Geronimo, Maria Angelica; Geronimo, Ralph Ernesto; Go, Camille-Marie; Go, Crystal Karen

January 24, 2011

Pulmonology Conference

General DataJ.M.3 months oldMaleRace: FilipinoBirthdaySampaloc, ManilaRoman CatholicDate of AdmissionInformant:Reliability

Chief Complaint

Difficulty of Breathing

CC: Difficulty of Breathing

Review of SystemsGeneral: (-) weight changesCutaneous: (-) rashes, (-) jaundice HEENT: (-) eye redness (-) eye discharge (-) ear

discharge (-) gum bleedingCardiovascular: (-) cyanosisRespiratory: see HPI Gastrointestinal: (-) acholic stools

Review of SystemsGenitourinary: (-) tea-colored urine (-) oliguria (-)

dischargeNervous/Behavior: (-) seizures (-) tremors (-)

mood/behavioral changesEndocrine: (-) polyuria (-) polydipsia (-) polyphagia (-)

heat/cold intoleranceMusculoskeletal: (-) edema (-) swelling (-) limitation of

motion (-) tendernessHematopoietic (-) bleeding tendencies (-) easy

bruisability

Gestational HistoryMother: 36 year-old G1P0 housewifeFather:37 year old seamanRegular prenatal checkups USTH OPD for 7 times(-) viral exanthem, radiation and any intake of illicit,

prohibited or abortifacient drugs, intake of alcohol and smoking

UTI (September 2010) - Cefalexin for 7 days and claimed to be compliant; Repeat UA - normal

OGCT and Hepatitis screening were not done

Gestational HistoryPreeclampsia (HBP 160/100; UBP is 110-10/70mmHg)

Magnesium sulfateNicardipine drip Betamethasone

Emergency CS secondary to preeclampsia

Birth HistoryLive, preterm, singleton male, delivered via “E” CS

secondary to preeclampsiaBW 1.66 kgBL 44 cmHC 31 cmCC 25 cmAC 22 cmAS 8,9MT 32-33 weeksAGA

Neonatal History1st hour of life –Bakit kinailangan mag chest xray?in

distress?panu nasabing in distress? CXR: air bronchogram with densities on the right lower lobe

Nagbigay antibiotics?Persistent respiratory distress intubated (NICU)PDA: grade II continuous murmur(ano binigay/ginawa for the pda?)

2nd day of life – hyperbilirubinemia (6.8) Phototherapy on the 5th HDNeonatal hepatitis

Neonatal History2D echocardiography: PDA, patent foramen ovale,

LVE, LAE and pulmonary arterial hypertensionBlood CS: Klebsiella pneumoniaAno meds?Assessment: sepsisDischarged at his 52nd day of life

Feeding HistoryMixed Breastfed and Milk formula

15 minutes/breast3x a day alternating with Formula S26 lactose free 1

scoop in 2 ounces every 3 hours Mother claims that there is not enough milk being

produce that’s why she started on powdered milkGood appetite with no feeding difficulties

24 Hour Food Recall

Developmental HistoryGood motor activityVisually tracks objects and looks aroundHas social smileMother do not practice him to sit with support or do

prone positionHas head lag when pulled

At par with age?

Past Medical HistoryOctober 10, 2010: sepsis, neonatal hepatitis and PDA No previous surgeries doneNo allergy, eczema, asthma, food or drug sensitivities

Immunization HistoryHepatitis B – 11/22/10, 12/22/10BCG - 11/24/10DTP and OPV - 12/22/10

Table form

Family Profile

Name Age Relation Educational Attainment

Occupation Health

SG 38 Father College graduate

Seaman Healthy

CG 36 Mother College graduate

Unemployed Preeclampsia

Family History(+) Asthma – paternal grandmother(+) HPN – maternal grandmother(-) DM, blood dyscrasia, autoimmune disease,

congenital disorders, thyroid diseases, cancer, allergy

Socioeconomic and Environmental History Rented studio type made of concreteAdequate space for each household member, well-lit and

well ventilatedWater stationMeals are home-cooked prepared by his mother or

sometimes they buy cooked-mealsNo pets, no factories or other industrial establishments

within the vicinity of the residenceGarbage is not segregated and is being collected everydayNot exposed to second hand smoke

