CASE PRESENTATION

Report
Duygu Unkaracalar, MD
PGY-1
2,5 y/o female with grunting
HISTORY
HISTORY
 1 week h/o dry cough, clear runny nose, diarrhea (non
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bloody, no mucous), vomiting (NBNB), decrease PO
intake
5 days ago PMD visit: Promethazine no improvement
Last 3 days fever (Tmax: 102), productive cough
2 days ago PMD visit: wheezing (+), b/l otitis media
Prednisolone, Albuterol, Azithromycin no improvement
Motrin was given 1 hour prior to the ER visit
Difficulty breathing, grunting started about 1/2 hour ago,
no PO, BM, vomiting or urine output today
Sick contact (+) father had flu-like symptoms last week
No travel, no pets or smoking
HISTORY
 Birth hx: FT, NSVD, no NICU
 PMH: Intermittent asthma ( x2 attacks/year, no hosp
or ER visits), no surgeries
Meds: Albuterol PRN
 UTD, no flu vaccine
 NKDA
 FH: non-contributory
PE
PE
 General: Pt was in respiratory distress, grunting, perioral
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cyanosis, GCS:15
Vitals: RR: 56/min, HR: 143/min, sO2: 86%(on RA),
T: 98,4 F, BP: 116/77 mm-Hg
HEENT: Perioral cyanosis, b/l Tms dull, oropharinx-tonsils
wnl, no LAPs
Lungs: Tachypnea, B/L decrease breath sounds on the
bases(L>>R), intercostal retractions(+), wheezing (+), no
rales
Heart: Tachycardia, RRR, S1,S2(+), no m/g/r
Abd: Soft, (+) BS, NTND, no HSM
Ext: Warm, cap refill<2 sec, b/l good pulses
Neuro: Oriented x3, CNII-XII wnl, no lateralitazions, no
babinski, b/l DTRs wnl, no neck stiffness
Work-up
 CBCWBC: 6.1, Hb: 13, Htc: 38.4, Plt: 199 (83% N,
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13% L, 4% M)
CMP Na: 137, K: 3.7, Cl: 117, HCO3: 18, BUN:59,
Cr: 1.0, Glu: 121, Ca:8.4, PO4: 5.5, Mg: 1.2, Alb: 2,
Prt:3.9, ALT:41, AST:36, ALP: 98, T./D.Bil: 0.6/0.4
CRP: 8.4
ABGpH: 7.35, pCO2: 44, HCO3: 19, BE: -2.2, pO2: 58,
sO2: 88%
Flu A/B: (-), RSV: (-)
Blood Culture
CXR
Differential Diagnosis?
Differential Diagnosis
 Respiratory: Viral/Bacterial Pneumonia, Empyema,
Pulmonary TB, Hemothorax, Chylothorax,
Pulmonary Embolism
 Hem/Onc: NHL, Hodgkin Lymphoma, Sickle Cell
Disease ( ACS)
 CVS: Congestive Heart Failure (CHD, Myocarditis,
Tamponade)
 Renal: Nephrotic Syndrome, Renal Failure
 GI: Liver Failure, Hypoalbuminemia, Pancreatitis
 Rheumotology: SLE, JRA
ER Course
4L nasal O2 95%
Ceftriaxone 2 g IV
Solumedrol 60 mg IV
Alb/Atr neb x3
x1 Bolus
Laboratory
Admission to the PICU
PICU Course
 BIPAP 95%
 L chest tube pH: 6.9, prt: 3.6g/dl, glu: 45.6mg/dl, cloudy
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12500 WBC, 50 RBC
gr(+) cocci in pairs, cx pending
Respiratory failure Intubated
Acute renal failure ( 59/1, 37/0.7)Hemodialysis x2
T: 37.6-39.8
Subsequent CXRsworsen R pleural effusion R chest tube
Repeat CBCWBC: 59, Hb: 10.4, Htc: 29.6, Plt: 225
(78%PMNL, 17%L, 5%M)
Ctx, Vancomycin, Famotidine, Alb neb, CS, Tylenol, TPN
Blood cx: (-), H1N1, Flu A/B PCRs (-)
Pleural Effusion
 Collection of at least 10-20 mL of fluid in the pleural
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space
Normally 0.1-0.2 mL/kg of a colorless alkaline fluid,
which has less than 1.5 g/dL of protein
Lymphocytes, macrophages, and mesothelial cells,
with an absence of neutrophils
Infection is the most common cause of pleural
effusion, 2. Congenital heart disease (CHD),
3.Malignancy
Classified as transudates and exudates
Pleural Effusion
Exudate
Transudate
 Cloudy
 Clear
 pH < 7.2
 pH=7.45 or =serum pH
 PP/SP > 0.5 or prt >3 g/dl
 PP/SP<0.5 or prt < 3 g/dl
 P LDH/S LDH > 0.6
 P LDH/S LDH < 0.6
 P Glu/S Glu < 0.5 or Glu<60mg/dl
 P Glu/S Glu > 0.5
 Infection, pancreatitis (left-sided),
 Congestive heart failure,
rheumatologic diseases,
chylothorax, malignancy, or
trauma
hypoalbuminemia, nephrosis,
hepatic cirrhosis, and iatrogenic
causes (eg, misplaced central line,
