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CASE PROTOCOL

PGI MICHELLE G. CASTILLO-MERCENE

GENERAL DATA

This is a case of VPR, 18 years old, male, Filipino, Catholic, student,


born on May 12, 1996 at Bauan Batangas, presently residing at Banaba, San
Pascual, Batangas admitted for the first time at Batangas Medical Center on
December 12, 2014.
This is a case of S.S., 1 year old female, Filipino, Catholic, born on
November 16, 2013 at Cabuyao laguna, presently residing at Laguna
admitted for the first time at Btangas Medical Center on January 31, 2015

CHIEF COMPLAINT
Difficulty of Breathing

HISTORY OF PRESENT ILLNESS


Patient was apparently well until 2 weeks prior to admission, patient
was noted to have cough associated with difficulty of breathing and an
undocumented fever. No vomiting, diarrhea and colds noted. Patient sought
consult and was admitted with the diagnosis of Pneumonia. On the third
hospital day patient was for discharge but she had loose watery stool, mucoid
non bloody. Chest xray was also done and revealed Pneumonia on the right
lung and Pleural thickening/ hydrothorax on the right lung. Patient was
advised to have CTT hence transferred to BatMC.

PAST MEDICAL HISTORY


Patient was hospitalized when she was 7 day old with the diagnosis of
Neonatal Pneumonia.

REVIEW OF SYTEMS
General: (-) weight loss (-) growth delay
Cutaneous: (-) rashes (-) pigmentations
Head: (-) headache (-)dizziness
(-) visual difficulties (-) lacrimation (-) hearing difficulties (-) aural
discharge (-) nasal discharge (-) epistaxis (-) toothache (-) salivation (-)
sore throat
Respiratory: (-) chest pain (+) difficulty of breathing

Cardiovascular: (-) orthopnea (-) cyanosis (-) easy fatigability (-) fainting
spells
Gastrointestinal: (-)food intolerance (-) pica
Genitourinary: (-)urgency (-) frequency
Endocrine: (-) palpitations (-) cold/heat intolerance (-) polyuria (-) polydipsia
(-) polyphagia
Musculoskeletal: (-) joint/bone/muscular pain (-) limitation of motion
Hematopoietic: (-) pallor (-) bleeding (-) easy bruisability
Nervous: (-) tremors (-) sleep problems (-) convulsion (-) weakness or
paralysis (-) behavioural changes (-) mental deterioration (-) hallucination

BIRTH AND AMTERNAL HISTORY


Patient was born full term delivered via normal spontaneous delivery to
a 25 year old G1P1 (1001) on November 16, 2013 at a lying in clinic. Mother
had no history of illness, bleeding nor exposure to infections or radiation
during duration of pregnancy. She had regular prenatal consults and was
compliant with vitamin and dietary prescriptions

NEONATAL ILLNESS
Patient had a history of neonatal pneumonia.

FAMILY HISTORY
Her father works as a clerk. Both Maternal grandparents are
hypertensive. Mother is a housewife. No other member of the family is ill.
No other heterofamilial diseases were reported. There is no family history of
TB, Hepatitis A or B, nor are there any other chronic infectious conditions
existing in their family.

IMMUNIZATION HISTORY
The patient received 1 dose of BCG at birth. He received the following
vaccines at the Health Center with unrecalled dates: Hepatitis B - 3 doses,
OPV - 3 doses, DPT - 3 doses, Measles - 1 dose. He did not receive any
immunization after 9 months old.

NUTRITIONAL HISTORY
Patient was bottlefed since birth with Nestogen at 1:1 dilution until 3
months because mother had to resume work. Bona at the same dilution was
started as follow-on formula at 12 months.At 12 months, she would join the
family meals and tolerated table foods. Presently, she eats a variety of food with
preference for chicken, soup, fruits. Feeding Schedule comprises 3 main meals
of about a cup full of rise, fish or chicken, and fruits for desert. Morning and
afternoon snacks are given. She has no intake of multivitamins nor food
supplement.

SOCIAL AND ENVIRONMENTAL HISTORY


Sophia is the first child of Roberto and Sally. She is the only child and
lives in a one storey 2 bedroom house with adequate ventilation. Water
supply comes from Nawasa and distilled water is used for drinking. Food
eaten is cooked by mother at home. Mother spoon feeds her and prepares
herself before feeding food. Toiled is flush type and garbage is collected by a
dump truck 3 times a week.

