1. Case Presentation
2006/09/01

2. Basic Information Name: 楊x婷 Chart NO: 0476xxxx
11-year-2-month-old girl
Admission date: 2006/08/28
Bed NO: 4P106

3. Chief Complaint
Progressive tachypnea for 10+ days

4. Present Illness A patient of 3~4 days prior to 8/19
Corrected TGA, VSD, ASD, pulmonary atresia, situs inversus s/p Rastelli operation in 92/2
Hypoxic encephalopathy
3~4 days prior to 8/19
Spiking fever up to 39C, cough, irritable, poor intake
8/19  Chi-Mei hospital
CXR: RLL pneumonia
Lab: WBC 18900, Seg 83%, CRP 213, Hb 6.4, MCV 62.8, RBC 3.36
PLT 589k
Admission
Antibiotic with Augmentin

5. Admission Course in CMH
8/23~8/25  PICU
8/23: progressive tachypnea  PICU
Hb 5.4 g/dL  blood transfusion with pRBC
8/25: tachypnea improved  general ward
8/25~
Still spiking fever up to 39C
Antibiotic  Vancomycin + Ceftriaxone
Poor appetite, easily choking due to tachypnea, progressive tachypnea
8/28
Antibiotic  Vancomycin + Ceftazidime
Family asked for transferring to our hospital

6. 8/ /26

7. 8/28

8. Past History Birth history: Feeding: soft diet
G5P3, NSD, GA 39 weeks, BBW 3650gm
DOIC (-), PROM (-), APGAR 9  9
Feeding: soft diet
Vaccination: on schedule
Growth and Development
BW 22Kg (<3th%), BL can not check
Development milestone: delay
Family history
Older brother: cough

9. Physical examination Conscious: alert
Vital sign: T/P/R 37.4/104/40, BP 106/76
HEENT: conjunctive: not anemic
sclera: not icteric
throat: not injected eardrum: not injected
Chest: symmetric expansion, subcostal retraction (+)
B.S.: bilateral coarse, crackles, rhonchi
H.S.: RHB, systolic murmur Gr III/VI
Abdomen: soft, no tenderness, normative bowel sound
Liver/Spleen: impalpable/impalpable
Extremities: freely movable,
pitting edema at bilateral forearm
Skin: tugor fine, rash at perineum

10. Lab Data on 8/28 CBC WBC Band Seg Mono Lym Hb RBC MCV 16700 9 84 1 6
7.6
3.5
70.1
PLT PT
APTT
Fib
FDP
540k
13.10/12.0
32.90/27.20
460
>1050
BCS
BUN
Cre
GOT
GPT
Bil T/D
LDH
Alb
T.P. 7
0.5 31 21
0.4/0
304
2.7
7.2
CRP
145.1

11. Gas pH
PCO2
PO2
HCO3 BE
O2 supply
15:56 V
7.308
58.8
26.9
28.8
2.5
Simple mask
18:37 C
7.460
43.9
47.2
30.5
6.7

12. CXR in NCKUH on 8/28

13. Chest echo Right pleural effusion Thoracocentesis
100ml pus-like effusion was drained

14. GPC in group, GPC in chain, GNB
Pleural effusion
Empyema
Gram stain
GPC in group, GPC in chain, GNB
Appearance
Pus-like
Seg
100% pH
6.509
LDH
46785 (serum 304)
T.P. -

15. Tentative Diagnosis Bilateral lung pneumonia with empyema
Microcytic anemia
R/O infection-related
R/O iron deficiency anemia
R/O hemolytic uremic syndrome
Corrected TGA, ASD, VSD, pulmonary atresia, situs inversus s/p Rastelli operation
Hypoxic encephalopathy

16. Plan Antibiotics with Vancomycin + Ceftriaxone Aggressive chest care
Chest tube insertion
Check urine pneumococcus Ag
Pursue all culture results (blood, pleural effusion, sputum)
Blood transfusion with pRBC
Cardiac echo

17. Clinical Course

18. 8/29
Urokinase for complicated empyema, but…

19. SaO2 under non-rebreathing mask: 70~80%
Re-on chest tube
Normal saline  leak to subcutaneous tissue
Hold urokinase
Keep chest tube for drainage
Microgas: pH 7.405, PCO2 58.8, HCO3 35.9
SaO2 under non-rebreathing mask: 70~80%
 impending respiratory failure
 endotracheal tube intubation
Antibiotics: Vancomycin + Cefepime

20. 8/30 Chest echo: much pleural effusion at right side
Poor drainage function of chest tube
 Consult chest surgeon for re-on
Chest surgeon
Re-on chest tube may injure the lung parenchyma tissue
Suggest to arrange chest CT

21. Chest CT on 8/30

23. Decortication on 8/31

24. 8/31

25. Lab data CBC WBC Band Seg Mono Lym Hb MCV PLT 8/29 16700 9 84 1 6 7.6
70.1
540k
8/30
9600 15 71 2 10
9.2
74.2
347k
8/31
11200 19 65 7
11.5
77.7
339k
BCS
CRP
145.1
82.6
65.3
23.6

26. Culture result 8/28 8/31 Blood: negative Sputum: yeast-like, moderate
Empyema: negative
Urine pneumococcus Ag: negative
8/31
Empyema: pending

27. Management of pleural effusion

28. Thanks for your attention !

29. Evaluation for anemia Reticulocyte 3.3% , RDW 29.4% 
Haptoglobin 222 
Iron 26 
TIBC 158 
Ferritin
Transferin 144 
T-antigen: negative