MORBILI, BRONCHOPNEUMONIA, ACUTE

DIARRHEA IN A CHILD


By
Mira Febriani Hontong

Supervisor
dr. Audrey Wahani, SpA(K)
1
June 2014
INTRODUCTION
2
Morbili (measles,
rubeola)
An acute
contagious
disease caused
by an infection of
morbilivirus
Incidence in Indonesia from
1990 to 2002 is appr. 3.000-
4.000 cases a year
Most common complications :
Bronchopneumonia and
gastroenteritis
Self-limitting
uncomplicated: supportive
tx; complicated: antibiotics
INTRODUCTION
3
Bronchopneumonia
An
inflammation
on lung
parenchyma
Mostly caused by
microorganism
In morbili: caused by morbilivirusor
by superimposed infection caused
by other agents.
INTRODUCTION
4
Acute Diarrhea
In infant or
children
defecation of
>3x/day with a
change in stool
consistency, in
which the stool
may become soft
or even liquid
In morbilli, diarrhea may result from
the replication of morbilli virus
inside the gastrointestinal tract.
CASE REPORT
5
RS, , 6
months
old
Gorontalese
admitted :
May 29
th
,
2014
chief
complaints
shortness of
breath since
1 day prior
to
admission
preceded by
cough and
fever since
1 week
prior to
admission

6
Fever and
cough (1
week prior
to
admission)
Shortness
of breath
(1 day
prior to
admission)
Shortness
of breath,
fever,
cough
Red rashes
(1 day
after
admission)
ADMISSION:
May 29
th
,
2014

7


History of prenatal care and birth
ANC : regular , tetanus toxoid : twice
This patient was born spontaneously
aterm, birth weight was 3300 grams


History of experienced illness
He had history of diarrhea and
several bouts of cough before
Family Tree
8
7/24/2014

9
Developmental milestones
Social smile : 4 months
Turning in prone position: 5 months
Sitting : -
Crawling : -
Standing : -
Calling mama/papa : 6 months
Walking :-

Normal according to the
development age

10
History of feeding
Breast feeding : birth 6 months
Formula milk : birth - 6 months
Milk porridge : 5 months - present
Soft rice porridge : -
Rice : -

Immunization
he received basic immunization completely as
recommended

7/24/2014
It is normal to his age

11
Social, economic and environment
father 46 years old , a farmer, junior high
graduate
mother 34 years old, a housewife, junior high
graduate
They live in a permanent house 3 bedrooms,
with 5 adults and 4 children
In-house bathroom and lavatory
Electricity from government company
Water from artesian well
Wastes are collected and thrown away
This patient is using
JAMKESMAS

12
Physical Examination
General conditions : Looked ill
Consciousness : Compos mentis
Body weight 7.5 kg
Body height 64 cm





13
Vital sign : Pulse rate : 130 times/minutes, regularly
Respiratory rate : 40 times/minutes
Temperature : 37.4 C
Head : mesochepaly, thick black hair, not easily pulled
out
Eyes : conjungtiva was not anemic, sclera was not icteric,
palpebral edema (-/-), facial edema (-), both pupil were round,
same diameter with size of 3-3 mm, eyes reflexes were normal
Ears : clear external ear canal, normal ear drums
Nose : there was no secretes nor flares
Mouth : there was no cyanosis, no signs of hyperemic
pharynx nor both tonsils
Neck : no lymph nodes enlargement

Within normal limit

14
Chest : symmetrical respiratory movement, no
retractions
Heart : normal rate, regular rhythm, no murmur, no
thrill
Lungs : bronchovesicular breathe sound, no crackles
nor wheezing, rales +/+
Abdomen : round, soft, normal bowel sound, liver and
spleen were not palpable
Extremities : warm, not cyanotic, capillary refill time less
than 2 seconds, normal muscle tone, normal physiological
reflexes and no pathological reflexes was found
Genitalia :male, no abnormality
Laboratory and Diagnostic Workups
(May 29
th
, 2014)
15
Malaria : -
Haemoglobin : 10.3 g/dL
Hematocrits : 30.8 %
Leukocytes : 4.8 x 10
3
/mm
3

Thrombocytes : 558 x 10
3
/ mm
3

Sodium :129 mmol/L
Potassium :4.6 mmol/L
Chloride :103 mmol/L
CRP : 12
Plain chest X-ray : indicative of bronchopneumonia

