BRONCHOPNEUMONIA WITH

MARASMUS

DINA RYANTI 100100122

KESHIA KHALIDA SIREGAR 100100218
 Introduction
Pneumonia is an acute infection of the
pulmonary parenchyma which includes
alveolar and interstitial tissue
There are two main types of acute bacterial
pneumonia : bronchopneumonia (with lobular
topography) and lobar pneumonia (lobar
topography)
 BRONCHOPNEUMONIA

inflammation of the lung parenchyma involving

bronchi / bronchioles in the form of shaped
distribution of patches (patchy distribution).
Consolidation spots centered around the bronchial
inflammation is usually multifocal and bilateral .
 WHO 2009
Cause of death
Influenza and
pneumonia

Household healthy
survey 2001
Bronchopneumonia
Second death was one of the most
causal in indonesia
was lower
Epidemilogy tenth diseases at
hospitalization
respiratory tract
infection

At 2001
bronchopneumonia
was increased
become 1,61% after
bronchitis
Bronchopneumonia is a condition that child with
respiratory distress; any of: rapid, noisy, or
difficult breathing; respiratory rate >60/min; chest
retractions; cough; grunting; who has a positive
blood culture or predisposing factors.

In bronchopneumonia, the focus of infection and

the inflammatory response is in the bronchi and
surroundingparenchyma.
 Etiology

Newborn Infant(1-3 months) Older children and

adolescents
Group B Streptococcus Mycoplasma
Streptococcus pneumoniae pneumoniae
Listeria
monocytogenes
Gram-negative(eg,
E. Coli, Klebsiella
pneumoniae)
RSV
 Pathogenesis
Stage I / hyperemia (4-12 hours of first / congestion)

Stage II / Red Hepatization (48 hours later)

Stage III / Grey Hepatization (3-8 days)

Stage IV / Resolution (7-11 days

 Clinical manifestation

Newborn Infants( 1-3 Children and

months) adolescents
Poor feeding Cough Constitutional
symptoms,
headache, pleuritic
chest pain, vague
abdominal pain
irritability Tachypnea Vomiting
Tachypnea Retraction Diarrhea
Retraction Hypoxemia Pharyngitis
Grunting Congestion, fever, Otalgia/ otitis
irritability,
decreased feeding
Hypoxemia
 Diagnosis

- History
- Physical examination
- Diagnostic test :
. Cultures
. Serology
. Complete blood cell count (CBC)
. Chest radiography
. Ultrasonography
 Treatment

The majority of children diagnosed with pneumonia in the

outpatient setting are treated with oral antibiotics. High-
dose amoxicillin is used as a first-line agent for children
with uncomplicated community-acquired pneumonia.
Second- or third-generation cephalosporins and macrolide
antibiotics such as azithromycin are acceptable alternatives.
Combination therapy (ampicillin and either gentamicin or
cefotaxime) is typically used in the initial treatment of
newborns and young infants.

In areas where resistance is very high (>25% of strains

being nonsusceptible), a third-generation cephalosporin
might be indicated instead. Older children, in addition, may
receive a macrolide to cover for atypical infections.
 Prognosis

Morbidity and mortality from RSV and other viral

infections is higher among premature infants and
infants with underlying lung disease.
Significant sequelae occur with adenoviral disease,
including bronchiolitis obliterans and necrotizing
bronchiolitis.
With neonatal pneumonia, even if the infection is
eradicated, many hosts develop long-lasting or
permanent pulmonary changes that affect lung
function, the quality of life, and susceptibility to
later infections.
 Prevention

Vaccination is the primary mode of prevention.

