PEDIATRIC

CASE PRESENTATION

Preceptor:
Dr. Ma. Consuelo Manuel

Presenters:
Matias, Graizelle
Uganiza, Charles Kevinson
Siuagan, Angelica
Date of Interview: February 20, 2019
Time of History: 1:30 PM
Informant/s: Mother
Reliability: 90%

GENERAL DATA:
Name: AJ
Age: 3 years old
Gender: Female
Date of Birth: May 31, 2015
Address: Baculud, Iguig
Religion: Roman Catholic
Citizenship: Filipino
Number of Admission: 1
Date of Admission: February 19, 2019

CHIEF COMPLAINT: INTERMITTENT FEVER

HISTORY OF PRESENT ILLNESS:

Present illness started 4 days PTA, patient presents with intermittent high-grade fever,
persistent, progressive, nonproductive cough, and was noted by the mother to be breathing
heavily. Paracetamol 5ml was able to provide relief for the fever. No medications were given for
cough and difficulty in breathing; it was resolved by resting but recurs at night.
1 day PTA, patient presents with the same constitutional signs and symptoms; however,
cough was aggravated by nasal congestion and is now accompanied by headache. Paracetamol
and Salbutamol was given, however, salbutamol did not provide relief.
Few hours PTA, the symptoms persisted and worsened with accompanying body
weakness and loss of appetite. This prompted her mother to bring her to CVMC for admission.

PAST MEDICAL HISTORY:

Patient had common colds and flu. She was diagnosed with asthma when she was about 2
and takes Salbutamol (Asvent). Her last asthma attack was in 2018. No known allergies to any
foods and drugs. No history of surgery, trauma or blood transfusion

BIRTH HISTORY:

PRENATAL
The patient’s mother had complete prenatal check-up during the course of her
pregnancy. She took Ferrous sulfate as supplement. She had no exposure to radiation and
infectious diseases such as measles and chickenpox. The mother’s diet consisted of a mixture of
meat, vegetables and fish. No threatened abortion was noted throughout her pregnancy.

NEONATAL
Patient was noted to have a good suck and a good cry at birth. No cyanosis, no jaundice
nor respiratory distress noted. The patient was born, preterm, to a hypertensive, G1P1 (1001)
mother, 20 years old at the time of birth, at CVMC via CS due to preeclampsia. Birth weight was
2.6 kg. Mother claims that the patient was put to NICU after birth for 2 days due to prematurity.

FEEEDING HISTORY:
 • Breast-feeding: The patient was breast fed for 1 year and 6 months.
• Bottle-feeding: The patient was given formula milk alternately with breast milk within 24
hours after birth.
• Supplements: None
• Eating habits: Introduced rice and soup at the age of 1. Patient prefers to eat vegetables
and pork; prefers water and powdered juices over carbonated drinks.

GROWTH AND DEVELOPMENTAL HISTORY:

• Physical growth: Weight and height is within normal range on her age.
• Developmental milestones: No defects were noted in her development. Before 1 year old,
the patient started crawling. She can walk alone at 1 year old and 4 months.

IMMUNIZATION HISTORY:
• According to the patient’s mother, complete vaccinations were given (Barangay Health
Center). These are the BCG, Hepatitis, DPT, OPV, Hib, Measles, and MMR.

FAMILY HISTORY:
§ Maternal Hx: (+) HPN, (-) DM, (-) Asthma, (-) Blood dyscrasia, (-) Heart disease,
o (-) Cancer (-)PTB, (-) allergy, (-) Renal Disease

• Paternal Hx: (-) HPN, (-) DM, (+) Asthma, (-) Blood dyscrasia, (-) Heart disease,
o (-) Cancer (-)PTB, (-) allergy, (-) Renal Disease

REVIEW OF SYSTEMS:
INTEGUMENTARY: No pruritus
HEENT: With headache, no sinus pain, stuffy nose, pain in swallowing
CARDIORESPIRATORY: with difficulty of breathing, cough and colds
GIT: No nausea, vomiting and abdominal pain. No diarrhea. With loss of appetite.
GUT: No dysuria, oliguria, hematuria. No urinary urgency, retention and incontinence.
HEMATOLOGIC: No epistaxis and gum bleeding
MUSCOLOSKELETAL: With generalized weakness and fatigue. No myalgia, arthralgia,
backache, stuffiness and joint swelling.
CNS: No seizure

Physical Examination:
General Survey: The patient is lying on bed, awake, conscious and coherent; oriented to person,
time and place, weak looking and not in respiratory distress
Vital Signs:
Temperature: 36.7oC
Respiratory rate: 26 cpm (20-30 cpm)
Pulse rate: 125 bpm (80-130 bpm)

Anthropometric measurements:
Recumbent length: 90 cm
Weight: 13Kg

Skin: No pallor, jaundice or rashes. Good skin turgor.

