CC : difficulty breathing, cough 7 days prior to admission
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Prepared by...
Virat Sirisanthana, M.D. |
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Department of Pediatrics,
Chiang Mai University
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| Patient: A 5.5-month-old Thai infant |
| Address: Chiang Mai |
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CC : difficulty breathing, cough 7 days prior to admission |
| PI : | |
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At age 1.5 month he was
refered to CMU hospital because of fever, convulsion and dyspnea. The LP
revealed: wbc 10 mono 100% protein 57 sugar 47/71 ,latex agglutination negative, culture no growth. He was treated as "sepsis" with Cefotaxime 200 MKD. During admission he developed respiratory failure. CXR : Perihilar - peribronchial infiltration (click for CXR) . He was intubated. Suction obtained secretion which was positive for AFB 4+ (click for sputum smear),. Antit-tuberculous drugs were added (2IRZS /4IR). His serum HIV-Ab was positive. Trimetroprim/sulfamethoxazole was also added for Pnemocytis carinii pneumonia prophylaxis. He slowly recovered and was discharged from the hospital at the age of 2.5 months. |
| > | At 3 and 4 month old he was
followed up at the OPD. He was continued on anti-tuberculous drugs, but
did not have the refill of trimetroprim/sulfamethoxazole prophylaxis. |
| > | At 5 month old he was followed
up at the OPD. He was continued on anti-tuberculous drugs and trimetroprim/sulfamethoxazole was restarted for PCP prophylaxis. |
| > | At 5 month and 7 days old
(ie. 7 days prior to this admission) he started having low grage fever with
dry | cough and progressive difficult breathing. A few days prior to admission his symptoms got worse. He became "blue" while sucking or crying. He took less feeding, so his mother brought him to the OPD. |
| PAST HISTORY | |
| - | PRENATAL : He
is the only child. Both mother and father are HIV-infected persons. His mother is healthy looking. |
| - | NATAL : He was born at a primary care hospital without complication. (birth weight of 2,300 gm) |
| - | POSTNATAL: normal |
| - | FEEDING : infant formular |
| - | IMMUNIZATION : as schedule |
| - | FAMILY HISTORY: his father died of pulmonary tuberculosis |
| PHYSICAL EXAMINATION | |
| > | VITAL SIGN :
T 37.8 c PR 140 / min RR : 60 /min BP: 90/50 mmHg OXYGEN SATURATION AT ROOM AIR 60% |
| > | GA : Thai boy, good conciousness, dyspnea, cyanosis, flaring ala nasi |
| > | HEENT :mild pale conjunctivae, no icteric sclera, AF 1x2 cm, not tense, oral thrush |
| > | CHEST : subcostal
retraction, LUNG : creppitation at both lower lung with occational rhonchi
HEART : regular rythm, tachycardia, no murmur |
| > | ABDOMEN :normal contour, active bowel sound, soft. Liver: 2 cm below RCM , SPLEEN: not palpable |
| > | EXTRIEMITIES : wnl |
| INVESTIATION | |
| - | CBC :Hb 9.2 Hct 30 WBC 14,900
N 72 L 28 PLATELET 207,000 U/A : NO CELL pH 6 Sp. Gr.1.017 BUN :28 Cr : 0.5 ELECTROLYTE : N a 138 K 4.5 C l 107 CO2 21 |
| - | ABG :ON CANNULAR O2 4 LPM
pH 7.255 PaO2 37 Paco2 50.6 HCO3 21.7 BE -0.4 O2 SAT 89.7 ON BOX O2 10 LPM pH 7.352 PaO2 77.2 Paco2 47.5 HCO3 27.3 BE 0 O2 SAT 94.4 A-a gradient 576 |
| - | CXR : There are patchy infiltration at left perihilar region and both lower lung fields (click for CXR). |
| - | SERUM LDH : 788 |
| PROBLEM LIST | |
| 1. | HIV exposed infant with history of pulmonary tuberculosis |
| 2. | another attack of pneumonia
(tachypnea, low grade fever, hypoxia, creppitation both lower lungs, abnormal CXR) |
| TREATMENT | |
| 1. | OXYGENATION |
| 2. | ANTI TB DRUG : INH + RIFAMPIN |
| 3. | CEFOTAXIME 100 MKD IV |
| 4. | BACTRIM 20 MKD IV |
| COURSE IN THE HOSPITAL |
| The patient deteriolated
and was intubated. He expired on the 6th day of admission. Lung necropsy
was done |
| HISTOPATHOLOGY |
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