Physical ExaminationAwake, alert, in respiratory distress, ambulatory, well-

hydrated, well nourished, ill-lookingHR 135 bpm, regular, RR 48 cpm, regular, T36.7oC,

SpO2 91%Wt: 3.26 kg (z score below -3 severely underweight)Lt: 51 cm (z score below -3 severely stunted)BMI: 12.53 (z score below -2 severely wasted)Warm, moist skin, no jaundice, no visible gross skin

lesions, good skin turgor

Physical ExaminationNormocephalic head, no visible scalp lesions, patent

anterior fontanelPink palpebral conjunctivae, anicteric sclerae, pupils

2-3 mm ERTLNo tragal tenderness, intact tympanic membraneNo nasoaural discharge, nasal septum midline,

turbinates not congestedMoist buccal mucosa, nonhyperemic posterior

pharyngeal walls, tonsils not enlarged,

Physical ExaminationSupple neck, no palpable cervical lymphadenopathy,

thyroid gland not enlargedSymmetrical chest expansion, (+) subcostal

retractions, equal tactile and vocal fremiti, (+) crackles over both lung field with occasional wheezes at left lung field

Adynamic precordium, apex beat at 4th LICS MCL, no heaves/lifts, no thrills, normal rhythm, S1 louder than S2 at the apex, S2 louder than S1 at the base, (+) Grade II continuous murmur

Physical ExaminationGlobular abdomen, normoactive bowel sounds, soft,

no tenderness, no palpable masses, Traube’s space not obliterated

Genitalia: grossly male with both descended testesPulses are full and equal, no edema, no cyanosis

Neurologic ExaminationAwake, alert Cranial nerves: CNI not assessed, pupils 2-3mm equally

reactive to light, (+) direct and consensual light reflex, (+) ROR, EOM full and equal, no gross facial asymmetry, gross hearing intact (able to localize sound), CN IX, X, XI, XII not assessed

No spasticity, rigidy, flaccidity, no limitation in movementNo sensory deficitsDTR +2 No nuchal rigidity, Brudzinski’s and Kernig’s (+) Moro, grasp, plantar, sucking reflex

Salient Features3 month old maleHistory of colds, non-productive coughPE: tachypneic, (+) subcostal retractions, (+) crackles

over both lung field with occasional wheezes at left lung field

Approach to DiagnosisSymptom, sign or laboratory finding pointing to an

organ or part of an organ system

3 month old maleHistory of colds, non-productive cough, difficulty of breathingPE: tachypneic, (+) subcostal retractions, (+) crackles over both lung field with occasional wheezes at left lung field

Pulmonary Pathology

Pneumonia

Approach to the Diagnosis

Differential Diagnosis

Admitting Diagnosis

Course in the Wards

Discussion na lang ito.PPS Clinical Practice Guideline

for PCAP 2004

Complete Blood Count

Bacterial Viral

WBC 15,000 – 40,000 WBC < 20,000

Granulocytes Lymphocytes

Chest Xray (PA Lat)

Gold standard for the diagnosis of pneumoniaIndicates complications PCAP such as a pleural effusion or empyema

COURSE IN THE WARDS

ADMITTING ORDERSNPO, Hgt every 8 hoursVital signs every hourIVF? Input & Output recorded every shiftRequested:

CBC with platelets, CXR

Meds:Ampicillin 150mg/ SIVP over 30 Q6 hours (MKD?)Gentamicin 13 mg/ SIVP over 30 mins Qday(MKD?)Salbutamol nebulization (1 neb every how many hours?

In our patient...