PHYSICAL EXAMINATION
General Survey:
The patient is awake, oriented, febrile, not in cardiorespiratory distress, with
the following vital signs and anthropometric measurements:
CR = 175 bpm RR=45/min Temp: 35.8oC
Weight: 12 kgs

Height: BMI:

O2 sat: 100%

IBW:

Weight for age= 0 z-score


Height for age= 0 z-score
BMI= 0 z-score
Head : Normocephalic, symmetrical, with abundant thick black straight hair, no
lesions
HEENT : Pink palpebral conjunctiva, anicteric sclera, moist lips, moist buccal
mucosa, pink turbinates, minimal brownish material on both ears, patent ear canal;

Neck: supple, (-) cervical lymphadenopathy


Chest/Lungs: symmetrical chest expansion, (+) subcostal retraction, decreased
breath sounds on the right lung, tachypneic
Heart : Adynamic precordium, tachycardic, regular rhythm, no murmur
Abdomen: flat, inverted umbilicus, soft, non-tender, normoactive bowel sounds,
tympanitic all over, non palpable liver edge, no costovertebral angle tenderness
Genital; grossly male
Extremities: full and equal pulses, CRT <2 sec
Skin good skin turgor, no active skin lesion
NEUROLOGIC EXAMINATION
Sensorium Awake, oriented to time place and person
Cerebellum (-) ataxia, dysmetria, dysdiadocokinesia
Cranial Nerves
I: intact sense of smell
II: 2-3 mm pupils equally and briskly reactive to light
III, IV & VI: (-) ptosis, (+) conjugate gaze
V: positive corneal reflex
VII: no facial asymmetry
VIII: follows verbal commands
IX, X, XII: midline tongue with no fasciculations
XI: (+) shoulder shrug
MOTOR

SENSORY
5/5
5/5

5/5

5/5

REFLEXES
100% 100%

100%

100%

+2

+2
+2
+2
+2
+2

+2

+2

+2

+2

0
Reflexes
Meningeal irritation (-) Nuchal rigidity (-) Kernig sign (-) Brudzinski sign

SALIENT FEATURES

Fever
Cough
Difficulty of breathing
Decreased breath sounds on the right lung

DIFFERENTIAL DIAGNOSIS
INFLUENZA
Conditions that present with an influenza-like syndrome, such as
influenza itself, may mimic the febrile phase of dengue. The patient
presented with fever, headache, joint pains and tonsillopharyngeal
congestion which could be both seen in influenza and dengue infections
however, he has no cough and rhinitis. Patients with dengue usually have
gastrointestinal symptoms (i.e. abdominal discomfort, vomiting and
sometimes diarrhoea) during the febrile phase. In the above case, patient
also complained of abdominal pain which could not be seen in influenza.
CHIKUNGUNYA
Chikungunya virus is transmitted to people by mosquitoes. The most
common symptoms of chikungunya virus infection are fever and joint pain.
Other symptoms may include headache, muscle pain, joint swelling, or rash.
The patient in our case presented with fever, headache, joint pains,
malaise and leukopenia which are common in both chikungunya and dengue.
However, symmetric arthritis of small joints is pathognomonic of the former
which was not seen in the patient. In addition, pronounced thrombocytopenia
is more frequent in dengue which was also seen in our patient.

MALARIA
Malaria is a mosquito-borne infectious disease of humans and other
animals caused by parasitic protozoans of thePlasmodium type. Malaria
causes symptoms that typically
include fever,fatigue, vomiting and headaches. Leukopenia and
thrombocytopenia, with or without bleeding, may also be clinical
manifestations of infectious diseases such as malaria. The patient presented
with symptoms confluent with malaria, however he has no history of travel to
endemic areas making this diagnosis very unlikely.
DENGUE
The signs and symptoms that the patient presented( fever, headache,
malaise,abdominal pain, tonsillopharyngeal congestion,joint pains,
leukopenia and thrombocytopenia) as well as the endemicity of dengue in
this country fits the criteria for the diagnosis of dengue in this case.

INITIAL DIAGNOSIS
DENGUE WITH WARNING SIGNS
ACUTE TONSILLOPHARINGITIS NONEXUDATIVE

COURSE IN THE WARD


The patient was seen in the emergency room on her day 14th of
illness. She was awake, consious ,coherent and in cardiorespiratory distress.
She was afebrile, tachycardic (160bpm) and tachypneic (RR 60). She was
hooked to oxygen at 3 lpm via nasal cannula and was referred to the
department of surgery for the CTT procedure. Patient was admitted to Station
V. Diagnostics requested were CBC with platelet count and blood typing,
urinalysis and chest xray ap/l. Therapeutics given were IVF: IVF: D5IMB 50 ccx
46 gtts/ min.Meropenem 240mg IV q8 and Amikacin 90mg IV q8 was started.
Shee was put on diet as tolerated. Input and output monitored shiftly. Vital
signs monitored every 4 hours.