HEENT:
Head: No deformity. No lesions, lumps, or tenderness.
 Eyes: Non-icteric sclera, pinkish conjunctiva, no eye pain or redness noted.
Ears: No ear tags, redness, swelling, or foul-smelling discharge.
Nose: No sinus tenderness, congestion, and lesion; with discharge.
Mouth and Throat: No bleeding of gums or sore throat.
Neck: No cervical lymphadenopathy, mass, or nuchal rigidity.
Chest and Lungs: Symmetrical chest expansion, no retractions, with coarse crackles on both
lungs, no wheezing noted.
Heart: Adynamic precordium, PMI at 4th ICS left midclavicular line; normal rate, regular rhythm,
no murmurs.
Abdomen: Flat, soft abdomen; normoactive bowel sound.
Extremities: No gross deformities, edema or clubbing; pinkish nailbeds; CRT <2 seconds; full and
equal pulses
Neurologic
Cranial Nerves:
CNI: able to smell
CNII: pupils equally reactive to light
CNIII, IV and VI: no ptosis; able to follow object without eye
deviation
CNV: with corneal reflex, shows teeth
CNVII: no facial asymmetry
CN VIII: able to hear
CN IX, X: able to swallow
CN XI: able to elevate shoulders
CN XII: no tongue deviation
Motor: able to move extremities in different directions (grade: 5/5)
Pathologic reflex: (-) babinski reflex, (-) kernig’s sign, (-) brudzinski

Salient Features:
§ Patient is 3 years old
§ High-grade, intermittent fever
§ Non-productive cough
§ Colds
§ Difficulty of breathing – not relieved by Salbutamol
§ Body weakness, Fatigability
§ Loss of appetite
§ Family history of Asthma
§ Diagnosed with Asthma
§ Coarse crackles on both lungs
§ No wheezes

Differential Diagnosis:
One of our differential diagnoses is Asthma exacerbation because it could also present
with cough colds and difficulty of breathing. The patient also had history of asthma. This is
considered less likely because fever is not seen in asthma attacks, the most likely breath sound in
expiratory wheezing instead of crackles and her mother noted that her symptoms are not
relieved by her asthma medication.

Rule in Rule out

Non- productive Cough (-) Wheezing
Tachypnea (+) Fever
DOB (-) Relief by anti-asthma meds
History of Asthma
Body weakness
Fatigability

Pediatric bronchitis, an inflammation of the bronchi caused by RSV. It initially presents

with sneezing, clear rhinorrhea, and non-productive cough. Then further develop with a
productive cough usually with white to yellow sputum with accompanying loss of appetite and
fever. The disease progression is usually gradual, with ensuing respiratory distress, dyspnea, and
tachypnea. However, this is considered less likely because bronchitis is a common disease of the
lower respiratory tract in infants, not in children ages 3-years-old. Another reason for not
considering is that high-grade fever is relatively uncommon in bronchitis.

Rule in Rule out

Colds Most common in infants
Loss of appetite (+) High-grade fever
DOB Non-productive cough

Croup is a heterogeneous group of mainly acute and infectious processes that are
characterized by a bark-like or brassy cough and may be associated with hoarseness, inspiratory
stridor, and respiratory distress. This also presents with cough and fever. This is less likely
considered because there was no stridor and hoarseness of voice.

Rule In Rule Out

Cough And Colds (-) Inspiratory Stridor
Fever (-) Hoarseness Of Voice

Given a case of a 3-year old girl presenting with intermittent fever (38 ->39o C)
accompanied with tachypnea, non-productive cough, nasal congestion, and headache, the
primary consideration is Pneumonia.