16
Working diagnosis
Bronchopneumonia


Treatment
Cefixime 2 x 35 mg pulv
Paracetamol 3 x tsp
Zinc 1 x 20 mg
Oralyte 70-100 mL
Nebulization with Ventolin R + 2,5 mL NaCL / 8 hours


17

Date

Compl
Physic
Exam
Lab Dx
Tx

05/30/13
(2
nd
day)















Fever (+),
soft stool
(+) once
Red rashes
on skin (+)






RR 38x/min
Pulse
146x/min
T 38.7
0
C

Chest :
symmetrical,
no retraction,
no heart
murmur,
bronchovesicul
ar respiratory
sound, no
wheezing,
rales +/+

Other aspects of
examinations
were within
normal limit
- Bronchopneu
monia

Acute
Diarrhea
without
dehydration

Hyponatremia

Cefixime 2 x 35 mg pulv
Paracetamol 3 x tsp
Zinc 1 x 20 mg
Oralyte 70-100 mL
Nebulization with
Ventolin R + 2,5 mL
NaCL / 8 hours
Salycil Talk 3 x app




18

Date

Comp
Physic
exam
Dx Tx
05/31/14
to
06/01/14
(3
rd
& 4
th


day)















fever (+),
Red
rashes
(+),
shortness
of breath
(+)







RR 60x/min
Pulse 144x/min
T 37.9
0
C

Chest :
symmetrical,
retraction (+),
no heart
murmur,
bronchovesicula
r respiratory
sound, no
wheezing, rales
+/+

Others: WNL

Bronchopneumonia
Acute Diarrhea
without dehydration
Hyponatremia
Morbilli

Fecal Analysis
(May 31
st
):
pH: 7
Color: yellowish
Blood: -
Leukocyte : 1-2
Erythrocyte : -
Epithelial cells: 1-2





Cefixime 2 x 35 mg pulv STOP
Paracetamol 3 x tsp
Zinc 1 x 20 mg
Oralyte 70-100 mL
Nebulization with Ventolin R +
2,5 mL NaCL / 8 hours
Salycil Talk 3 x app

Planning:
Stop oral medications
O2 1-2 L/min
IVFD KaEn 1B (NS) 10-11 gtt/min
Ampicillin inj. 4 x 150 mg i.v
Chloramphenicol inj. 4 x 200 mg
.i.v
Consult tropical-infection division
Close observation
Move to isolation room


19

Date

Comp
Physic
exam
Dx Tx
06
/02/14
(5
th
day)















Fever (+),
cough
decreased
, red
rashes (+)
turning
blackish,
shortness
of breath
decreased







RR 28x/min
Pulse 110x/min
T 37.5
0
C

Chest :
symmetrical,
minimal
suprasternal
retraction (+),
no heart
murmur,
bronchovesicula
r respiratory
sound, no
wheezing, rales
+/+

Status Localis:
red rashes
turning black on
all body
surfaces

Others: WNL


Bronchopneumonia
Post-Acute Diarrhea
without dehydration
Morbili
Hyponatremia




O2 1-2 L/min
IVFD KaEn 1B (NS) 10-11 gtt/min
Ampicillin inj. 4 x 150 mg i.v (3)
Chloramphenicol inj. 4 x 200 mg
.i.v (3)
Paracetamol 3 x tsp
Zinc 1 x 20 mg
Tropic feeding with 8 x 10 cc milk
via NGT

Planning
Urinalysis
Complete Fecal Analysis



20

Date

Comp
Physic
exam
Dx Tx
06
/03/14
(6
th
day)















Fever (-),
cough
decreased
, red
rashes (+)
turning
blackish
and
decreasin
g,
shortness
of breath
decreased
, no rapid
breathing,
intake (+)






RR 30x/min
Pulse 108x/min
T 36.5
0
C


Chest :
symmetrical,
minimal
suprasternal
retraction, no
heart murmur,
rough
bronchovesicula
r respiratory
sound, no
wheezing, rales
+/+ minimal

Status Localis:
red rashes
turning black on
all body
surfaces

Others: WNL

Bronchopneumonia
Post-Acute Diarrhea
without dehydration
Morbili
Hyponatremia


Urinalysis :
Molecular weight:
1,005
Leukocytes: 1-2
Erythrocytes: 0-1
Epithelium: 2-3
Protein : -
Billirubins: -
Urobillins:
normal
Blood/
erythrocytes: 0-1

