9 29.7
MCV 72.6 75.2
PLT 190000 206000
Neut 92.3 89.5
Lym 3.3 5.5
Mono 2.3 1.6
Eos 0.3 0.5

8
Urinalysis
5/3 5/4
Appearance Y-CLEAR Y-CLEAR
SP. Gr. 1.010 1.015
PH 6.0 6.0
Protein 1 1
Glucose - -
OB - -
Bilirubin - -
Nitrate - -
RBC 0-2 8-10
WBC 4-6 40-50
Bacteria
9
Biochemistry
Glu BUN Cr AST ALT Na K
5/3 94 6.0 0.5 117 39 125 4.5
5/4 129
5/7 93 3.0 0.5 85 179 137 4.0

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Blood culture

• 5/3 NO GROWTH
• 5/7 NO GROWTH

12
Urine culture

• 5/5 NO GROWTH

13
Serology

• CRP
• 5/4 163 mg/l
• 5/7 126 mg/l
• Mycoplasma Pneumoniae Antibody
• 5/4 NEGATIVE

14
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

15
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.

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Serology

• 5/7 IgA 126 (70-400)
• IgM 105 (40-230)
• IgG 778 (700-1600)
• 5/8 Measles IgM (-)
• Rubella IgM (-)

18
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.

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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.

21
Abdominal echo

• Date 91/05/07
• Ultrasonic Impression
• Negative finding of abdominal
  ultrasonography

22
Pleural Effusion Study (I)

• 5/8 Pleural fluid
• Appearance cloudy
• Color reddish-yellow
• Bloody ()
• Chylous (-)
• Coagulation ()
• Sp. Gr. 1.025

23
Pleural Effusion Study (II)

• WBC 630 cumm
• Polynuclear cells 55.0
• Mononuclear cells 45.0
• Abnormal cells (-)
• Pleural, Acid-Fast Stain Not Found
• Pleural, Grams Stain Not Found

24
Pleural Effusion Study (III)

• Pleural Effusion
• Glucose 71 mg/dl
• LDH 3149 IU/L (H)
• Protein 3.30 g/dl (L)

25
Pleural Effusion Study (IV)

• Pleural effusion culture
• on 5/8 no growth
• on 5/13 no growth

26
Pleural Effusion Study (V)

• 5/8 Pleural effusion cytology
• No evidence of malignancy
• 5/14 Pleural PCR assay for mycobacteria
• result Negative

27
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

28
CBC/DC
5/3 5/7 5/10 5/13 5/15
WBC 9100 10110 19570 26450 12270
Hgb 11.9 10.6 8.8 8.4 8.9
Hct 32.9 29.7 25.2 24.2 25.1
MCV 72.6 75.2 85.7 76.2 74.1
PLT 190000 206000 378000 551000 707000
Neut 92.3 89.5 92.9 92.8 87.1
Lym 3.3 5.5 4.2 3.5 6.9
Mono 2.3 1.6 2.2 1.9 2.6
Eos 0.3 0.5 0.4 0.8 1.8

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Urinalysis
5/3 5/4 5/11 5/14
Appearance Y-CLEAR Y-CLEAR Y-CLEAR Y-CLEAR
SP. Gr. 1.010 1.015 1.010 1.020
PH 6.0 6.0 5.0 6.5
Protein 1 1 - -
Glucose - - - -
OB - - - -
Bilirubin - - - -
Nitrate - - - -
RBC 0-2 8-10 0-2 0-1
WBC 4-6 40-50 0-2 8-10
Bacteria -- --
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Biochemistry
Glu BUN Cr AST ALT Na K Alb
5/3 94 6.0 0.5 117 39 125 4.5
5/4 129
5/7 93 3.0 0.5 85 179 137 4.0
5/9 5.0 0.4 46 99 131 5.2
5/11 136 3.0
5/14 11.2 0.4 85 175
5/16 71 146 3.5

