Khamphouvane, M.D. Pediatric department Setthathirath Hospital Case presentation Khamphouvane, M.D. Pediatric department Setthathirath Hospital

General status 4 year old boy From : Nasai village. Saysettha district. Vientian province. Admitted on: 3/10/09 at the PICU.

Chief complaints Fever 7 days + rash

History Before one week he has fever, height grade fever, all day, associate cough, running nose, 4 days of the fever he has rash like Measles at back and spread to body, itching he took some medicine but not improved, he was weakness and height grade fever( 39,5◦c - 40◦c) His mother took him to ER and admitted to Settha hospital 3-10-09

Past Medical History he is the second of family He was healthy Vaccination complete No food or drugs allergies Family healthy. He went to forest 2 weeks ago

Physical exams General : Look sick. Vital sign : BT: 39,3 º c, P:120 bpm,RR:38 bpm,BP:90⁄50, SaO2: 99%, weigh:15kg, high: 100cm, W/A >-1SD, W/H:Median HEENT : Dry cough ,no central cyanosis, no nasal flaring inspiration. Throat: small red, cervical lymph node ≈ 3cm Respiratory: no retraction, Crackles on the right middle and upper lobe, no wheezing, decreased breath sounds at right upper lobe.

CVS : regular, no murmur. GI : Soft abdominal, palpable of liver:3cm, No splenomegaly GU : normal NS : normal Skin : rash Ext : warm

Problem list height grade fever for 7 days Rash after fever 4 days Cough (dry cough) Crackles on the right middle and upper lobe Decrease breath sound right upper lobe.

What Differential diagnosis ? Measles Staphylococcus scalded skin syndrome Staphylococcal Pneumonia Scarlet fever DHF Kawasaki disease

3-10-09 5-10-09 6-10-09 WBC 19500 21000 19800 LYM 6 11,5 21,5 MONO 3,3 6,3 47 GR 90,7 82,4 73,8 RBC 4,46 3,68 3,46 HGB 9,4 8 7,3 HCT 28,4 23,5 22 MCV 63,7 63,9 63,8 MCH 21,1 21,7 MCHC 32,9 34,2 33,3 RDW 13,8 14,2 PLT 544. 526 586 PCT 0,38 0,35 0,36 MPV 7 6,7 6,2 PDW 44,5 46,8 49,8

7-10-09 (d10) 8/10/ (d11) 12/10/ (d15) 20/10/ F/u wbc 331OO 22,400 15300 10.000 lym 22,7 13 13,7 30 mid 8,5 10,9 9,9 10 gr 68,8 76 76,4 60 HB 9,5 8,8 8 9 RBC 5,36 5,27 5,38 5,78 HCT 51,2 48 40 35 MCV 105 92,7 92,9 92,3 MCH 35,4 31,9 32,6 MCHC 33,8 34,4 34 33 RDW 58,8 14,7 14,4 21,7 PLT 175. 176 64.0000 200. MPV 9,7 7,2 0,05 PDW 15,2 49,8 8,1 16 PCT 0,16 0,13 51,6 1,16

INVESTIGATE 7-10-09 AST:22 ui⁄l 1. Hemoculture : Negative ( 4/10/09) ALT:9ui⁄l Stool exam: Nega Leucocytes test: Neg 2 . Hemoculture : positive (9 /10/09) CRP: negative staph. aureus U⁄A Ely: (9/10/09) 12/10/09 PH:7 Na:137 mmol/l Na: 127 Leu: 100 Ket: 150 K : 4.64 K : 5.38 SG: 1010 UBG: Normal CL : 109.3 CL : 100 NIT: Neg BIL: Neg. Pro: Neg GLU: normal Hb.typing : A : 100 U/C : Negative

Pneumonia of unknown etiology Children 3 months to 5 years of age -respiratory viruses 75% Respiratory syncytial virus,Adenovirus,Parainfluenzae virus,Influenzae virus, Streptococcus pneumoniae H. influenzae type b,Klebsiella pneumoniae Staphylococcus aureus. Upper airway infection due to Staph. aureus: pharyngitis, tonsillitis, otitis media, sinusitis, tracheitis complicating viral croup. Therapy: always should be initiated with penicillinase-resistant antibiotic – 90% of staphylococci are resistant to penicillin Reports : (Scandinavia, Japan, USA) ,Red Book Edition.

Etiology of pneumonias Community-acquired Hospital-acquired Strep. pneumoniae Staph. aureus H. influenzae P. aeruginosa Legionella sp. M. pneumoniae Ch. pneumoniae Enterobacteriaceae Anaerobic 30-70% 3-9% 8-20% <2% 2-8% 2-15% 2-6% 4-12% 5-15% 3-8% 10-20% 1-8% 12-20% <4% rare 30-50% 2-20%

Staph. aureus –preferred therapy -oxacillin or cloxacillin only for monomicrobial infections caused by methicillin-susceptible strains -vancomycin uniformly active for both methicillin-susceptible and resistant strains - cloxacillin 50 mg/kg IM or IV every 6 hrs and Gentamycin 7.5 mg/kg IM or IV once a days. when the child improves ,continue Cloxa.orally 4 times a day for a total couse of 3 weeks. Alternative agents: cefazolin, clindamycin, imipenem Methicillin-resistant Staph. aureus: Preferred therapy: vancomycin. (Hospital care for children WHO, Red Book Edition)

Final diagnosis Staphylococcal Pneumonia Measles