1. Case presentation
R1馬宜君

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

3. Chief complaint
Fever on and off for one week    

4. 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.

5. 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

6. 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

7. 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

8. 2/16 CXR

9. Cold agglutinins test positive
Lab data
Cold agglutinins test positive

10. 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

11. Clinical course

13. Mycoplasma pneumoniae infection in children
Discussion
Mycoplasma pneumoniae infection in children

14. 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.

15. 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.

16. 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)

17. 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.

18. Clinical finding of M. pneumoniae

19. 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.

20. 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.

21. 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.

22. Thanks for your attention!