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Short case presentations
PAEDIATRIC RESPIRATORY REVIEWS (2000) 1, 294–296 doi: 10.1054/prrv.2000.0064, available online at http://www.idealibrary.com on
SELF ASSESSMENT
Short case presentations CASE 1: PRESENTATION The case of the opaque hemithorax A 5-year-old boy was admitted to the specialist paediatric hospital with a 2-week history of productive cough. He had recently been on a 7-day camping holiday running around and playing as normal. He returned home 4-days before the admission and had become progressively unwell, with left-sided chest pain worse on coughing. He had previously been a well child, with no significant illness. On examination he was alert and pink with an oxygen saturation in air of 99%. His temperature was 38.5°C, heart rate 120 per min and respiratory rate 60 per min. He had intercostal recession with dullness to percussion and decreased air entry in the left side of the chest. A clinical diagnosis of left sided pneumonia was made, and he was commenced on augmentin. Full blood count revealed haemoglobin 10.5 g per dl, white blood cell count 12.9 ×
10.9 per litre, platelets 363000. Urea, electrolytes and liver function tests were normal. A chest X-ray was taken (Fig. 1). a) What abnormalities are present on the chest X-ray? b) What is the likely diagnosis and the differential diagnosis? c) Which imaging procedure would you request to follow?
CASE 2: PRESENTATION A twin presentation A pair of 3-month-old, non-identical twin girls were seen in Accident & Emergency (A&E) last winter, with a 4-day history of nasal discharge and fever. On examination, twin 1 had signs and symptoms of a mild upper respiratory tract illness. She was sent home with antipyretic advice. Twin 2, however, had a severe lower respiratory tract illness, with wheeze and tachypnoea, requiring admission. Nasal pharyngeal aspirates taken from both infants at presentation in A&E confirmed RSV infection. Twin 2 subsequently deteriorated clinically, requiring ventilatory support in paediatric intensive care. She eventually made a full recovery and was sent home 2 weeks later. a) Who most likely exposed the twins to RSV? b) What possible risk factors could account for the severe disease seen in twin 2? c) Discuss the underlying immunopathological mechanisms accounting for the differences in disease severity of the twins.
CASE 3: PRESENTATION Persistent atelectasis in bronchopulmonary dysplasia
Case 1.
Figure 1.
1526–0550/00/030294 + 03 $35.00/0
The technological progress in neonatal intensive care has led to improved survival rates even in extreme pre-term babies, with a parallel increase in late respiratory morbidity and mortality, particularly due to chronic lung disease (CLD) and bronchopulmonary dysplasia (BDP).1 Severe BPD is characterized by presence at the same time of areas of atelectasis and emphysema, with accumulation of © 2000 Harcourt Publishers Ltd
SELF ASSESSMENT: SHORT CASE PRESENTATIONS
viscous and infected secretions that may worsen the hypoxaemia to the point of requiring continuous mechanical ventilation (MV).1 CM was born at 24 weeks of gestational age; he required surfactant therapy for hyaline membrane disease (HMD). He developed bronchopulmonary dysplasia (BPD) and he was treated with diuretics, steroids, bronchodilators and physiotherapy. It was possible to stop the mechanical ventilation after 2 months of life; nevertheless, he was oxygendependent for a further 2 months. A right upper lobe atelectasis was demonstrated for the first time at the age of 4 months and a treatment with antibiotics, aerosolized β2agonists, steroids and chest physiotherapy was promptly started. The child clinically ameliorated even when the radiographic picture was unchanged in the following 2 months. He received several courses of systemically antibiotics, since tracheal aspirates (TA) or bronchoalveolar lavage (BAL) fluid cultures were repeatedly positive for Pseudomonas aeruginosa and Serratia marcescens. He was dismissed from the hospital at 4 months of age. At 6 months of age, CM presented with an acute episode of severe wheezing, and he required urgent hospitalization, oxygen administration and systemic steroid treatment. The radiographic picture confirmed the persistence of a complete atelectasis of the right upper lobe (Fig. 1). Treatment with antibiotics inhaled β2-agonists, and steroids