1. Case Presentation
R2 陳志安
2011/03/24

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

3. 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

4. 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

5. 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: cm (75-90th percentile)
Family History: not contributary

6. 3/4 5 am
Bilateral hemilung opaciites. 3. Pneumomediastinum. 4. Both CP angles are sharp.
focal radiolucent area at anterior mediastinum.

7. 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

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

9. 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

10. 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: cm 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

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

12. 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.

13. 3/8 03 pm

14. Discussion

15. 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%)

16. 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

18. 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

19. Risk of complication Infection Sudden respiratory distress
Pneumothorax
Malignancy

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

22. Thanks