2nd HDAmpicillin dose was increased to 160 mg/ SIVP over

30 mins, Q6Hgt monitoring was discontinuedFeeding was resumed

Nebulization was discontinued

3rd HD

6th HDDecreased monitoring to Q4IVF consumed

7th HDLast dose of antibiotics givenDischarged stable and improved

Pneumonia

Discussion

• Inflammation of parenchyma of the lungs

• Etiologic agent vary with the age and immune status of the child, as well as with some environmental conditions

Signs and Symptoms• Symptoms of pneumonia vary, depending on the age of the

child and the cause of the pneumonia. Common symptoms include:– fever– chills– cough– tachypnea– breathing with grunting or wheezing sounds– labored breathing leading to retractions– vomiting– chest pain– abdominal pain– decreased activity– loss of appetite (in older kids) or poor feeding (in infants)– in extreme cases, cyanosis

Pathophysiologyresults from inflammation of the alveolar space and may

compromise air exchangeMost commonly, this inflammation is the result of

invasion by bacteria, viruses, or fungi, but it can occur as a result of chemical injury or may follow direct lung injury (eg, near drowning).

Four stages of lobar pneumonia have been described. The first stage, occurring within 24 hours of infection

the lung is characterized microscopically by vascular congestion and alveolar edema

Many bacteria and few neutrophils are present The stage of red hepatization (2-3 d)

similarity to the consistency of liver, is characterized by the presence of many erythrocytes, neutrophils, desquamated epithelial cells, and fibrin within the alveoli

In the stage of gray hepatization (2-3 d)the lung is gray-brown to yellow because of

fibrinopurulent exudate, disintegration of red cells, and hemosiderin

The final stage of resolution is characterized by resorption and restoration of the pulmonary architectureFibrinous inflammation may extend into the

pleural space, causing a rub heard by auscultation, and it may lead to resolution or to organization and pleural adhesions.

Bronchopneumonia, a patchy consolidation involving one or more lobes, usually involves the dependent lung zonesThe neutrophilic exudate is centered in bronchi

and bronchioles, with centrifugal spread to the adjacent alveoli

* Bacterial superinfection of viral pneumonia : mixed pattern of interstitial and alveolar airspace inflammation

In interstitial pneumonia, patchy or diffuse inflammation involving the interstitium is characterized by infiltration of lymphocytes and macrophages The alveoli do not contain a significant exudate,

but protein-rich hyaline membranes similar to those found in adult respiratory distress syndrome (ARDS) may line the alveolar spaces

Miliary pneumonia is a term applied to multiple, discrete lesions resulting from the spread of the pathogen to the lungs via the bloodstream. miliary tuberculosis, histoplasmosis,

and coccidioidomycosis may manifest as granulomas with caseous necrosis

to foci of necrosisFactors that bypass or inactivate local defenses (eg,

tracheostomy tubes, immotile cilia syndrome) predispose the child to pneumonia The result is loss of surfactant activity with local

collapse and consolidation.

Pathogens implicated in pneumonia vary with the age of the child, the underlying patient-specific risk factors, immunization status, and seasonality.

Newborns and infantsvia the maternal genital tract group B streptococci, Escherichia coli and other

fecal coliforms, and C trachomatis. Group B streptococci most often is transmitted to

the fetus in utero, usually as a result of colonization of the mother's vagina and cervix by the organism.

However, most pneumonia in this age group is community acquired and involves Streptococcus pneumoniae, Staphylococcus aureus, and non-typeable Haemophilus influenzae.

Young childrenViruses are a common cause of pneumonia among

toddlers and preschoolersStreptococcus pneumoniae is by far the most common

bacterial cause of pneumoniaChildren in this age group are also at risk for infection by M

pneumoniae

Older children and adolescentsM pneumoniae is a frequent cause of pneumonia

among older children and adolescentsOlder adolescents may have lost their immunity to

pertussis and may become infected by this organism

Bacterial pneumonia in this age group most often is caused by Streptococcus pneumoniae.