showed no clinical improvement: cough persisted and haemoglobin saturation was less than 92%. A bronchoscopic toilette was performed, and abundant mucous was aspirated; during the operative section, intrabronchial rhDNase (2.5 mg) was administered. After the procedure the infant displayed significant reduction of cough accesses. Haemoglobin saturation increased from 89% to 95%, and the chest X-ray showed a partial resolution, with areas of transparency in the central part of the atelectasis. Aerosol administration of rhDNase was continued for another 7 days (2.5 mg daily), and clinical conditions of the patient further improved. At the end of the treatment the chest X-ray showed a complete resolution of the previous persistent atelectasis (Fig. 2). The secretions became significantly more fluid, allowing a more efficacious chest physiotherapy and aerosol therapy. The patient was dismissed at home after a week in stable clinical conditions. The following TA and BAL cultures were, and remained, negative in the weeks following the treatment. In this case report, the use of bronchoscopy associated with aerosolized rhDNase was effective in treating a persisting atelectasis in a 6-month-old baby. Identify two other non-CF clinical problems for which the use of rhDnase has been reported to be of value.
295
Case 3.
Figure 1.
Case 3.
Figure 2.
CASE 4: PRESENTATION Bronchiolitis: an important health issue
REFERENCES 1.
Greenough A. Chronic lung disease. In: Greenough A, Robertson NRC, Mulner AD (eds). Neonatal Respiratory Disorders. London: Arnold, 1996, pp. 393–425.
A 6-week-old infant has recently been admitted to the hospital with RSV bronchiolitis for which the child only received supplemental oxygen for 3 days. The child was previously healthy:
296
SELF ASSESSMENT: SHORT CASE PRESENTATIONS
a)
Estimate the risk the child will have of continuing with wheezing episodes during early childhood. b) Does the child have increased risk of becoming atopic as a consequence of the RSV infection? c) What is the role of inhaled corticosteroids during or subsequent to the RSV infection in the prevention of long-term airway morbidity?
CASE 5: PRESENTATION Cough and fever in a child with leukaemia A 9-year-old girl presented to a general paediatric clinic with 1 month’s history of vomiting, headache and intermittent abdominal pain. She developed right-sided facial weakness on the day prior to admission and some double vision on right lateral gaze. There was no other history of note. She had been previously well and there is no past medical history of note. On examination, her general condition was good. However, on neurological examination she had a right lower motor neurone facial nerve palsy and a right sixth nerve palsy. She also had bilateral papilloedema. Examination was otherwise unremarkable. Her blood count at that time was normal: however, her CSF demonstrated a white cell count of 3000 and immunophenotyping confirmed acute lymphoblastic leukaemia. She was commenced on standard treatment for acute lymphoblastic leukaemia and tolerated this well. All her neurological abnormalities resolved. She was commenced on maintenance chemotherapy according to the protocol. Her usual medication was as follows: 6 mercaptopurine daily, methotrexate weekly, cotrimoxazole three times weekly with pulsed vincristine, with 5 days of prednisolone monthly. Sixteen months into therapy she developed a low grade fever. She was not neutropenic at the time: however, she had a central venous catheter in situ and was admitted for intravenous antibiotics. Her temperature
Case 5.
Figure 1.
settled and she was allowed home. Two days later the fever recurred and she was re-admitted to hospital. Initially her fever was low grade (no greater than 37.8°C), but after 10 days her fever became high grade (reach ing 40°C daily). Her general condition remained good, although she developed a dry cough. This was nonproductive and there was no respiratory distress. On examination she was pink in air. Her oxygen saturation was 96% in air. Respiratory rate was 18 per min, and no focal abnormality on auscultation. A chest radiograph performed 3 weeks following the onset of fever is shown in Figure 1. a)
What additional information from the recent history would be helpful? b) What investigations would be most valuable? c) What is the most likely diagnosis? d) What treatment would you plan?
