Patients Details
Name: xxxxx
Age: 14 months
Gender: Male
Race: Malay
Date of Admission: 7 December 2016
Date of Clerking: 8 December 2016
History
Chief Complaint
xxxx, 14 months old Malay boy, presented with 3 days history of cough, fever and rapid breathing.
History of Presenting Illness
He was apparently well until 3 days before admission, he developed cough. The cough was chesty in nature and was non-productive. It was non-paroxysmal cough with no facial congestion. He had one episode of post tussive vomiting which he vomited milk and whitish sputum.
He also had fever for 2 days, which his mother admitted that he was warm to touch, however the temperature was not measured at home. He was irritable but consolable and no rashes noted during the illness. His activity and feeding was reduced. Normally, he had 4 bottles of milk per day, however, during the illness, he only drank 1-2 bottles. The mother gave him suppository Paracetamol and tepid sponging on day 3 of illness, however the fever did not resolve.
On day 3 of illness, he developed rapid breathing which was associated with noisy breathing. The mother noticed these when he suddenly awoke from sleep, crying and breathing rapidly.
He was then brought to the GP and was given nebuliser once. As his condition did not improved, he was referred to Hospital Ampang for further management. In the red zone, once again, he was given nebuliser for two times before admitted to the ward.
For the interval symptoms, patient denied any daytime or nocturnal symptoms. However, he had cold-induced cough, especially after having cold drinks or in cold weather. He did not have any eczema or exercise-induced cough. Patient had pets at home, however the mother claimed that the pets are outside of their house. There was no carpets in the house. As their house’s location is near the main road, the environment was dusty for most of the days. Patient’s older brother had asthma and his father has allergic rhinitis and eczema. He had sick contact at home, which was his older sister who had upper respiratory tract infection.
This is his first admission to the hospital, however, he had four episodes of cough this year, which was relieved by nebuliser taken at GP.
Otherwise, patient had no travel history, no diarrhoea and the micturition and the bowel movements were good.
Past Medical/Surgical History
There was no significant past medical or surgical history.
Birth History
He was delivered at term through spontaneous vertex delivery. The birth weight was 4.38 kg. Antenatally was uneventful. Patient had two admissions to Neonatal Intensive Care Unit (NICU) after birth. First admissions was for 8 days due to GBS infection. Patient was intubated for 2 days and was on oxygen support. He was discharge well and was under Hospital Ampang follow-up until 1 years old.
The second NICU admission was 2 days after he was discharged from the previous admissions. He had fever and was admitted to NICU for 4 days. Lumbar puncture was done once and he was diagnosed as sepsis and was discharged with antibiotics.
Feeding History
He was breastfed exclusively up to 5 months old. Since then, he drinks formula milk (Lactogen) for 5 oz, 3 to 4 bottles daily and breastfeed at night only. Complementary feeding started at 6 months old and his diet consists of various food such as rice, chicken, vegetables and fruits. He ate three times per day with snacks in between.
Developmental History
For gross motor development, he was able to walk at 11 months old and now he can runs around and climb stairs by himself. For the fine motor, he scribbled spontaneously at 12 months old and he can speak 2-3 meaningful words (mama, papa) at 13 months old. Socially, he could wave goodbye at 12 months old.
Immunisation History
The immunisation was up to the age. The last immunisation taken was MMR when he was 12 months old and the next immunisationn scheduled was at 18 months old, which is for booster dose of DTaP, Hib and IPV.
Allergies/Drug History
He is allergic to eggs. He developed generalised swelling and redness all over the body, however the condition resolved within an hour without taking any medications.
Family History
He was the youngest out of five siblings. He has 2 older brothers and two older sisters. The second brother has asthma, otherwise others are alive and well. His father has allergic rhinitis and eczema while his mother has no known medical illness.
Social History
He lives with his parents in Kg. Cheras Baru. There are 7 occupants in their bungalow house. His father, 42 years old graphic designer, is a smoker and a teetotaller. His mother, 37 years old, is a full time housewife. They are financially stable with monthly income of RM 5000 per month.
PHYSICAL EXAMINATION
General Examination
On examination, patient was lying down on his bed, alert, conscious, pink and was crying. He was not in respiratory distress. There was no dysmorphic features seen. He had branula attached to the dorsum of his left hand. The hands were warm and dry, with no clubbing, no peripheral cyanosis. The pulse rate was 120 beats per minute with regular rhythm and good volume. The conjunctiva was pink with no scleral jaundice. There was no nasal flaring or nasal obstruction. The throat was not injected or enlarged and the hydration status was good. There was no pedal oedema. The vital signs were as follows:
Temperature: 36.9 C
Blood pressure: 97/56 mmHg
Pulse rate: 120 beats per minute
Respiratory rate: 38 breaths per minute
Systemic Examination
Respiratory System
On inspection of the chest, there was no chest deformity such as pectus excavated or pectus carinatum. The chest moves with respiration. There was no scar, no dilated veins and no skin discolouration. The chest expansion was equal on both side. There was no recession of the chest wall or use of accessory muscle seen. On palpation, the trachea was centrally located with negative tracheal tug. The apex beat was located at the fifth intercostal space of the left mid-clavicular line. The chest expansion was normal. The percussions were resonance and equal on both side. On auscultation, there was vesicular breath sound heard with equal air entry bilaterally. There was generalized crepitations all over the chest wall with no rhonchi.