Rule in Rule out

Fever History of asthma
Cough
Not relieved by anti-asthma meds
Crackles
Body weakness, fatigability
(-) Expiratory wheezes

IMPRESSION: PNEUMONIA
 Paraquat is the most toxic dipyridilium herbicide. Concentrated
solutions (12-20%) tend to be more dangerous than dilute solu-
tions. Its toxic effects result from the production of superoxides
and other highly reactive free radicals that cause the peroxidation
of cell membranes and selective mitochondrial damage, resulting
in cell death. Paraquat selectively concentrates in the lungs
because of an amine uptake process that exists in alveolar epi-
thelial cells. Additionally, paraquat-induced injury is significantly
increased in the presence of high concentrations of oxygen.
Although its use is banned or restricted in some countries, para-
quat is still used extensively, particularly in many developing and
transitional countries including tourist destinations. Most cases
of paraquat intoxication are self-inflicted (suicide attempts).
There have been case reports of fetal poisoning after maternal
ingestion of paraquat (readily crosses placenta) with poor prog-
nosis for the fetus.
DISCUSSION: For the full continuation of this chapter, please visit the Nelson
Textbook of Pediatrics website at www.expertconsult.com.
attributable to the introduction of antibiotics, vaccines, and the
expansion of medical insurance coverage for children. Haemoph-
ilus influenzae type b (Hib) (Chapter 186) was an important
cause of bacterial pneumonia in young children but has become
uncommon with the routine use of effective vaccines. The intro-
duction of heptavalent pneumococcal conjugate vaccine and its
impact on pneumococcal disease (Chapter 175) has reduced the
overall incidence of pneumonia in infants and children in the USA
by ≈30% in the 1st yr of life, ≈20% in the 2nd yr of life, and
≈10% in children >2 yr of age. In developing countries, the
introduction of measles vaccine has greatly reduced the incidence
of measles-related pneumonia deaths.
Injuries
3%
AIDS
3%
Measles
4% Other neonatal causes
27%

Epidemiology: Malaria
8%

Pneumonia or391.4theEosinophilic Lung Disease

inflammation of the lung
Others
10%
Oren Lakser
parenchyma is a substantial cause of morbidity and mortality
The findings of pulmonary infiltrates and circulating or tissue
in childhood throughout the world.
eosinophilia describe the heterogenous group of disorders
referred to as eosinophilic lung diseases or pulmonary infil- Diarrhoeal Neonatal severe
trates with eosinophilia (PIE) (see Table 391-2 the Nelson Text- diseases infections
book of Pediatrics website at www.expertconsult.com). There 17% (mainly
are numerous classification schemes for these types of lung pneumonia/sepsis)
disease. PIE syndromes can be divided into primary (idiopathic) 10%
Etiology: and secondary eosinophilic lung diseases. Primary eosinophilic
Note that undernutrition is
implicated in 53% of all deaths
Pneumonia
19%
lung diseases include simple pulmonary eosinophilia (Löffler among children under 5.
syndrome), acute eosinophilic pneumonia, chronic eosinophilic Figure 392-1 Pneumonia is the leading killer of children worldwide, as shown by this
Pneumonia can be caused via infectious or noninfectious
pneumonia, and idiopathic hypereosinophilic syndrome. Sec-
ondary eosinophilic lung diseases include tropical pulmonary
(aspiration, foreign bodies,
illustration of global distribution of cause-specific mortality among children <5 yr in
2004. Pneumonia causes 19% of all under-5 deaths. This illustration, however, does not
hypersensitivity reactions) causes.
eosinophilia, pulmonaryEtiology
eosinophiliain an
with individual
asthma,
nodosa, Churg-Strauss syndrome, allergic bronchopulmonary
patient
polyarteritis is often difficult to determine
include deaths due to pneumonia during the neonatal period. It is estimated that 26% of
neonatal deaths, or 10% of under-5 deaths, are caused by severe infections. Large
because direct culture aspergillosis
of specimen (ABPA), fro
andthe respiratory
drug-induced tractlungor sputum
eosinophilic samples
proportions of these dobynot
infections are caused accurately
pneumonia/sepsis. If these deaths were
added to the overall estimate, pneumonia would account for up to 3 million, or as many
disease. Additional lung diseases such as idiopathic pulmonary
reflect the cause of lower respiratory
fibrosis, Langerhans cell tract infection.
granuloma, and other interstitial lung
as one third (29%), of under-5 deaths worldwide. (Sources of data: Cause-specific
mortality estimates from WHO. World Health Report 2005: Make Every Mother and Child
diseases may have associated eosinophilia but are better classi- Count. Geneva: World Health Organization, 2005; under-five mortality estimates from
fied elsewhere. UNICEF. The state of the world’s children 2006. New York: United Nations Children’s
For the full continuation of this chapter, please visit the Nelson
Streptococcus pneumoniae
Textbook of Pediatrics website at(pneumococcus)
www.expertconsult.com. isFund, the
children, most
Lancet 368:1048 –1050, common
2006.) bacterial
2005. From Wardlaw T, Salama P, Johansson EW: Pneumonia: the leading killer of