SELF ASSESSMENT
Short case presentations CASE 1: PRESENTATION The case of the opaque hemithorax A 5-year-old boy was admitted to the specialist paediatric hospital with a 2-week history of productive cough. He had recently been on a 7-day camping holiday running around and playing as normal. He returned home 4-days before the admission and had become progressively unwell, with left-sided chest pain worse on coughing. He had previously been a well child, with no significant illness. On examination he was alert and pink with an oxygen saturation in air of 99%. His temperature was 38.5°C, heart rate 120 per min and respiratory rate 60 per min. He had intercostal recession with dullness to percussion and decreased air entry in the left side of the chest. A clinical diagnosis of left sided pneumonia was made, and he was commenced on augmentin. Full blood count revealed haemoglobin 10.5 g per dl, white blood cell count 12.9 ×
10.9 per litre, platelets 363000. Urea, electrolytes and liver function tests were normal. A chest X-ray was taken (Fig. 1). a) What abnormalities are present on the chest X-ray? b) What is the likely diagnosis and the differential diagnosis? c) Which imaging procedure would you request to follow?
CASE 2: PRESENTATION A twin presentation A pair of 3-month-old, non-identical twin girls were seen in Accident & Emergency (A&E) last winter, with a 4-day history of nasal discharge and fever. On examination, twin 1 had signs and symptoms of a mild upper respiratory tract illness. She was sent home with antipyretic advice. Twin 2, however, had a severe lower respiratory tract illness, with wheeze and tachypnoea, requiring admission. Nasal pharyngeal aspirates taken from both infants at presentation in A&E confirmed RSV infection. Twin 2 subsequently deteriorated clinically, requiring ventilatory support in paediatric intensive care. She eventually made a full recovery and was sent home 2 weeks later. a) Who most likely exposed the twins to RSV? b) What possible risk factors could account for the severe disease seen in twin 2? c) Discuss the underlying immunopathological mechanisms accounting for the differences in disease severity of the twins.
CASE 3: PRESENTATION Persistent atelectasis in bronchopulmonary dysplasia
Case 1.
Figure 1.
1526–0550/00/030294 + 03 $35.00/0
The technological progress in neonatal intensive care has led to improved survival rates even in extreme pre-term babies, with a parallel increase in late respiratory morbidity and mortality, particularly due to chronic lung disease (CLD) and bronchopulmonary dysplasia (BDP).1 Severe BPD is characterized by presence at the same time of areas of atelectasis and emphysema, with accumulation of © 2000 Harcourt Publishers Ltd
SELF ASSESSMENT: SHORT CASE PRESENTATIONS
viscous and infected secretions that may worsen the hypoxaemia to the point of requiring continuous mechanical ventilation (MV).1 CM was born at 24 weeks of gestational age; he required surfactant therapy for hyaline membrane disease (HMD). He developed bronchopulmonary dysplasia (BPD) and he was treated with diuretics, steroids, bronchodilators and physiotherapy. It was possible to stop the mechanical ventilation after 2 months of life; nevertheless, he was oxygendependent for a further 2 months. A right upper lobe atelectasis was demonstrated for the first time at the age of 4 months and a treatment with antibiotics, aerosolized β2agonists, steroids and chest physiotherapy was promptly started. The child clinically ameliorated even when the radiographic picture was unchanged in the following 2 months. He received several courses of systemically antibiotics, since tracheal aspirates (TA) or bronchoalveolar lavage (BAL) fluid cultures were repeatedly positive for Pseudomonas aeruginosa and Serratia marcescens. He was dismissed from the hospital at 4 months of age. At 6 months of age, CM presented with an acute episode of severe wheezing, and he required urgent hospitalization, oxygen administration and systemic steroid treatment. The radiographic picture confirmed the persistence of a complete atelectasis of the right upper lobe (Fig. 1). Treatment with antibiotics inhaled β2-agonists, and steroids showed no clinical improvement: cough persisted and haemoglobin saturation was less than 92%. A bronchoscopic toilette was performed, and abundant mucous was aspirated; during the operative section, intrabronchial rhDNase (2.5 mg) was administered. After the procedure the infant displayed significant reduction of cough accesses. Haemoglobin saturation increased from 89% to 95%, and the chest X-ray showed a partial resolution, with areas of transparency in the central part of the atelectasis. Aerosol administration of rhDNase was continued for another 7 days (2.5 mg daily), and clinical conditions of the patient further improved. At the end of the treatment the chest X-ray showed a complete resolution of the previous persistent atelectasis (Fig. 2). The secretions became significantly more fluid, allowing a more efficacious chest physiotherapy and aerosol therapy. The patient was dismissed at home after a week in stable clinical conditions. The following TA and BAL cultures were, and remained, negative in the weeks following the treatment. In this case report, the use of bronchoscopy associated with aerosolized rhDNase was effective in treating a persisting atelectasis in a 6-month-old baby. Identify two other non-CF clinical problems for which the use of rhDnase has been reported to be of value.