Cardiovascular System
On inspection, the precordium was normal in shape, there was no visible apex beat, no scar and no skin discolouration. On palpation, the apex beat was not displaced, there was no heaves or thrill. On auscultation, the first and second heart sounds were heard with no murmurs.
Abdomen Examination
On inspection, the abdomen was not distended and move with respiration. There was no scar, no dilated vein or skin discolouration seen. The abdomen was soft and non-tender. There was no organomegaly noted. The kidneys were not ballotable.
Neurological Examination
He was neurologically intact and did not require formal neurological examination of reflexes, tone and others.
Summary
xxxx, 14 months old Malay boy, presented with rapid breathing preceded by 3 days history of cough and fever. It was associated with wheezing. He had cold-induced cough and family history of bronchial asthma and atopy. Physical examination revealed generalised crepitations with no rhonchi.
DIAGNOSES
Provisional Diagnosis: Pneumonia
Patient was presented with fever, cough and rapid breathing, which was common symptoms for pneumonia.
Differential Diagnosis: Acute exacerbation of bronchial asthma (AEBA)
He had family history of asthma and atopy. Besides that, he also had cold-induced cough and previous episodes of cough which needed nebulisers at the GP.
INVESTIGATION
Blood
Full Blood Count (FBC)
Blood urea and serum electrolyte (BUSE)
Culture and sensitivity
Result: No growth.
Imaging: chest radiograph showed patchy infiltrates all over the lungs.
Others
Mycobacterial serology: POSITIVE
Nasopharyngeal aspirate (NPA): NPA was not done in this case
MANAGEMENTS
He was admitted to the ward for further management. In the ward, the vital signs was monitored 4 hourly and oxygen support was given in order to maintain the SpO2 >95%. He was treated with broad spectrum antibiotics, which were Penicillin C and syrup Erythromycin 240 mg BD in view of the positive mycoplasma seology. He was also given nebulized saline 4 hourly. Besides that, chest physiotherapy was also given.
DISCUSSION
Pneumonia kills 3 million children worldwide each year, especially in children with underlying conditions such as chronic lung disease of prematurity, congenital heart disease, and immunosuppression (1). Most of the time, in 40-60% of cases, the aetiology cannot be determined as it is difficult to distinguish viral from bacterial disease (2). However, the age group plays an important role in predicting the aetiological agents in pneumonia.
In this case, the serological test done revealed that the pathogen involved was Mycoplasma. As we all know, serology is performed in patients with suspected atypical pneumonia. Atypical pneumonia tends to have milder symptoms compared to typical pneumonia. Hence, the antimicrobial agent given was macrolides (e.g erythromycin, azythromycin) as it reacts accordingly to mycoplasma, which unlike other bacteria, lacks cell wall.
Other investigation which help to confirm the diagnosis includes chest x-ray. As far as the chest x-ray helps in determining the types of pneumonia, with the exception of lobar pneumonia’s classic radiographic features, the findings are still considered as nonspecific. For example, radiographic findings of generalised patchy infiltrates in bronchopneumonia can also be due to other causes. However, chest x-ray is still considered to be useful as it rules out other pathology of the lungs (3).
Not all patient diagnosed with pneumonia needed to be admitted as it can be managed at home. According to the evidence-based guidelines for the management of pneumonia in childhood published by the Malaysian Ministry of Heath, the indications for admission include children aged 3 months and below, fever more than 38.5 oC, refusal to feed and vomiting, fast breathing with or without cyanosis, associated systemic manifestation, failure of previous antibiotic therapy, recurrent pneumonia and those who has underlying disorder (2). This child was admitted accordingly as he had fever, tachypnoea and difficulty in breathing as mentioned in the history.
Overall, the prognosis of pneumonia is good as most cases of viral pneumonia resolve without treatment and the common organisms respond well to the antimicrobial therapy given. Follow-up is not usually required for those who recovered clinically (4).
Bibliography
1. Bennett NJ. Paediatric Pneumonia: Medscape; 2016. Available from: http://emedicine.medscape.com/article/967822-overview.
2. Ismail HIHM, Ng HP, Kesihatan MK. Paediatric Protocols for Malaysian Hospitals. 3rd Edition ed: Ministry of Health; 2015.
3. Medicine E. Community-Acquired Pneumonia Diagnostic Studies 2017 [updated 01/03/2017]. Available from: https://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=99&seg_id=1877.
4. Lissauer T, Clayden G. Illustrated Textbook of Paediatrics: Mosby; 2012.