Morning Report

Elisabeth Kaza Monday, 08/22/2011

July in the ED
12Y 6M F with cough for ~ 1 week followed by severe headache Low grade fever on and off Seen by PCP
gave augmentin for positive strep then noted SOB and low O2 sat in office send her to ED for further work- up

July in the ED
In the outside ED:
O2 sats in 30s, tachypneic, placed on nonrebreather mask with improved sats to 70s80s Then transitioned to CPAP with PEEP 8 at 100% FiO2 with O2sat of 92% Tachycardic with temp of 38.1

Transport via Life Flight to PCMC PICU

More info
PMH: 28 week premature infant, twin A. 54 day NICU stay, was sent home with O2 x several weeks. Long h/o migraines. SURGERIES: PDA ligation (NICU stay) IMMUNIZATIONS: UTD MEDS: none ALLERGIES: none

More info
FH: Mom with migraines. Sister with recent cough 2 weeks ago. SH: Lives in Blanding, UT with mom. But has been in Spanish Fork, UT for vacation. Twin sister, 2 younger brothers. Dad is involved. Exposures:
No travel outside Utah No exposure to TB

Physical Exam
VITALS in the ED:
T: 38.1, HR: 140, RR: 35, BP: 113/65, O2sat: 87% on 15L FM. Height and weight: appropriate for age

GEN: awake, alert, respiratory distress HEENT: NC/AT, MMM CV: RRR, tachy, no murmur, cap refill <2sec

Physical Exam
RESP: tachypneic, coarse breath sounds bilaterally (not focal), no wheezing ABD: soft, NT, ND, no masses NEURO: CN II-XII intact, 5/5 strength SKIN: no rashes, pink

Differential
Infectious: Bacterial Pneumonia, Viral pneumonia (adenoviruses, parainfluennza, influenza), Tuberculosis, Fungal pneumonia, PCP (Pneumocystis pneumonia), Chlamydia pneumonia, Coxiella burnetii (Q fever), Legionella pneumonia, Anthrax, Tularemia, Plague, Histoplasmosis, Cryptococcus Respiratory: Empyema, Abscess, Pneumothorax, Pulmonary embolism, Aspiration of foreign body, Asthma, Bronchiolitis, Bronchiectasis, Pertussis Chemical: Aspiration Pneumonia/Inhalation injury Cardiac: CHF, R--->L shunting, pulmonary HTN Damage by physical agents: Lipoid pneumonia, Kerosene pneumonia, Near drowning, Smoke inhalation CNS: stroke, tumor, CNS infection (headache)

Laboratory
WBC 5.5 (9B, 64N, 21L, 1M), Hct 33.6, Plts 248 CRP 2.0 BNP 257, Troponin 0.1 ABG 7.44/39/51/26/2.1 Lactate 1.3 Na 135, K 40, Cl 103, CO2 26, BUN 8, Creatinine 0.45, Ca 7.7, Glc 128

Laboratory
Tox screen negative DFA/VRP negative Mycoplasma Pneumonia PCR detected Blood culture NGTD CBC on d/c: WBC 6.1 (1B, 62N, 30N, 5M, 2E), Hct 44.1, Plts 583

Initial Imaging
CXR (admission): diffuse heterogeneous pulmonary opacities, mild cardiomegaly, PDA clip CXR (discharge): near complete resolution of pulmonary infiltrates ECHO: Trace TV regurgitation, normal ventricular septum motion, normal LV/RV size and function. Bubble study normal

CXR on admission (portable)

During PICU stay

And upon discharge

Hospital Course
Outside ED:
CBC, BMP, ABG with Lactate, VRP, blood culture obtained NS bolus was given. CXR obtained 2 gm Rocephin, 400mg IV azithromycin given

Hospital Course
PICU and inpatient floor:
CPAP with PEEP 8, then increased to 12. Tox screen for potential linear pneumonitis. NPO given respiratory status. Azithromycin and Rocephin continued. Echo done. Slowly weaned on her FiO2 to HFNC, then to NC and d/c on RA Mycoplasma detected. Azithromycin x 5 days CBC initially: lymphopenia, resolved upon d/c BNP also normalized 257 --> 19

Atypical (walking) pneumonia

H/o oxygen for a few weeks after d/c from NICU suggests that she has less pulmonary reserve, may explain degree of hypoxia Caused by Mycoplasma pneumonia

M. pneumoniae
Smallest bacteria that can survive alone, lacking cell wall Prevalence:
30% in outpatient setting 15% inpatient

Transmitted from person to person by infected respiratory droplets School age kids

Laboratory Diagnosis
Diagnostic test Material Sens % Spec % Result Time Cold agglutinins Culture ELISA DNA probe PCR Serum NPA-PS Serum NPA-PS NPA-PS 30-50 61 83-100 89-100 78-100 50 100 variable 2-6 weeks Cost low low

79-100 Hours - 2 wks moderate Hours - 2 wks 89-98 moderate/high 92-100 Hours 1 wk moderate/high

Sens = Sensitivity. Spec = Specificity. NPA = nasopharyngeal aspirate. PS = Pharyngeal swab

Manifestation Fever Cough Crackles on CXR Malaise Headache Sputum production Sore throat/pharyngitis Chills Hoarseness Earache Coryza Diarrhea Nausea/vomiting Chest pain Lymphadenopathy Skin rash

Frequency observed ++++ ++++ +++ +++ ++ ++ ++ + + + + + + + + +

Chronology of M. pneumonia
Incubation
Weeks SYMPTOMS Headache, Malaise Fever Sore throat

Clinical illness

Convalescence

Cough
SIGNS Sputum Dullness Rales LABORATORY Positive culture CXR findings

Treatment
Usually benign Macrolide Severe life-threatening pneumonia possible (defined as refractory MP showing clinical/rad. deterioration after macrolide tx. Can try Ciprofloxacin (cartilage toxic) plus glucocorticoid

References
Combined treatment for child refractory Mycoplasma pneumoniae Pneumonia with ciprofloxacin and glucocorticoid. Lu A, Wang L, Zhang X, Zhang M. 3Pediatr Pulmonol. 2011 Jun 22. doi: 10.1002/ppul.21481. Infection by Mycoplasma pneumoniae and its importance as an etiological agent in childhood communityacquired pneumonias. Vervloet LA, Marguet C, Camargos PA. Braz J Infect Dis. 2007. Oct; 11(5):507-14. Advance in the diagnosis and treatment of Mycoplasma pneumoniae pneumonia and related complications. Zhang YM, Liu XY. Zhongguo Dang. 2011 Apr;13(4):358-60. Review. Pneumonia in the immunocompetent patient. Reynolds JH, McDonald G, Alton H, Gordon SB. Br J Radiol. 2010. Dec, 83 (996)998-1009. Community-acquired pneumonia in children: whats old? Whats new? Don M, Canciani M, Korppi M. Acta Paediatr. 2010 Nov;99)11):1602-8. The first atypical pneumonia: the history of the discovery of Mycoplasma pneumoniae. Cunha CB. Infect Dis Clin North Am. 2010. Mar; 24)1):1-5. Macrolide-resistant Mycoplasma pneumoniae: characteristics of isolates and clinical aspects of communityacquired pneumonia. Morozumi M, Takahashi T, Ubukata K. J Infect Chemother. 2010 Apr; 16(2):78-86. Mycoplasma pneumoniae infection in a clinical setting. Othman N, Isaacs D, Daley AJ, Kesson AM. Pediatr Int. 2008. Medical Microbiology. 4th edition. Baron S, editor. Galveston (TX):; 1996. Chapter 37. Mycoplasmas. Shmuel Razin.Ver