pathogen in children 3 weeks to 4 yrs of age, whereas Mycoplasma pneumoniae and

Chlamydophila pneumoniae are the most frequent pathogens in children 5 yrs old and older.
In addition to pneumococcus, other bacterial causes of pneumonia in previously healthy children
include Streptococcus pyogenes and Staphylococcus aureus. S. pneumoniae, H.
influenzae, and S. aureus are the major causes of hospitalization and death from bacterial
pneumonia among children in developing countries. As for children with HIV infection,
Mycobacterium tuberculosis, atypical mycobacteria, Salmonella, Escherichia coli, and
Pneumocystis must be considered.

Viral pathogens are a prominent cause of lower respiratory tract infections in infants and
children <5 yr of age. Unlike bronchiolitis, for which the peak incidence is in the 1st yr of life, the
highest frequency of viral pneumonia occurs between the ages of 2 and 3 yr, decreasing slowly
thereafter. Of the respiratory viruses, influenza virus, and respiratory syncytial virus (RSV) are
the major pathogens, especially in children <3 yrs of age. Other common viruses causing
pneumonia include parainfluenza viruses, adenoviruses, rhinoviruses, and human
metapneumovirus. The age of the patient may help identify possible pathogens.

ETIOLOGIC AGENTS OF PNEUMONIA: GROUPED BY AGE

Age Group Frequent Pathogens
(In order of Frequency)
Neonates (<1 months) Group B Streptococcus, Escherichia coli, other gram-negative bacilli,
S.pneumoniae, H.influenzae (type b)
1-3 months
Febrile pneumonia RSV, other respiratory viruses (parainfluenza, influenza,
adenoviruses), S.pneumoniae, H.influenzae

Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma

Afebrile pneumonia urealyticum, cytomegalovirus

3-12 months RSV, other respiratory viruses (parainfluenza, influenza,

adenoviruses), S.pneumoniae, H.influenzae, C. trachomatis, M.
pneumoniae, group A strep
 2-5 years RSV, other respiratory viruses (parainfluenza, influenza,
adenoviruses), S.pneumoniae, H.influenzae, M. pneumoniae,
Chlamydiphila pneumoniae, S.aureus, group A strep
5-18 years M.pneumoniae, S.pneumoniae, C.pneumoniae, H.influenzae,
influenza viruses, adenoviruses, other respiratory viruses
> 18 years M.pneumoniae, S.pneumoniae, C.pneumoniae, H.influenzae,
influenza viruses, adenoviruses, Legionella pneumophila
* Nelson Textbook of Pediatrics

CAUSES OF COMMUNITY ACQUIRED PNEUMONIA

*American Pediatric Association

 Pathophysiology:
Entry of microbial organisms:
inhalation/inoculation
Defects in bronchoalveolar defense
Sneezing
mechanism (mucociliary / IgA)
Invasion of the lungs

Cough
Activation of immune response
PGE2 Anterior Hypothalamus Fever
(alveolar macrophages-cytokines)

Ineffective immune response

Invasion of lung parenchyma

Release of endotoxins and

exotoxins

Continuous mucus secretion

Sputum production

Massive inflammation Dyspnea Chest retraction/nasal flaring

Hazy portion of chest

Altered gas exchange Cyanosis

Crackles/wheezes
Consolidation Decreased breath
sounds

CLINICAL MANIFESTATION OF CAP IN CHILDREN:

¢ Rhinitis
¢ Cough o Diminished breath sounds
¢ Fever o Ronchi
¢ Tachypnea o Lag in respiratory excursion
¢ Intercostal, subcostal, suprasternal o Abdominal distention
retractions o Abdominal pain
¢ Nasal flaring o Nasal flaring
¢ Crackles/ wheezes o Chest retraction
¢ Loss of appetite, poor feeding o Dullness on percussion
¢ Lethargy o Coarse crackles on auscultation
o Decreased breath sounds
o Bronchial breathing
 Figure 392-3 Radiographic findings characteristic
of pneumococcal pneumonia in a 14 yr old boy
with cough and fever. Posteroanterior (A) and
lateraldecreased
o Oxygen saturation may (B) chest radiographs reveal consolidation
B in the right lower lobe, strongly suggesting
bacterial pneumonia.
CRITERIA FOR HOSPITAL ADMISSION:

