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

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

3. Chief complaints
Fever 7 days
+ rash

4. 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

5. 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

6. 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.

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

8. 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.

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

10.
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

14.
(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
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

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

17. 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.

18. 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%

19. 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)

22. Final diagnosis
Staphylococcal Pneumonia
Measles