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Blood culture

• 5/3 NO GROWTH
• 5/7 NO GROWTH
• 5/11 NO GROWTH

32
Urine culture

• 5/5 NO GROWTH
• 5/10 NO GROWTH
• 5/12 NO GROWTH

33
Serology (I)

• CRP
• 5/4 163 mg/l
• 5/7 126 mg/l
• 5/14 113 mg/l

34
Serology (II)

• 5/13 Direct Coombs test positive
• Indirect Coombs test positive
• 5/14 RAlt 10.2 IU/ML (lt40.0)
• C3 166.0 mg/dl (90.0-180.0)
• C4 21.4 mg/dl (10.0- 40.0)

35
Serology (III)

• 5/14 Heterophil Ab Negative
• ANA Negative
• 5/14 Legionella Ab Negative
• Chlamydia Ab Negative

36
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

37
Serology (I)

• Mycoplasma Pneumoniae Antibody
• 5/4 Negative
• 5/7 160X
• 5/14 320X

38
Pleural Effusion Study (II)

• 5/8 Pleural fluid for Mycoplasmal
• pneumonia antibody 80X

39
Serology (III)

• 5/16 Cold hemaglutination 512 X (lt32X)

40
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.

41
CBC/DC
5/3 5/7 5/10 5/13 5/15 5/23
WBC 9100 10110 19570 26450 12270 9780
Hgb 11.9 10.6 8.8 8.4 8.9 10.1
Hct 32.9 29.7 25.2 24.2 25.1 30.2
MCV 72.6 75.2 85.7 76.2 74.1 78.9
PLT 190000 206000 378000 551000 707000 377000
Neut 92.3 89.5 92.9 92.8 87.1 66.1
Lym 3.3 5.5 4.2 3.5 6.9 22.3
Mono 2.3 1.6 2.2 1.9 2.6 10.0
Eos 0.3 0.5 0.4 0.8 1.8 1.0

42
Biochemistry
Glu BUN Cr AST ALT Na K Alb
5/3 94 6.0 0.5 117 39 125 4.5
5/4 129
5/7 93 3.0 0.5 85 179 137 4.0
5/9 5.0 0.4 46 99 131 5.2
5/11 136 3.0
5/14 11.2 0.4 85 175
5/16 71 146 3.5
5/23 21 30

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Serology (I)

• CRP
• 5/4 163 mg/l
• 5/7 126 mg/l
• 5/14 113 mg/l
• 5/30 5.2 mg/l

44
Final Diagnosis

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

45
DISCUSSION

46
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.

47
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.

48

• 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 198919(8)499-503
• Respiratory disease other than
• pneumonia unspecific URI, pharyngitis,
• AOM, croup, sinusitis, bronchitis,
• bronchiolitis, asthma.

49

• 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, 1994333-5
• 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 199130(1),42-9

50

• Hematologic manifestations
• Hemolytic anemia usually mild,
• however, it may become severe and
• result in 50 reduction in hemoglobin
• concentration.
• Pediat Infec
  Dis J 199817(2)173-7
• Direct Coombs test usually positive.
• Steroid administration may be
• beneficial.
• South
  Med J 199083(9)1106-8

51

• 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

52

• 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.

53

• 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 19908182-7

54

• Liver dysfunction was observed more frequently in
  patients with pleuropneumonia than in simple
  pneumonia cases.
• Pediatr Pulmonol 19908182-7

55
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
• ???????? 19939(4)204-11

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Radiographic Manifestation (II)

• Unilateral infiltration 84
• Lower lobe predominance 60
• Confluent consolidation 56
• Patchy consolidation 33
• Pleural effusion 24
• ?????? 199114(3)156-62

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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
  gt164 is suggestive of infection
  Anti-mycoplasmal Ab detection, fourfold or
  greater rise are considered diagnostic.

58
Diagnosis (II)

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

59
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).

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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

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• 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.

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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.

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• 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

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CONCLUSION
65

• Presence of pleuropneumonia appears to be
  associated with more severe and prolonged course
  of illness
• Pediatr Pulmonol 19908182-7

66

• Even in patients with clinically mild pneumonia,
  Mycoplasma pneumoniae may be the cause of severe
  anemia
• Ann of Hematol
  200180(3)180-2

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• 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 199317(Suppl 1)S47-51

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THANKS FOR YOUR ATTENTION !

• 
  THE END