Case Presentation R2 陳志安 2011/03/24

Basic information Chief complaint Age: 3 hrs /o Gender: GA: 40+4wk male Admission date: 2011/3/04 Chief complaint Tachypnea after birth

Present illness 2010.Oct : GA 20wks intrathoracic mass over left atrial and aorta area (1.7cm) No polyhydramnios or oligohydramnios 2011. Jan : GA 36wks intrathoracic mass over left atrial and aorta area (2.6cm) 3/4: GA: 40+4wk variable deceleration ->emergent C/S ->meconium stain ->Apgar score: 8->9

Physical examination Consciousness: clear Appearance: ill-looking Vital sign: BT: 36.4 C, P: 164/min, R: 60/min, BP: 63/38 mmHg SpO2: 90% with room air Head: Ant fontanelle: not depressed conj: not anemic sclera: not icteric Nasal flaring(-) No dysmorphic face Neck: supple Chest: symmetric expansion Suprasternal retraction (+) B.S.: bilateral coarse H.S.: regular heart beat, no murmur Abd: soft, not distended L/S: both impalpable BS: normoactive Extremities: freely movable Skin: turgor fine capillary refilling time<2sec nail: no meconium

Past history Birth History: G1P1, GA: 40+4wk Vaccination: nil Growth BW:　3.665 kg (75-90th percentile) BL:　50　cm (75-90th percentile) HC: 33 cm (75-90th percentile) Family History: not contributary

3/4 5 am Bilateral hemilung opaciites. 3. Pneumomediastinum. 4. Both CP angles are sharp. focal radiolucent area at anterior mediastinum.

Lab Vein gas Ph: 7.313 PCO2: 47.5 HCO3: 23.5 Be: -3 PH:7.313 CO2:47.5 BE:-3 HCO3:23.5

Tentative diagnosis Tachypnea Fetal distress suspect meconium aspiraton pneumonitis suspect mediastinal mass related Suspect perinatal infection Pneumomediastinum Fetal distress Mediastinal mass, etiology?

Management →On N-CPAP →Arrange cardiac echo →Septic workup and empirical antibiotics with Ampicillin and gentamicin →Arrange chest CT to differentiate mediastinum lesion seen in prenatal examination

PDA; inter-atrial shunt with mild TR Suspect mediastinal mass beside LA 1)Situs solitus, levocardia 2)No chamber dilation 3)A patent ductus arteriosus with size: 0.22cm, L't to R't shunt, with PG: 8.4mmHg 4)An inter-atrial left to right shunt, size: 0.41- 0.45cm 5)Good LV systolic function with LVEF: 77% 6)Mild tricuspid regurgitation with PG: 17mmHg 7)Suspect a heterogenous mass beside LA, origin to be determined 8)Left arch, no COA

3/5 11 am 3/5 10 pm Bilateral lower lung opaciites. 4. Progressive radioluvent area superimposed on upper meidastinum. R/O pneumomediastinum.

l. Bilateral lower lobes and RUL consolidation. 2 l. Bilateral lower lobes and RUL consolidation. 2. Small amount of right pneumothorax and massive pneumomediastinum with floating of thymus tissue. 3. One 30x6.6mm cystic lesion below LA and surrounding the distal esophagus. Bronchogenic cyst should be suspected. 4. The trachea and bilateral main bronchi are normally identified without endobronchial lesion. 5. The diaphragm appear unremarkable. 6. The visible liver and adrenal glands are negative. IMP: l. Bilateral lower lobes and RUL consolidation. 2. Small amount of right pneumothorax and massive pneumomediastinum with floating of thymus tissue. 3. One 30x6.6mm cystic lesion below LA and surrounding the distal esophagus. Bronchogenic cyst should be suspected.

3/8 03 pm

Discussion

Pulmonary air leak in the newborn Respiratory distress syndrome Meconium aspiration syndrome (10-20%) Pulmonary hypoplasia Pneumonia Transient tachypnea of the newborn Mechanical ventilation Spontaneous (1-2%)

Neonatal pneumomediastinum The diagnosis is confirmed by chest x-ray Angel-wing sign or spinnaker sign (大三角帆) The lateral radiograph is important and more sensitive than the posterior-anterior view Up to 50% of the cases will be missed on a standard PA view

Congenital cystic lung disease Congenital cystic adenomatoid malformation Pulmonary sequestration Congenital lobar emphysema bronchogenic cysts R/O neurenteric duplication cysts R/O congenital thoracic neuroblstoma Remnants of primitive foregut

Risk of complication Infection Sudden respiratory distress Pneumothorax Malignancy

Time for surgery Life-threatening Progressive pulmonary insufficiency from compression of adjacent normal lung

Thanks