Case presentation 2009-03-05 R1馬宜君

Patient profile Name: 鄭X宬 Chart No: 13XX2440 Birthday: 2006/06/30 Admission Date: 2009/02/16        Bed No: 04C82B Age: 2y8m/o

Chief complaint Fever on and off for one week    

Present illness This 2y8m/o child was well-being before. High spiking fever around 39~40℃ about q6h for one week. He was brought to LMD for help where some medication was prescribed( including Augmentin oral form) but in vain. Progressive cough with sputum (hard to expectoration) was noted in recent 2 days. Associated s/s showed as following: rhinorrhea(-), nasal obstruction(+), abdominal discomfort(+) observed by his mother, diarrhea(-), decreased urine amount(+), poor intake(+), body weight loss about 1.7 Kg in recent one week(+), poor activity(+), short of breath when fever attack. Then he was brought to 奇美 ER where left lower lobe pneumonia was impressed. Due to no bed available, he was transferred to our ER.

Past history Birth History: G3P3, GA: 37weeks, BBW:3300g, DOIC(-), PROM(-) Feeding: on full diet Vaccination: pneumococcus(-) Growth and Development:     BW:14Kg(50-75th%), BL:99.6cm(>97th%), HC:48cm(25-50th%)     Developmental milestones: WNL Medical problem: 1. Denied other major disease 2. Denied hospitalization history Travel History: nil Pet history: nil Current Medications: unknown drug from LMD Drug Allergy History: NKDA Family History: her cousin got mycoplasma pneumonia during chinese new year

Review of Systems General:         poor activity (+), Fever (+), Body weight loss(+), Malaise (+)     Cardiovascular         Tachycardia (+), Central cyanosis (-) Pulmonary         Cough(+) with sputum(+), Wheezing(-), tachypnea(+) with retraction (-) Alimentary         poor appetite (+), abdominal discomfort (+), nausea (-), vomiting (-)         bowel habit change (-), diarrhea (-) Genitourinary         dysuria (-), nocturia (-) Skeletal         ROM: no limitation

Physical examination Consciousness: clear Appearance: ill-looking Vital sign: TPR:36.8’C/ 136/min/ 38/min, BP:104/72mmHg Activity: poor     Head:        conj: not anemic        sclera: not icteric        throat: not injected        tonsil: not enlarged        eardrum: intact Neck: supple, LAP(-) Chest: symmetric expansion, subcostal  retraction( - )   B.S.: decreased over left side no crackles/wheezing   H.S.: RHB, no murmur    Abd: soft, not distended,   no tenderness, rebound pain(-)   BS: normoactive, percussion: tympanic   no knocking pain L/S: impalpable / impalpable      Extremities: freely movable, no pitting edema    Skin: fine turgor, no rash

2/16 CXR

Cold agglutinins test positive Lab data Cold agglutinins test positive

Diagnosis & Plan Lower segmental pneumonia of left upper lobe, suspect mycoplasma related DX: pneumococcus, virus infection Diagnostic plan: Pending B/C, Mycoplasma Ab, urine pneumococcus Ag, Throat swab for virus isolation Therapeutic plan: Empiric antibiotics: Unasyn + Zithromax Supportive Tx: mucolytic agent and intensive chest care

Clinical course

Mycoplasma pneumoniae infection in children Discussion Mycoplasma pneumoniae infection in children

Introduction Mycoplasma pneumoniae is one of three species of Mycoplasma that frequently produce infection in humans. Mycoplasmas are ubiquitous and are the smallest bacteria that can survive alone in nature. M. pneumoniae causes a wide variety of clinical manifestations in children and adults, principally pneumonia.

Epidemiology M. pneumoniae is transmitted from person to person by infected respiratory droplets during close contact. The incubation period after exposure averages 3 weeks. Infection occurs most frequently during the fall and winter but may develop year-round. The relative importance of M. pneumoniae rises during the school years. Account for 20％ acute pneumonias in middle and high school students.

Clinical features Respiratory tract disease: Extrapulmonary disease : nonproductive to mildly productive cough, wheezing, dyspnea (uncommon), chills,  pharyngitis, rhinorrhea, and ear pain Extrapulmonary disease : Hemolysis  Skin disease  CNS involvement (uncommon)  Others: GI symptoms, arthralgia, Cardiac and renal involvement (unusual)

Radiographic features Four frequently described CXR patterns: Bronchopneumonia Plate-like atelectasis Nodular infiltration Hilar adenopathy The most common CXR finding is the peribronchial pneumonia pattern, which consists of a thickened bronchial shadow, streaks of interstitial infiltration, and areas of atelectasis; these changes have a predilection for the lower lobes.

Clinical finding of M. pneumoniae

Laboratory features  Subclinical evidence of hemolytic anemia is present in most patients with pneumonia, as suggested by a positive Coombs test and an elevated reticulocyte count. WBC is normal or slightly elevated with neutrophilia. Thrombocytosis can occur and probably represents an acute phase response.

Diagnosis Cold agglutinins: not a cost-effective approach, neither sensitive nor specific Serology: complement fixation (CF) test is most widely used which measures "early" IgM (predominantly) and IgG A fourfold or greater increase in titer in paired sera A single titer of greater than or equal to 1:32. The CF test is highly sensitive for the detection of M. pneumoniae infection.

Treatment Erythromycin (30 to 40 mg/kg per day in four divided doses for 10 days) Clarithromycin (15 mg/kg per day in two divided doses for 10 days) Azithromycin (10 mg/kg in one dose on the first day and 5 mg/kg in one dose for four days) Tetracycline (20 to 50 mg/kg per day in four divided doses for 10 days, maximum daily dose 1 to 2 g) or doxycycline (2 to 4 mg/kg per day in one or two divided doses for 10 days, maximum daily dose 100 to 200 mg) may be used in children eight years of age or older.

Thanks for your attention!