complication of ventriculopleural
shunt)
Pleural Effusion-LAB
 CBC with diff, CRP, Blood culture, serum LDH, CMP
 Serology Mycoplasma, Legionella Ag, viral
 Pleural fluid analysis gram staining and culture;
acid-fast staining and culture; cell counts; cytology;
and determination of pH, protein, glucose, LDH, and
triglyceride levels, Htc if hemothorax
 ppd
 Coag tests
Definitions
 Parapneumonic effusion
Pneumonia with evidence of effusion
 Uncomplicated (or simple)
free flowing pleural fluid
 Complicated
loculated pleural fluid
 Empyema
Pus in pleural space
Signs & Symptoms
 Fever
 Decreased breath sounds
 Cough
 Decreased chest
 Dyspnea
 Cyanosis
 Lethargy
 Pleuritic chest pain
 Abdominal pain
 Vomiting
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expansion
Crackles
Friction rub
Dullness on percussion
Tracheal shift
Etiology
 Pneumonia(viral,bacterial,tuberculosis,
mycotic)
 Lung abscess
 Trauma
 Postoperative
 Extension of subphrenic abscess
 Generalized sepsis
Etiology
 The most commonly –S. pneumoniae, S. aureus, and
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group A streptococci (a complication of an infectious skin
disorder)
Haemophilus influenzae-rarely (since H influenzae B
vaccine)
Methicillin-resistant S Aureus is a concern in the older
age group
Tuberculosis-worldwide
Anaerobic infections -secondary to aspiration
Fungal or mycobacterial infections – immunosuppressed
Loculated pleural effusion-USG
B/L Pleural effusion-CT
Treatment
 Antibiotics (10-14 days of intravenous antibiotics) Sulbaktam-
Ampicillin, 2nd generation cephalosporins (e.g Cefuroxime), 3rd
generation cephalosporins (e.g Ceftriaxone), Vancomycin,
Clindamycin
1-3 wks PO antibiotics-according to clinical picture and respond
 Diagnostic thoracentesis and chest tube drainage are
effective therapies in more than 50% of patients
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large effusion-greater than or equal to half the hemithorax,
loculated effusion,
thickened pleura on contrast-enhanced CT scan
positive Gram stain or culture
pH less than 7.20
pleural fluid consists of pus
 Multiloculated effusions (tPA- via chest tube, surgery)
Prognosis
 Complications are rare and prognosis is quite
good in pediatric population
 Radiographic abnormalities by 3-6 months
following therapy
 PFT: Mild obstructive abnormalities were the
only findings observed in patients evaluated 12
years (±5) following recovery from empyema
 Some increased bronchial reactivity
Follow-up
 Afebrile and improving clinicallythe IV drugs can
be switched to PO medications for 1-3 weeks
 Children should be examined within 2-4 weeks after
discharge, depending on the patient's clinical status
 Some experts recommend serial chest radiography
to ensure clearing
 Some perform CT scanning after the plain
radiographs clear
Back to the Case
 x3/day fever spikes T: 39.9
 Urine Strep. Pneumonia Ag: (+)
 Repeat Blood cultures (-)
 Pleural effusion culture(-)
 ppd(-)
 Repeat CXRsimprovement
 Extubated on day 8
 On day 9
 Respiratory distress (RR: 55/min, sO2: 88%)
 Tachycardia (148-188/min)
 Hypotension (56-102/35-57 mm-Hg)-not enough improvement with
Dopamine/Epinephrine infusion
 Lactic acidosis (pH: 7.28, PCO2:40, HCO3:12, PO2: 45, BE:-10, LA:5)
 CVP:9-1823-24 mm-Hg)
 BiPAP not tolerated
 Intubated again
PE Findings
 Alert, in respiratory distress
 HR: 188/min, RR:55/min, sO2: 88%(2L NC), T:38.5,
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BP: 56/35 mm-Hg, CVP: 24 mm-Hg
Lungs: B/L decrease breath sounds, b/l intercostal,
subcostal retractions, b/l course breath sounds, no
w/r/r
Heart: RRR, (+) S1, S2, muffled heart sounds, no
m/r/g
Abd: Distended, (+)BS, NT, 4 cm HM(+), no SM
Ext: Cap refill 3 sec, b/l weak pulses, edema
What is the diagnosis?
Management?