On the 1st-2nd hospital day, patient was febrile (37.8 C) with cough.
No difficulty of breathing was noted after CTT was done. Initially, 200cc of
purulent pleural fluid was evacuated. Upon auscultation, there was a
decreased breath sounds on the right lung. No retractions noted.
There
was a total output of 110cc from the chest tube.
Patient was also noted to have 8 episodes of loose watery stools,
mucoidal non bloody in character with associated 2 episodes of vomiting, non
projectile non billious in character. Patient was given probiotics and zinc
sulfate syrup. Meropenem and Amikacin were also continued.
On the 3rd hospital day, patient was afebrile. Patient had no subjective
complaints such as difficulty of breathing, loose bowel stools , vomiting or
abdominal pain. Patient has fair appetite. Still upon auscultation there was a
decreased breath sound on the right lung. No output was noted from the
cehst tube. Medications were continued.
On the 4th-5th hospital day,patient has stable vital signs (T 36.4 C RR
38 CR 120). Patient had no subjective complaints such as vomitng, difficulty
of breathing, cough and diarrhea. Medications were continued.
On the 6th hospital day, patient has stable vital signs (T 36.8 C RR 35
CR 125).CBC was done and revealed a decreased hemoglobin level (Hgb 85).
She was then transfused with 155cc of aliquot pRBC. Patient had no
subjective complaints such as vomitng, difficulty of breathing, cough and
diarrhea. Medications were continued.
On the 7th hospital day, patient has stable vital signs. Patient had no
subjective complaints such as vomitng, difficulty of breathing, cough and
diarrhea. Patient was scheduled for repeat CBC and chest xray AP/L.
Medications were continued.
On the 8th hospital day, patient has stable vital signs. Patient had no
subjective complaints such as vomitng, difficulty of breathing, cough and
diarrhea. CBC result revealed: HGB 130 HCT 0.39 WBC 12.5 PLT 669. Patient
had no subjective complaints such as vomitng, difficulty of breathing, cough
and diarrhea. Medications were continued.
On the 9th-12th hospital day, patient has stable vital signs. Patient had
no subjective complaints such as vomitng, difficulty of breathing, cough and
diarrhea. Medications were continued.

FINAL DIAGNOSIS
Empyema Thoracis secondary to Pneumonia

LABORATORY RESULTS
2/2/15

2/3/15

2/8/15

Erythrocytes

3.41

2.61

3.89

Hemoglobin

85

86

130

Hematocrit

0.270

0.264

0.393

Leukocyte

13.9

14.0

12.5

Neutrophil

0.808

0.506

0.596

Eosinophil

0.009

0.016

0.018

Basophils

0.007

0.012

0.007

Lymphocytes

0.140

0.394

0.333

Monocytes

0.036

0.072

0.046

433

164

669

24.9

25.4

26.8

MCV

79.2

78.1

84.9

MCHC

0.31

0.33

0.32

RDW

14.2

14.3

14.9

MPV

5.3

6.1

5.5

Complete
Count

Thrombocytes
MCH

Blood

Urinalysis
Color
Character
Spec. gravity
pH
Sugar
Albumin
Pus cells
RBC
Amorp.
Urates
Epithelial
cells
Bacteria

9/29/14
Dark yellow
Slightly
turbid
1.030
6
(-)
(-)
1-3
0-2

Few
Few

Acid Fast Bacilli (-)


Gram Stain: no organism seen
Chest Xray (AP/L) 1/15/2015
Confluent Pneumonia, right lung. Pleural Thickening and/or hydrothorax right.

CASE DISCUSSION

Introduction
Empyema is an accumulation of pus in the pleural space. It is most often
associated with pneumonia (Chapter 392) due to Streptococcus pneumoniae,
although Staphylococcus aureus is most common in developing nations and
Asia as well as in post-traumatic empyema. The relative incidence of
Haemophilus influenzae empyema has decreased since the introduction of
the Hib vaccination. Group A streptococcus, gram-negative organisms,
tuberculosis, fungi, and malignancy are less common causes. The disease can
also be produced by rupture of a lung abscess into the pleural space, by
contamination introduced from trauma or thoracic surgery, or, rarely, by
mediastinitis or the extension of intra-abdominal abscesses.
Epidemiology
Empyema is most frequently encountered in infants and preschool children. It
is increasing in frequency. It occurs in 5-10% of children with bacterial
pneumonia and in up to 86% of children with necrotizing pneumonia.
Pathology
Empyema has 3 stages: exudative, fibrinopurulent, and organizational.
During the exudative stage, fibrinous exudate forms on the pleural surfaces.
In the fibrinopurulent stage, fibrinous septa form, causing loculation of the
fluid and thickening of the parietal pleura. If the pus is not drained, it may
dissect through the pleura into lung parenchyma, producing bronchopleural
fistulas and pyopneumothorax, or into the abdominal cavity. Rarely, the pus
dissects through the chest wall (i.e., empyema necessitatis). During the
organizational stage, there is fibroblast proliferation; pockets of loculated pus
may develop into thick-walled abscess cavities or the lung may collapse and
become surrounded by a thick, inelastic envelope (peel).
Clinical Manifestations
The initial signs and symptoms are primarily those of bacterial pneumonia.
Children treated with antibiotic agents may have an interval of a few days