O2 1-2 L/min
IVFD KaEn 1B (NS) 10-11 gtt/min
Ampicillin inj. 4 x 150 mg i.v (4)
Chloramphenicol inj. 4 x 200 mg
.i.v (4)
Paracetamol 3 x tsp
Zinc 1 x 20 mg
Tropic feeding with 8 x 10 cc milk
via NGT gradual rapid increase to
8 x 40-50 mL milk
Try oral feeding today




Attending Physicians Advice:
Remove INT and NGT
Switch to oral antibiotic
(Cefixime 2 x 40 mg pulv)
Discharge tomorrow

21

Date

Comp
Physic
exam
Dx Tx
06
/04/14
(7
th
day)















Cough (-),
shortness
of breath
(-), rapid
breathing
(-), fever
(-), red
rashes (+)
turning
blackish
and
decreasin
g, intake
(+)






RR 28x/min
Pulse 110x/min
T 36.3
0
C


Others: WNL



Bronchopneu
monia
Morbili
Hyponatremi
a




Cefixime 2 x 40 mg pulv
Paracetamol 3 x tsp
Zinc 1 x 20 mg
Milk on demand
Nebulization with Ventolin
respule + 2.5 mL NS every 12
hours


Planing :
Discharge
DISSCUSSION
22
Morbili
Infectious disease coused by
morbilivirus
Mainly affects children
Classification
Prodromal phase
Eruption phase
Convalescing phase
DISSCUSSION
23
Clinical Sympoms
Prodromal phase:
Cold
Coughs
Enanthema on cheek mucosa
Inflammation on pharynx and
conjunctiva
Eruption phase
Occurrences of rash
Starting from the back of the ear, spreading
to face, trunk and extremities
Preceded by increasing body temp
DISSCUSSION cont
In this case
Dx base : history, physical examination
24
History : fever and cough since 6 days before admission and the
cough later accompanied by shortness of breath since 1 day prior to
admission. This clinical symptom indicative of a bronchopneumonia
is also accompanied by cold, coryza and reddish coloration of
conjunctiva especially in the mornings indicative of a prodromal
phase of morbilli.
rashes then started to darken in color (hyperpigmentation) with mild
desquamation starting day 4 of treatment, indicating that the patient
has entered the convalescence phase of morbilli
PE: other than rales on both lungs, other aspects of
patients physical examination were within normal
limit
DISSCUSSION
25
It is known that morbilli may
cause certain degree of
immunosuppression, facilitating
the occurrences of secondary
infection or complications.
The most common
complications of morbilli is
bronchopneumonia (75.2%) and
gastroenteritis (7.1%)
Complication Disscussion cont
26
Defecation frequency of more
than 3 times in 24 hours with soft
stool consistency lasting less than
a week.
The invasion of virus into to
intestinal mucosa yields in an
inflammation on the mucosal
layer which in turn causes
diarrhea and malabsorption.
Acute
Diarrhea
soft stool since 3 days prior
to admission, with 5 times a
day frequency
No signs of dehydration

In this patient
Complication Disscussion cont
27
inflammation on lung
parenchyma.
in morbili might be the result of
an infection by the morbilivirus
itself or due to bacterial invasion.
characterized by cough, increased
respiratory frequency and wet
soft crackles (rales)
Bronchopneumonia
Cough, shortness of breath,
rales
X-ray confirms diagnosis

In this patient
Management Disscussion
cont
28
Uncomplicated morbili treat as
outpatient, supportive treatment
Complicated morbili treat as
inpatients, consider antibiotic
administration
Manage
ment
Given antibiotics
Symptomatic treatment for fever and cold symptoms
Treated in isolation room due to the contagious
nature of the disease
In
this
patie
nt
Prevention Disscussion cont
29
The most effective way to prevent and
eradicate morbilli is vaccination,
may be given as both active and
passive immunization
Vaccina
tion
Not yet vaccinated (due to age)
Explains the more severe clinical course compared to
other cases
In
this
patie
nt
30
Prognosis
DISSCUSSION cont..
The prognosis is
excellent if given
the correct and
rapid treatment
This patients
prognosis is
good
31