Pericardial Effusion
Cardiac Tamponade
Cardiogenic Shock
Pericardial Effusion
 Pericardial space contains approximately 20 mL of fluid
 Most commonly occurs as a direct extension of an infection
from an adjacent pneumonia or empyema, rarely
hematogenously seed
 Most cases occur in children younger than 4 years
 Symptoms are often nonspecific- fever, respiratory distress,
and tachycardia, chest pain
 Most patients have a preceding or concurrent infection:
 Pneumonia
 Meningitis
 Acute osteomyelitis
 Acute arthritis
 Soft tissue infections
Cardiac Tamponade
 Pericardial fluid accumulates rapidly enough or in
sufficient volume to impair diastolic filling
 Complications: Pulmonary edema, shock, death
 During tamponade, all 4 cardiac chambers compete
for space within the pericardium;
 Increased systemic venous and atrial pressure- HM,
edema, JVD, increased CVP
 Increase pulmonary venous pressure- pulmonary
edema, hypoxia, respiratory distress
Cardiac Tamponade
 Tachycardia
 Kussmaul sign-paradoxical
 Tachypnea
increase in venous
distention and pressure
during inspiration
 Pulsus paradoxus- >12 mm
Hg or 9% drop in systemic
blood pressure during
inspiration
 Hepatomegaly
 Diminished heart sounds
 JVD
 Hypotension
 Increase CVP
 Delayed cap refill
 Weak pulses
Cardiac Tamponade-Causes
 HIV infection
 Infection - Viral, bacterial , fungal
 Drugs - Hydralazine, procainamide, isoniazid, minoxidil
 Postcoronary intervention (ie, coronary dissection and perforation)
 Trauma
 Postoperative pericarditis
 Postmyocardial infarction (free wall ventricular rupture, Dressler syndrome)
 Connective tissue diseases - Systemic lupus erythematosus, rheumatoid arthritis,
dermatomyositis
 Radiation therapy
 Iatrogenic - After sternal biopsy, transvenous pacemaker lead implantation,
pericardiocentesis, or central line insertion
 Uremia
 Idiopathic pericarditis
 Complication of surgery at the esophagogastric junction such as antireflux surgery
 Pneumopericardium (due to mechanical ventilation or gastropericardial fistula)
Back to the Case
 CXR: L pleural effusion and infiltration (little
improvement), enlarged heart silhoutte
 ECHO: Dilated IVC, RA diastolic compromise,
flattened/paradoxically septum movement (dancing),
moderate pericardiac fluid collection around RA/RV
anteriorly, also seen posteriorly ( largest 20 mm),
smallest collection is inferiorly measuring 3-4 mm in
diastole
 Surgery: Pericardial window, mediastinal tube
placement about 150 cc cloudy, yellow fluid, culture
was sent
Back to the Case
 Fluid culture results (-)
 Viral Serologies, PCRs (-)
 After surgery vitals and clinical picture improved
 1 day later extubation, afebrile
 3 days later all tubes were removed
 Transferred to the floor
 Afebrile during floor course and discharged with
Cephalexin
A 16 m/o African-American boy presents to ED with 3 days of fever and
cough. Has not been hungry but continues to drink well. His fever has
persisted despite antipyretics and is now 39.0. No other symptoms, sick
contacts or travel history. On PE child looks toxic but is well hydrated.
HR:140 RR: 52 Sat: 82% (RA), the only significant finding on exam is
markedly decreased breath sounds on the Right hemithorax. No HSM or
adenopathy noted. CXR reveals an opacified Right hemithorax with slight
mediastinal shift to the Left. What is the next diagnostic procedure
indicated?
A) Throat Culture
B) Review of the Blood Smear
C) US of the Right Hemithorax
D) Nasopharyngeal aspirate for viral screen
A 16 m/o African-American boy presents to ED with 3 days of fever and
cough. Has not been hungry but continues to drink well. His fever has
persisted despite antipyretics and is now 39.0. No other symptoms, sick
contacts or travel history. On PE child looks toxic but is well hydrated.
HR:140 RR: 52 Sat: 82% (RA), the only significant finding on exam is
markedly decreased breath sounds on the Right hemithorax. No HSM or
adenopathy noted. CXR reveals an opacified Right hemithorax with slight
mediastinal shift to the Left. What is the next diagnostic procedure
indicated?
A) Throat Culture
B) Review of the Blood Smear
C) US of the Right Hemithorax
D) Nasopharyngeal aspirate for viral screen
What is the appropriate first therapeutic intervention?
A) O2 supplementation
B) ABG
C) Thoracostomy tube placement
D) Bronchoscopy
What is the appropriate first therapeutic intervention?
A) O2 supplementation
B) ABG
C) Thoracostomy tube placement
D) Bronchoscopy
THANK YOU

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