between the clinical pneumonia phase and the evidence of empyema. Most
patients are febrile, develop increased work of breathing or respiratory
distress, and often appear more ill. Physical findings are identical to those
described for serofibrinous pleurisy, and the 2 conditions are differentiated
only by thoracentesis, which should always be performed when empyema is
suspected.
Laboratory Findings
Radiographically, all pleural effusions appear similar, but the absence of a
shift of the fluid with a change of position indicates a loculated empyema
(Figs. 404-3 to 404-5). Septa may be confirmed by ultrasonography or CT. The
maximal amount of fluid obtainable should be withdrawn by thoracentesis
and studied as described in Chapter 404.2. The effusion is empyema if
bacteria are present on Gram staining, the pH is <7.20, and there are
>100,000 neutrophils/?L. The appearance of pus produced by different
organisms is not distinctive; cultures of the fluid must always be performed.
In pneumococcal empyema, the culture is positive in 58% of cases. In
patients with negative culture results for pneumococcus, the pneumococcal
polymerase chain reaction (PCR) analysis is most helpful to making a
diagnosis. Blood cultures have a high yield, possibly higher than cultures of
the pleural fluid. Leukocytosis and an elevated sedimentation rate may be
found.
Other local complications include purulent pericarditis, pulmonary abscesses,
peritonitis from extension through the diaphragm, and osteomyelitis of the
ribs. Septic complications such as meningitis, arthritis, and osteomyelitis may
also occur. Septicemia is often encountered in H. influenzae and
pneumococcal infections. The effusion may organize into a thick peel,
which may restrict lung expansion and may be associated with persistent
fever and temporary scoliosis.
Treatment
Treatment includes systemic antibiotics and thoracentesis and possibly chest
tube drainage with or without a fibrinolytic agent, video-assisted thorascopic
surgery (VATS), or open decortication (Chapter 392); controlled studies are
needed. If empyema is diagnosed early, antibiotic treatment plus
thoracentesis achieves a complete cure. The selection of antibiotic should be
based on the in vitro sensitivities of the responsible organism. See Chapters
174, 175, and 186Chapter 174 Chapter
175 Chapter 186 for treatment of infections by Staphylococcus, S.
pneumoniae, and H. influenzae, respectively. Clinical response in empyema is
slow; even with optimal treatment, there may be little improvement for as
long as 2 wk. With staphylococcal infections, resolution is very slow, and

systemic antibiotic therapy is required for 3-4 wk. Instillation of antibiotics


into the pleural cavity does not improve results.
When pus is obtained by thoracentesis, it is unclear whether optimal
management is closed-chest tube drainage or VATS followed by chest tube
drainage. Multiple aspirations of the pleural cavity should not be attempted. If
pleural fluid septa are detected on ultrasound, immediate VATS can be
associated with a shortened hospital course. Closed-chest tube drainage is
controlled by an underwater seal or continuous suction; sometimes more
than 1 tube is required to drain loculated areas. Closed drainage is usually
continued for about 1 wk. Chest tubes that are no longer draining are
removed.
Instillation of fibrinolytic agents into the pleural cavity via the chest tube may
promote drainage, decrease fever, lessen need for surgical intervention, and
shorten hospitalization; it does not shorten the course of disease when used
after VATS, however. The optimal drug and dosage have not been
determined. Streptokinase 15,000 U/kg in 50 mL of 0.9% saline daily for 3-5
days and urokinase 40,000 U in 40 mL saline every 12 hr for 6 doses have
been evaluated in randomized trials in children. There is a risk of anaphylaxis
with streptokinase, and both drugs can be associated with hemorrhage and
other complications.
Extensive fibrinous changes may take place over the surface of the lungs
owing to empyema, but they eventually resolve. In the child who remains
febrile and dyspneic >72 hr after initiation of therapy with intravenous
antibiotics and thoracostomy tube drainage, surgical decortication via VATS
or, less often, open thoracotomy may speed recovery. If pneumatoceles form,
no attempt should be made to treat them surgically or by aspiration, unless
they reach sufficient size to cause respiratory embarrassment or become
secondarily infected. Pneumatoceles usually resolve spontaneously with time.
The long- term clinical prognosis for adequately treated empyema is
excellent, and follow-up pulmonary function studies suggest that residual
restrictive disease is uncommon, with or without surgical intervention.

REFERENCES: Nelson Textbook of Pediatrics, 19th edition

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