espiratory viral Table 392-5 FACTORS SUGGESTING NEED FOR HOSPITALIZATION OF

CHILDREN WITH PNEUMONIA
ection requires
l fluid, or lung. Age <6 mo
s of pneumonia Sickle cell anemia with acute chest syndrome
Multiple lobe involvement
ve in only 10%
Immunocompromised state
d agglutinins at Toxic appearance
patients with M. Moderate to severe respiratory distress
are nonspecific Requirement for supplemental oxygen
may also cause Dehydration
iae can be diag- Vomiting or inability to tolerate oral fluids or medications
reaction (PCR) No response to appropriate oral antibiotic therapy
ologic evidence, Social factors (e.g., inability of caregivers to administer medications at home or
be useful in the follow up appropriately)
Adapted from Baltimore RS: Pneumonia. In Jenson HB, Baltimore RS, editors: Pediatric
infectious diseases: principles and practice, Philadelphia, 2002, WB Saunders, p 801.

DIAGNOSTICS:
ased on the pre- of presumptive diagnosis of a viral infection, deterioration in
1. Radiographs: (+) Infiltrates
nce of the child. clinical status should signal the possibility of superimposed bacte-
lization, amoxi- • Viral
rial infection, andPneumonia: hyperinflation
antibiotic therapy shouldwith bilateral interstitial infiltrates and peribronchial
be initiated.
high percentage cuffing
Indications for admission to a hospital are noted in Table
of amoxicillin 2. Peripheral
392-5 WBC Count
. In developing countries, oral zinc (20 mg/day) helps accel-
apeutic alterna- • Bacterial
erate recovery Pneumonia:
from severe á WBCThe
pneumonia. – 15,000-40,000
optimal duration / mmof3; predominance of granulocytes
clavulanate. For antibiotic• treatment for pneumonia
Viral Pneumonia: WBC –has not been
normal well-established
or elevated; usually not > 20,000 / mm3;
fection with M. in controlledpredominance
studies. For pneumococcal
of lymphocytes pneumonia, antibiotics
macrolide antibi- should
3. Sputumprobably be Identify
GS/CS: continued until the
etiologic patient
agent has been afebrile
and sensitivity to antibiotic
. In adolescents, for 72 hours, and the total duration should not be less than 10
ifloxacin, gemi- to 14 days (or 5 days if azithromycin is used). Available data do
IMCI:
In developing not support prolonged courses of treatment for uncomplicated
a (≈41% in sub- pneumonia.
ver. In response,
national groups
ocal health care
PROGNOSIS
eumonia. Typically, patients with uncomplicated community-acquired bac-
pneumonia in a terial pneumonia show response to therapy, with improvement in
on the clinical clinical symptoms (fever, cough, tachypnea, chest pain), within
teral cefotaxime 48-96 hr of initiation of antibiotics. Radiographic evidence of
bacterial pneu- improvement lags substantially behind clinical improvement. A
staphylococcal number of factors must be considered when a patient does not
l antimicrobial improve with appropriate antibiotic therapy: (1) complications,
amycin. such as empyema; (2) bacterial resistance; (3) nonbacterial etiolo-
ble to withhold gies such as viruses and aspiration of foreign bodies or food; (4)
who are mildly bronchial obstruction from endobronchial lesions, foreign body,
n, and are in no or mucous plugs; (5) pre-existing diseases such as immunodeficien-
th known viral cies, ciliary dyskinesia, cystic fibrosis, pulmonary sequestration,
ns. Therefore, if or cystic adenomatoid malformation; and (6) other noninfectious
apy on the basis causes (including bronchiolitis obliterans, hypersensitivity
Treatment Modalities:

Hospital admission
 DOF: Penicillin G (IV) – del Mundo
2nd generation cephalosporins (Cefuroxime) – Nelson’s

Medications: Cefuroxime 335 mg IV q 8 hours (100.5 mg/kg/day)

Paracetamol 120 mg IV q 4 hours (72 mg/kg/day)
Ipatropium + salbutamol neb q 6 hours

*Oral zinc (20mg/day)

Prognosis:
− Most children recover rapidly and completely
− With treatment, most types of bacterial pneumonia can be cured w/ in 1-2 weeks
− Usually viral pneumonia is a self-limiting condition and may last longer than bacterial
pneumonia

Prevention:
1) Frequent Hand Washing
2) Good personal hygiene
3) Pneumococcal Vaccine (2 yo)
4) Hygienic handling of foods
THERAPEUTIC MANAGEMENT OF CAP: