1. Pulmonology Conference
Geronimo, Maria Angelica; Geronimo, Ralph Ernesto;
Go, Camille-Marie; Go, Crystal Karen
January 24, 2011

2. General Data J.M. 3 months old Male Race: Filipino Birthday
Sampaloc, Manila
Roman Catholic
Date of Admission
Informant:
Reliability

3. Difficulty of Breathing
Chief Complaint
Difficulty of Breathing

4. 10 days PTA
Colds color of discharge?, non-productive cough
USTH ERCD – suction of secretions – discharged improved and stable Take home meds and take home advice?
Interval History
Persistence of difficulty of breathing
Good suck, good activity
Meds?intervention?
6 days PTA
Consulted at USTH-SBC: Acute Nasopharyngitis
0.65% NaCl Solution (Salinase) 2-3 drops/nostril every 6 hours
Erythromycin (3.5 mkd) for 7 days
Compliant?

5. CC: Difficulty of Breathing
Few hours PTA
Persistence of the difficulty of breathing(if tinanung kung pano nasabi difficulty of breathing: may alar flaring?cyanosis?tachypnea?)persistent pa rin cough?
Whitish-yellow nasal secretions
No fever, loss in appetite, decrease activity, vomiting
ADMISSION

6. Review of Systems General: (-) weight changes
Cutaneous: (-) rashes, (-) jaundice
HEENT: (-) eye redness (-) eye discharge (-) ear discharge (-) gum bleeding
Cardiovascular: (-) cyanosis
Respiratory: see HPI
Gastrointestinal: (-) acholic stools

7. Review of Systems
Genitourinary: (-) tea-colored urine (-) oliguria (-) discharge
Nervous/Behavior: (-) seizures (-) tremors (-) mood/behavioral changes
Endocrine: (-) polyuria (-) polydipsia (-) polyphagia (-) heat/cold intolerance
Musculoskeletal: (-) edema (-) swelling (-) limitation of motion (-) tenderness
Hematopoietic (-) bleeding tendencies (-) easy bruisability

8. Gestational History Mother: 36 year-old G1P0 housewife
Father:37 year old seaman
Regular prenatal checkups USTH OPD for 7 times
(-) viral exanthem, radiation and any intake of illicit, prohibited or abortifacient drugs, intake of alcohol and smoking
UTI (September 2010) - Cefalexin for 7 days and claimed to be compliant; Repeat UA - normal
OGCT and Hepatitis screening were not done

9. Gestational History Preeclampsia (HBP 160/100; UBP is 110-10/70mmHg)
Magnesium sulfate
Nicardipine drip
Betamethasone
Emergency CS secondary to preeclampsia

10. Birth History
Live, preterm, singleton male, delivered via “E” CS secondary to preeclampsia
BW 1.66 kg
BL 44 cm
HC 31 cm
CC 25 cm
AC 22 cm
AS 8,9
MT weeks
AGA

11. Neonatal History
1st hour of life –Bakit kinailangan mag chest xray?in distress?panu nasabing in distress? CXR: air bronchogram with densities on the right lower lobe
Nagbigay antibiotics?
Persistent respiratory distress  intubated (NICU)
PDA: grade II continuous murmur
(ano binigay/ginawa for the pda?)
2nd day of life – hyperbilirubinemia (6.8)
Phototherapy on the 5th HD
Neonatal hepatitis

12. Neonatal History
2D echocardiography: PDA, patent foramen ovale, LVE, LAE and pulmonary arterial hypertension
Blood CS: Klebsiella pneumonia
Ano meds?
Assessment: sepsis
Discharged at his 52nd day of life

13. Feeding History Mixed Breastfed and Milk formula
15 minutes/breast
3x a day alternating with Formula S26 lactose free 1 scoop in 2 ounces every 3 hours 
Mother claims that there is not enough milk being produce that’s why she started on powdered milk
Good appetite with no feeding difficulties

14. 24 Hour Food Recall CHO CHON Fats Kcal Breakfast Milk 2 ounce 6 4 5 85
Merienda
Lunch
Milk 4 ounce 12 8 10
170
Dinner
ACI
510
RENI
560 %
91%

15. Developmental History
Good motor activity
Visually tracks objects and looks around
Has social smile
Mother do not practice him to sit with support or do prone position
Has head lag when pulled
At par with age?

16. Past Medical History
October 10, 2010: sepsis, neonatal hepatitis and PDA
No previous surgeries done
No allergy, eczema, asthma, food or drug sensitivities

17. Immunization History Hepatitis B – 11/22/10, 12/22/10 BCG - 11/24/10
DTP and OPV - 12/22/10
Table form

18. Educational Attainment
Family Profile
Name
Age
Relation
Educational Attainment
Occupation
Health SG 38
Father
College graduate
Seaman
Healthy CG 36
Mother
Unemployed
Preeclampsia

19. Family History (+) Asthma – paternal grandmother
(+) HPN – maternal grandmother
(-) DM, blood dyscrasia, autoimmune disease, congenital disorders, thyroid diseases, cancer, allergy

20. Socioeconomic and Environmental History
Rented studio type made of concrete
Adequate space for each household member, well-lit and well ventilated
Water station
Meals are home-cooked prepared by his mother or sometimes they buy cooked-meals
No pets, no factories or other industrial establishments within the vicinity of the residence
Garbage is not segregated and is being collected everyday
Not exposed to second hand smoke

21. Physical Examination
Awake, alert, in respiratory distress, ambulatory, well- hydrated, well nourished, ill-looking
HR 135 bpm, regular, RR 48 cpm, regular, T36.7oC, SpO2 91%
Wt: kg (z score below -3 severely underweight)
Lt: 51 cm (z score below -3 severely stunted)
BMI: (z score below -2 severely wasted)
Warm, moist skin, no jaundice, no visible gross skin lesions, good skin turgor

22. Physical Examination
Normocephalic head, no visible scalp lesions, patent anterior fontanel
Pink palpebral conjunctivae, anicteric sclerae, pupils 2- 3 mm ERTL
No tragal tenderness, intact tympanic membrane
No nasoaural discharge, nasal septum midline, turbinates not congested
Moist buccal mucosa, nonhyperemic posterior pharyngeal walls, tonsils not enlarged,

23. Physical Examination
Supple neck, no palpable cervical lymphadenopathy, thyroid gland not enlarged
Symmetrical chest expansion, (+) subcostal retractions, equal tactile and vocal fremiti, (+) crackles over both lung field with occasional wheezes at left lung field
Adynamic precordium, apex beat at 4th LICS MCL, no heaves/lifts, no thrills, normal rhythm, S1 louder than S2 at the apex, S2 louder than S1 at the base, (+) Grade II continuous murmur

24. Physical Examination
Globular abdomen, normoactive bowel sounds, soft, no tenderness, no palpable masses, Traube’s space not obliterated
Genitalia: grossly male with both descended testes
Pulses are full and equal, no edema, no cyanosis

25. Neurologic Examination
Awake, alert
Cranial nerves: CNI not assessed, pupils 2-3mm equally reactive to light, (+) direct and consensual light reflex, (+) ROR, EOM full and equal, no gross facial asymmetry, gross hearing intact (able to localize sound), CN IX, X, XI, XII not assessed
No spasticity, rigidy, flaccidity, no limitation in movement
No sensory deficits
DTR +2
No nuchal rigidity, Brudzinski’s and Kernig’s
(+) Moro, grasp, plantar, sucking reflex

26. Salient Features 3 month old male
History of colds, non-productive cough
PE: tachypneic, (+) subcostal retractions, (+) crackles over both lung field with occasional wheezes at left lung field

27. Approach to Diagnosis
Symptom, sign or laboratory finding pointing to an organ or part of an organ system

28. Approach to the Diagnosis
3 month old male
History of colds, non-productive cough, difficulty of breathing
PE: tachypneic, (+) subcostal retractions, (+) crackles over both lung field with occasional wheezes at left lung field
Pulmonary Pathology
Pneumonia

29. Differential Diagnosis

30. Admitting Diagnosis

31. Course in the Wards

32. Discussion na lang ito.PPS Clinical Practice Guideline for PCAP 2004

33. Complete Blood Count
Bacterial
Viral
WBC 15,000 – 40,000
WBC < 20,000
Granulocytes
Lymphocytes
Chest Xray (PA Lat)
Gold standard for the diagnosis of pneumonia
Indicates complications PCAP such as a pleural effusion or empyema

34. COURSE IN THE WARDS

35. ADMITTING ORDERS NPO, Hgt every 8 hours Vital signs every hour IVF?
Input & Output recorded every shift
Requested:
CBC with platelets,
CXR
Meds:
Ampicillin 150mg/ SIVP over 30 Q6 hours (MKD?)
Gentamicin 13 mg/ SIVP over 30 mins Qday(MKD?)
Salbutamol nebulization (1 neb every how many hours?

36. In our patient... 01/12/11 Hgb 89 RBC 2.85 Hct 0.26 MCV 92.90 MCH
31.10
MCHC
33.50
RDW
15.90
MPV
9.0
Platelet
382
WBC
9.80
Neutrophils
0.28
Segmenters
Bands -
Metamyelocyte
Lymphocytes
0.64
Monocytes
Eosinophils
0.08
Basophils
Myelocytes
Reticulocyte Count

40. 2nd HD Ampicillin dose was increased to 160 mg/ SIVP over 30 mins, Q6
Hgt monitoring was discontinued
Feeding was resumed

41. 3rd HD
Nebulization was discontinued

42. 6th HD
Decreased monitoring to Q4
IVF consumed

43. 7th HD
Last dose of antibiotics given
Discharged stable and improved

44. Pneumonia

45. Discussion Inflammation of parenchyma of the lungs
Etiologic agent vary with the age and immune status of the child, as well as with some environmental conditions

46. Signs and Symptoms
Symptoms of pneumonia vary, depending on the age of the child and the cause of the pneumonia. Common symptoms include:
fever
chills
cough
tachypnea
breathing with grunting or wheezing sounds
labored breathing leading to retractions
vomiting
chest pain
abdominal pain
decreased activity
loss of appetite (in older kids) or poor feeding (in infants)
in extreme cases, cyanosis

47. Pathophysiology
results from inflammation of the alveolar space and may compromise air exchange
Most commonly, this inflammation is the result of invasion by bacteria, viruses, or fungi, but it can occur as a result of chemical injury or may follow direct lung injury (eg, near drowning).

48. Four stages of lobar pneumonia have been described.
The first stage, occurring within 24 hours of infection
the lung is characterized microscopically by vascular congestion and alveolar edema
Many bacteria and few neutrophils are present
The stage of red hepatization (2-3 d)
similarity to the consistency of liver, is characterized by the presence of many erythrocytes, neutrophils, desquamated epithelial cells, and fibrin within the alveoli

49. In the stage of gray hepatization (2-3 d)
the lung is gray-brown to yellow because of fibrinopurulent exudate, disintegration of red cells, and hemosiderin
The final stage of resolution is characterized by resorption and restoration of the pulmonary architecture
Fibrinous inflammation may extend into the pleural space, causing a rub heard by auscultation, and it may lead to resolution or to organization and pleural adhesions.

50. Bronchopneumonia, a patchy consolidation involving one or more lobes, usually involves the dependent lung zones
The neutrophilic exudate is centered in bronchi and bronchioles, with centrifugal spread to the adjacent alveoli
* Bacterial superinfection of viral pneumonia : mixed pattern of interstitial and alveolar airspace inflammation

51. In interstitial pneumonia, patchy or diffuse inflammation involving the interstitium is characterized by infiltration of lymphocytes and macrophages
The alveoli do not contain a significant exudate, but protein-rich hyaline membranes similar to those found in adult respiratory distress syndrome (ARDS) may line the alveolar spaces

52. Miliary pneumonia is a term applied to multiple, discrete lesions resulting from the spread of the pathogen to the lungs via the bloodstream.
miliary tuberculosis, histoplasmosis, and coccidioidomycosis 
may manifest as granulomas with caseous necrosis to foci of necrosis
Factors that bypass or inactivate local defenses (eg, tracheostomy tubes, immotile cilia syndrome) predispose the child to pneumonia
The result is loss of surfactant activity with local collapse and consolidation.

53. Pathogens implicated in pneumonia vary with the age of the child, the underlying patient-specific risk factors, immunization status, and seasonality.

54. Newborns and infants
via the maternal genital tract
group B streptococci, Escherichia coli and other fecal coliforms, and C trachomatis. 
Group B streptococci most often is transmitted to the fetus in utero, usually as a result of colonization of the mother's vagina and cervix by the organism.
However, most pneumonia in this age group is community acquired and involves Streptococcus pneumoniae, Staphylococcus aureus, and non- typeable Haemophilus influenzae. 

55. Young children
Viruses are a common cause of pneumonia among toddlers and preschoolers
Streptococcus pneumoniae is by far the most common bacterial cause of pneumonia
Children in this age group are also at risk for infection by M pneumoniae

56. Older children and adolescents
M pneumoniae is a frequent cause of pneumonia among older children and adolescents
Older adolescents may have lost their immunity to pertussis and may become infected by this organism
Bacterial pneumonia in this age group most often is caused by Streptococcus pneumoniae.