Influenza vaccine is recommended for children
aged 6 months and older.
The pneumococcal conjugate vaccine (PCV13) is
recommended for all children younger than 59
months old.
The 23-valent polysaccharide vaccine (PPVSV) is
recommended for children 24 months or older who
are at high risk of pneumococcal disease.
CASE REPORT
 Case Report
Name : H.S.
Age : 29 days
Sex : male
Date of Admission: 9th Dec 2014
 Chief Complaint
SHORTNESS OF BREATH

2ND
CHOKING Became worst
Became worst
2 1ST CHOKING 4 SHORTNESS 12 being
admitted TO
29 being
OF BREATH admitted TO
DAYS DAYS FEVER DAYS OTHER
HOSPITAL
DAYS RSHAM
COUGH
 History of previous illness : -
History of drugs : not clear
History of pregnancy :
patient is the 7th child, the mother was 39 years old when she was pregnant.
The mother did not have any history of fever, hypertension, diabetes mellitus,
nor history of consuming any drugs and herbal medicines.
History of labor :
Term, spontaneous, attended by midwife,cried instantly, weight is 3000grams,
mother dont remember the length of the baby.
History of infant feeding :
birth till 2days : breast fed
3 days till now: SGM
History of development : -
History of immunization : -
 Generalized status
Body weight : 2800 grams, body length : 50 cm
Body weight according to age : z score < -3SD
Body length according to age : z score < -2SD
Body weight according to length : z score < -2SD
Interpretation : poor nutrition
 Conciousness : GCS 12 (E3V5M4), blood
pressure; 80/50
HR; 150 bpm
RR: 88x/i
body temperature: 36,9C
body weight; 2810 gr, body length; 50cm
anemic (-), icteric (-), cyanosis (-), edema (-),
dyspnea (+)
 Eye : isochoric pupil (3mm/3mm), light reflex (+/+),
conjunctiva palpebra inferior pale (-/-), icteric sclera (-/-)
Nose: nasal flaring (+), mucosa color; dark pink, discharge (-
), polyps (-), nasal septum ; no deviation; nasal canul fixed
Ear : external auditory canal ; no discharge, tympanic
membrane; intact,no inflammation
Mouth: lips; red in color, buccal; dark pink,glistening
Tongue: dark pink, papilla atrophy (-), tremor (-)
Teeth and gums : no teeth
Tonsil: within normal limit
Neck : lymph node enlargement (-), neck rigidity (-), JVP ; R-
2 cmH20
 Thorax :
Inspection : symmetrical fusiformis, retraction (+) epigastrial,
subcostal, respiration rate; 88x/i, reguler.cardiac bulging (-)
Palpation : ictus cordis ICR VI
Percusion : heart border; -upper: ICR III sinistra
-left : 1cm medial linea mid clavicular
sinistra
-right: linea sternalis dextra
Auscultation : lung; stridor (-)
Heart; heart rate; 150 bpm,reguler,S1 (+), S2 (+)
normal, murmur (-)
 Abdomen
Inspection : symmetrical, distention (-)
Palpation : soft, liver and spleen are not palpable
Percussion : tympanic
Auscultation : normoperistaltic
Extremities
Superior : pulse 150 bpm, reguler, adequate pressure per
volume, warm, capillary refill time (CRT) <3, spastic (-/-), pitting
oedem (-/-),
Inferior : pulse 150 bpm, reguler, adequate pressure per
volume, warm, capillary refill time (CRT) <3, spastic (-/-), pitting
oedem (-/-), baggy pants (+)
Urogenitals : male, within normal limit.
 Complete blood count : Difftel
Hemoglobin : 14,9 gr% Neutrofil : 49,70 %
Hematocrite : 47,40 % Limfosit : 38.90 %
Erithrocyte : 6.130.000 Monosit : 8,3 %
/mm3 Eosinofil : 2,70 %
Leucocyte : 8.450 / mm3 Basofil : 0,400 %
Platelet : 304 000 / mm3
MCV : 77,30 fL
MCH : 24,30 pg
MCHC : 31,40 g %
RDW : 17,80 %
MPV : 9,70 fL
PCT : 0,29
PDW : 14,7
 Arterial Blood Gases Carbohydrate
pH : 7,329 Metabolism
pCO2 : 42,7 mmHg blood glucose ad
pO2 : 63,4 mmHg random :156,2 mg/dl
HCO3 : 22,0 mmol/ Electrolyte
L Na + : 135 mEq/L
Total CO2 : 23,0 K+ : 4,6 mEq/L
mmol/L Cl- : 102 mEq/L
BE : - 3,8
Immunoserology
O2 saturation : 91,0
Procalcitonin : 7,3 ng/ml
X-ray (8th Dec)
 Trachea is found in the middle line, both
costopherenicus angle are sharp, smooth
diaphragm, infiltrates are found in both lungs,
CTR <50%, bones and soft tissues are in
normal condition.
- Bronchopneumonia dd/ Lung TB
 Differential Diagnosis :
bronchopneumonia
dd/ bronchiolitis
Working Diagnosis : Bronchopneumonia +
marasmus
 Management : Diagnostic Planning :
O2 1 l/I mask sat. O2 is Complete Blood Count
88% Blood Glucose
IVFD D5 % NaCL 0,225 % Electrolyte
11 gtt/i Procalcitonine
Inj. Ampicilin 100 mg/ 6 Qualitative C- reactive
hours/ iv (Day 1) protein (CRP)
Inj. Gentamicin 15 mg/ 24 Arterial blood gas
hours /iv (Day 1)
X-ray
Paracetamol 3x 30 mg syr
Blood Culture
Diet ; fasting
Urinalisa
Follow up 9th Dec - 28th Dec
 GCS 13 RR: 88 10 GCS 13
Meylon correction Diet 20cc/ 3 hours
GCS 13 RR: 78
ETT fixed
Procalcitonin: 17,3
PICU full >0,5
Nebule
ETT released
9 11-14

