1. NCKUH Pediatric Department Morning Meeting Case Presentation
Presenter: Intern 李京軒

2. Identifying Information
5y4m /o Girl
Admission Date:

3. Chief Complaint
Fever up to 39+ ℃
with cough and sputum for 3 days

4. No underlying systemic disease
Present Illness
5y4m /o Girl
No underlying systemic disease
Asthma, cough variant
Morning
Fever up to 39+ ℃
Intermittent Cough
with Sticky and Yellowish sputum
(but not easily to be coughed out)
Poor appetite (+, mild), Poor activity (only when fever)
No short of breathe, wheezing, Stridor, increased work of breathe
Sore throat (-), rhinorrhea (-), vomiting(-), diarrhea(-), abdominal pain(-),
Dysuria(-), discomfort while urination(-), urinary urgency(-)
(observed by her mother).
Her younger sister was just recovered from URI.

5. Visited local clinic
“Common cold” was told, and some symptomatic Mx was given.
Fever had response to antipyretic agents, but it recurred within hours.
Because of persistent fever, her family brought her to徐慶鐘小兒科.
Physical examination revealed injected throat and rales over left lower lung.
As a result, she was transferred to our ER.
In ER
T/P/R = 37.3/140/21, BP=114/71mmHg
PE : Injected throat without ulceration,
Coarse breathe sound
Lab. results
Chest X-Ray

6. Past History Birth History:
G2P2, NSD ,GA: FT weeks, BBW: 2980Kg, DOIC(-), PROM(-)
Feeding:
On full diet
Vaccination:
On schedule
H. influenza B(+), Pneumococcus (+, conjugated), Influenza (-)
Growth and Development:
BW: 18.9 Kg(75 – 90 th%), BL: 111cm( th%)
Developmental milestones: WNL
Past History:
1. Asthma, (cough variant ?)
2. Denied hospitalization history
Social History:
Nothing particular
Travel History:
Denied
Drug Allergy History:
Not known drug allergy history

7. Review of Systems General Cardiovascular Pulmonary Alimentary
Poor activity (+, while fever, but seems easy while no fever), Fever (+, for 3 days), Body weight loss(-), Malaise (-)
Cardiovascular
Tachycardia (-), Central cyanosis (-)
Pulmonary
Cough(+) with sputum(+, yellowish, sticky), Wheezing(-), tachpnea(-) with retraction (-)
Alimentary
Poor appetite ((+, mild), abdominal discomfort (-), nausea (-), vomiting (-) bowel habit change (-), diarrhea (-)
Genitourinary
Dysuria (-), nocturia (-)
Skeletal
ROM: no limitation

8. PE Appearance: Fair looking
Consciousness: clear
Appearance: Fair looking
Vital sign: T/P/R = 36.9 ℃/ 145 /min/ 28/min
BP: 117/80mmHg
Activity: Fair, Spirit: Fair
Head:
Conj: not anemic , sclera: not icteric
Throat: not injected , tonsil: not enlarged
Neck: supple, LAP(-)

9. PE Chest: symmetric expansion, subcostal retraction( - )
B.S.: coarse, some rales over left lung (especially while taking a deep breath), no wheezing
H.S.: regular heart beat, no murmur
Abd: soft, not distended
L/S: impalpable / impalpable,
No tenderness, No rebounding pain
BS: normoactive
Extremities: freely movable, pitting edema (-)
Skin: turgor fine, no rash

10. Hemogram <緊急血液檢驗報告> 醫師: 謝旻玲 採檢:98/09/01 全血 8262A30452
WBC K/cmm | RBC M/cmm
Hb g/dl | Hct %
MCV fl | MCH pg
MCHC L 33.0 g/dl | RDW %
Pl L 144 K/cmm | Blast %
Pro % | Myelo %
Meta % | Band %
Seg % | Eos %
Baso % | Mono H 11 %
Lymph % | Aty-lym - %
NRBC % | Remarks -

11. Biochemistry Study <緊急生化檢驗報告> 醫師: 謝旻玲 採檢:98/09/01 血漿 8261A15687
ALK-P H 144 U/L | AST U/L
ALT U/L | CK U/L
CRP H 88.2 mg/L |

12. Influenza Rapid Antigen Test
Item Result
二病毒抗原檢驗 Rapid antigen diagnosis
301 influenza virus type A+B antigen
-Negative-Flu A
-Negative-Flu B

13. Chest X Ray AP view

14. Lateral View

15. Tentative Diagnosis Pneumonia, Left lower lobe
=> suspect Mycoplasma pneumoniae infection

16. Plan Diagnostic plan: Therapeutic plan: Educational plan:
Check serum Mycoplasma pneumoniae Ab
Check sputum routine/ culture
Check blood culture
Therapeutic plan:
Empiric antiobiotc
Ampicillin/ Sulbactam 1g Q8H
Azithromycin 250mg 3/4# qd*3 days)
Guaphen 5 ml QID use
Adequate hydration & nutrition supplement
Educational plan:
Encourage the family to performe chest care

17. Clinical course

18. Mycoplasma pneumoniae Ab=1:40(+-)
Ampicillin/Sulbactam 1g IVD Q8H
Azithromycin 10mg/Kg po QD* 3 days
Discharged
Mycoplasma pneumoniae Ab=1:40(+-)

19. Mycoplasma pneumoniae infection
Discussion
Mycoplasma pneumoniae infection

20. Mycoplasma pneumonia “ Walking ” Pneumonia
Mycoplasma pneumoniae infections prevail in children older than 2-5 years of age.
In Taiwan, Atypical pneumonia in children
M. pneumoniae (26%)
Chlamydophila pneumoniae (15%)

21. Chest X-ray of Mycoplasma pneumonia
Asymmetric Infiltrates
“Time lagging” character
Lower lobe preference(52%)
Atelectasis (29%)
Small pleural effusion(20%)
Hilar lymphadenopathy(7~22%)
Discrepancy with S/S
Radiology review, 4th edition

22. Diagnostic Methods for M. pneumonia
There are no distinguishing clinical or radiologic manifestations that allow a secure diagnosis of mycoplasma pneumonia versus chlamydial or viral pneumonia [9]. Compared to those with pyogenic pneumonia, however, patients with mycoplasma pneumonia tend to have a more gradual onset of symptoms, less respiratory distress, and usually a normal white blood cell count. However, these findings are neither sufficiently sensitive nor specific to exclude other etiologies. A positive Gram stain and sputum culture can establish the diagnosis of bacterial pneumonia, but young children cannot produce sputum and those that can may have a false negative result because they have already been treated with antibiotics.
International Journal of Dermatology 2009, 48, 673–681: Mycoplasma pneumoniae-induced cutaneous disease

23. Antibiotics of Choice [1/3]

24. Antibiotics of Choice [2/3]

25. Antibiotics of Choice [3/3]
A Mycoplasma pneumonia
May be treated by appropriate oral antibiotics for 10 days.
If azithromycin is used, the treatment should be continued for only 3-5 days

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