57. The Pediatric Infectious Disease Journal Volume 28 Number 6, June 2009
Efficacy of an 11-Valent Pneumococcal Conjugate Vaccine against Radiologically Confirmed Pneumonia Among Children Less Than 2 Years of Age in the Philippines A Randomized, Double-Blind, Placebo- Controlled Trial
Lucero et al
The Pediatric Infectious Disease Journal Volume 28 Number 6, June 2009
Lippincott Williams and Wilkins

58. Pneumococcus Leading cause of childhood pneumonia worldwide
Pneumococcal conjugate vaccines (PCV) have demonstrated efficacy against childhood invasive pneumococcal disease (IPD) and pneumonia in the US and Africa
No information is available from Asia on the impact of PCV on childhood pneumonia

59. Study Setting
6 municipalities in Bohol province in central Philippines
3 seasons: hot, rainy, cold
No HIV and no malaria
Infant mortality rate in Bohol: 28/1000 live births
Major cause of death: pneumonia and diarrhea
Study monitored by RITM and KTL

60. Study Design Randomized, placebo-controlled, double blind trial
Collaboration with government and private health services in Bohol
3 doses of 11PCV or a saline placebo given at 4 weeks interval to determine Vaccine Efficiency

61. Participants Informed consent of the mother Inclusion criteria
Children age <6 weeks to 6 months
The family was expected to remain in the study area for 2 years or until the end of December 2004
Infant was healthy
Exclusion criteria
First dose DTwP
Rectal temperature of 38°C
Neurologic disease
History of hospitalization or treatment for immune suppression
Enrolment in another clinical trial

62. Vaccine
11 PCV
Placebo
Saline
Vaccines were given intramuscularly in the anterolateral aspect of right thigh
Routine vaccines given in left thigh
1 μg S. pneumoniae capsular polysaccharide conjugated to tetanus toxoid for types 1, 4, 5, 7F, 9V, 19F, and 23F
3μg of polysaccharide of types 3, 14, and 18C conjugated to dipththeria toxoid
10μg pf polysaccharide of type 6B conjugated to diptheria toxoid
Manufactured by Sanofi pasteur

63. Definition of terms Community acquired pneumonia IPD
Pneumonia with onset either in the community or in hospital but less than 72 hours after admission
IPD
Bacteremia or culture proven meningitis
Trial end point: Radiologically defined CAP using WHO vaccine trialists’ standard guidelines
Presence of a dense opacity that could be a fluffy consolidation of a portion of a lobe, a whole lobe or the entire lung, often containing air bronchograms and sometimes associated with pleural effusion in the lateral pleural space
Associated with a pulmonary infiltrate or an effusion large enough to obscure such an opacity
Nosocomial pneumonia, >72 hours, excluded from all analysis

64. Secondary end points Hospitalized or not hospitalized
Culture proven invasive disease with a vaccine type- specific pneumococcus
Serious adverse events

65. Clinical Pneumonia (WHO Severity Grade)
History of cough and/or difficulty of breathing
Increased respiratory rate according to age
Lower chest wall indrawing (severe)
Cyanosis and/or inability to drink (very severe)
>60 if <2mos, >50 if 2-11mos, > mos

66. Surveillance for Clinical Episodes
Blood culture
Chest x-ray
CSF culture when indicated
Antibiotic treatment

67. Results July 2000-December 18, 2003 12,194 enrolled children
98.7% subjects received 3 doses of study vaccine
Median age was 1.8, 2.9, and 3.9 months for vaccination

71. Discussion
Prevention of 22.9% of radiologically defined pneumonia among children 2 years of age
Age stratified analysis of Vaccine Efficacy:
<12 months = 34.0%
12-23 months = 2.7%
Vaccine had no effect against clinical pneumonia

72. Conclusions
11 PCV show similar efficacy as the available 7PCV in other epidemiological and geographic settings
Use of WHO-PEP as feasible end point in clinical trials and good proxy for measuring pneumococcal pneumonia
1/5 of radiologically confirmed pneumonia is caused by pneumococcus in a low income, low mortality developing country such as the Philippines, and thus preventable by PCV
Inclusion in national program on immunization depends on specific disease burden measurement and cost- effectiveness calculation