GCS 15
17-18
(+) Vit. A ;
Multivitamin w/o Weight: Diet F100
Fe 2600grams
Diet F75

15-16 19
 Weight:
24 - 28 Dx + small PDA
2800grams Inj Ampicillin Move to non-
and Gentamicin infection
aff
Nebule aff
23 28
 Discussion
Theory
The symptoms may include difficulty in
breathing, cough, fever, vomiting and unable to
drink, whereas the signs may include nasal
flaring, retraction of the subcostal, and in more
severe cases stridor and wheezing may present.
The etiological agents in neonate and small
infants include Haemophilus influenza type B,
Streptococcus pneumoniae, Streptococcus group
B, Chlamydia trachomatis, and gram negative
bacteria such as E.coli, Pseudomonas, and
Klebsiella.
Our case
In our patient, we found that she was present
with difficulty to breath accompanied by cough,
fever. We also found nasal flaring and retraction
of the subcostal.
In our patient, blood culture were the preffered
method to identify the etiological agent of
pneumonia. The method is time consuming thus
the result is not obtained yet.
Theory
Immunization helps reduce deaths related to
childhood pneumonia by preventing children
from developing infections that cause
pneumonia or can lead to pneumonia as a
complication e.g. measles and pertussis.
Use of antibiotics early in the disease gives a
prompt and favorable response. The treatment
for pneumonia include antibiotics that are
susceptible to the etiological agents like beta
lactam class of antibiotics.
Our case
In this case, our patient arent immunization yet.
The drug of choice for this patient is both
ampicilin and gentamicin. She was treated with
ampicilin 90 mg/ 6 hours/ iv and gentamicin 30
mg/ 24 hours/ iv for 7 days. We reassess the
patient daily and found improvemnt in the
childs vital signs.
 Summary
Boy, 29 days, with a chief complaint of shortness
of breath and was diagnosed with
bronchopneumonia diagnosed with
bronchopneumonia + Marasmus based on
history, clinical examination, laboratory and
radiologic findings. The patient was treated with
comprehensive treatment with antibiotic,
analgethic antipyretic, micronutrient supplement.
Adequate nutrition is absolutely supporting child
healing from infection, and improving his growth
and development progress