Efficacy of an 11-Valent Pneumococcal Conjugate Vaccine against Radiologically Confirmed Pneumonia Among Children Less Than 2

Years of Age in the PhilippinesA Randomized, Double-Blind, Placebo- Controlled Trial

Lucero et alThe Pediatric Infectious Disease Journal

Volume 28 Number 6, June 2009Lippincott Williams and Wilkins

PneumococcusLeading cause of childhood pneumonia worldwidePneumococcal conjugate vaccines (PCV) have

demonstrated efficacy against childhood invasive pneumococcal disease (IPD) and pneumonia in the US and Africa

No information is available from Asia on the impact of PCV on childhood pneumonia

Study Setting6 municipalities in Bohol province in central

Philippines3 seasons: hot, rainy, coldNo HIV and no malariaInfant mortality rate in Bohol: 28/1000 live birthsMajor cause of death: pneumonia and diarrheaStudy monitored by RITM and KTL

Study DesignRandomized, placebo-controlled, double blind trialCollaboration with government and private health

services in Bohol3 doses of 11PCV or a saline placebo given at 4 weeks

interval to determine Vaccine Efficiency

ParticipantsInformed consent of the motherInclusion criteria

Children age <6 weeks to 6 monthsThe family was expected to remain in the study area for 2

years or until the end of December 2004Infant was healthy

Exclusion criteriaFirst dose DTwPRectal temperature of 38°CNeurologic diseaseHistory of hospitalization or treatment for immune

suppressionEnrolment in another clinical trial

Vaccine

11 PCV 1 μg S. pneumoniae capsular

polysaccharide conjugated to tetanus toxoid for types 1, 4, 5, 7F, 9V, 19F, and 23F

3μg of polysaccharide of types 3, 14, and 18C conjugated to dipththeria toxoid

10μg pf polysaccharide of type 6B conjugated to diptheria toxoid

Manufactured by Sanofi pasteur

PlaceboSaline

Vaccines were given intramuscularly in the anterolateral aspect of right thigh

Routine vaccines given in left thigh

Definition of termsCommunity acquired pneumonia

Pneumonia with onset either in the community or in hospital but less than 72 hours after admission

IPDBacteremia or culture proven meningitis

Trial end point: Radiologically defined CAP using WHO vaccine trialists’ standard guidelinesPresence of a dense opacity that could be a fluffy

consolidation of a portion of a lobe, a whole lobe or the entire lung, often containing air bronchograms and sometimes associated with pleural effusion in the lateral pleural space

Associated with a pulmonary infiltrate or an effusion large enough to obscure such an opacity

Secondary end pointsHospitalized or not hospitalizedCulture proven invasive disease with a vaccine type-

specific pneumococcusSerious adverse events

Clinical Pneumonia (WHO Severity Grade)History of cough and/or difficulty of breathingIncreased respiratory rate according to ageLower chest wall indrawing (severe)Cyanosis and/or inability to drink (very severe)

Surveillance for Clinical EpisodesBlood cultureChest x-rayCSF culture when indicatedAntibiotic treatment

ResultsJuly 2000-December 18, 200312,194 enrolled children98.7% subjects received 3 doses of study vaccineMedian age was 1.8, 2.9, and 3.9 months for

vaccination

DiscussionPrevention of 22.9% of radiologically defined

pneumonia among children 2 years of ageAge stratified analysis of Vaccine Efficacy:

<12 months = 34.0%12-23 months = 2.7%

Vaccine had no effect against clinical pneumonia

Conclusions11 PCV show similar efficacy as the available 7PCV in other

epidemiological and geographic settingsUse of WHO-PEP as feasible end point in clinical trials and

good proxy for measuring pneumococcal pneumonia1/5 of radiologically confirmed pneumonia is caused by

pneumococcus in a low income, low mortality developing country such as the Philippines, and thus preventable by PCV

Inclusion in national program on immunization depends on specific disease burden measurement and cost-effectiveness calculation