295
Case 3.
Figure 1.
Case 3.
Figure 2.
CASE 4: PRESENTATION Bronchiolitis: an important health issue
REFERENCES 1.
Greenough A. Chronic lung disease. In: Greenough A, Robertson NRC, Mulner AD (eds). Neonatal Respiratory Disorders. London: Arnold, 1996, pp. 393–425.
A 6-week-old infant has recently been admitted to the hospital with RSV bronchiolitis for which the child only received supplemental oxygen for 3 days. The child was previously healthy:
296
SELF ASSESSMENT: SHORT CASE PRESENTATIONS
a)
Estimate the risk the child will have of continuing with wheezing episodes during early childhood. b) Does the child have increased risk of becoming atopic as a consequence of the RSV infection? c) What is the role of inhaled corticosteroids during or subsequent to the RSV infection in the prevention of long-term airway morbidity?
CASE 5: PRESENTATION Cough and fever in a child with leukaemia A 9-year-old girl presented to a general paediatric clinic with 1 month’s history of vomiting, headache and intermittent abdominal pain. She developed right-sided facial weakness on the day prior to admission and some double vision on right lateral gaze. There was no other history of note. She had been previously well and there is no past medical history of note. On examination, her general condition was good. However, on neurological examination she had a right lower motor neurone facial nerve palsy and a right sixth nerve palsy. She also had bilateral papilloedema. Examination was otherwise unremarkable. Her blood count at that time was normal: however, her CSF demonstrated a white cell count of 3000 and immunophenotyping confirmed acute lymphoblastic leukaemia. She was commenced on standard treatment for acute lymphoblastic leukaemia and tolerated this well. All her neurological abnormalities resolved. She was commenced on maintenance chemotherapy according to the protocol. Her usual medication was as follows: 6 mercaptopurine daily, methotrexate weekly, cotrimoxazole three times weekly with pulsed vincristine, with 5 days of prednisolone monthly. Sixteen months into therapy she developed a low grade fever. She was not neutropenic at the time: however, she had a central venous catheter in situ and was admitted for intravenous antibiotics. Her temperature
Case 5.
Figure 1.
settled and she was allowed home. Two days later the fever recurred and she was re-admitted to hospital. Initially her fever was low grade (no greater than 37.8°C), but after 10 days her fever became high grade (reach ing 40°C daily). Her general condition remained good, although she developed a dry cough. This was nonproductive and there was no respiratory distress. On examination she was pink in air. Her oxygen saturation was 96% in air. Respiratory rate was 18 per min, and no focal abnormality on auscultation. A chest radiograph performed 3 weeks following the onset of fever is shown in Figure 1. a)
What additional information from the recent history would be helpful? b) What investigations would be most valuable? c) What is the most likely diagnosis? d) What treatment would you plan?