MBBS Program Year 3 CASE WRITE-UP

PAEDIATRIC POSTING

NAME: KHOO ER HAU

STUDENT NO.: 16UMB05703

ACADEMIC YEAR: 2018/2019

GROUP: 4B

LECTURER IN-CHARGE: Dr. Veronica Poulsaeman

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 Faculty of Medicine and Health Sciences, UTAR
Score sheet for CASE Write-Up
In Paediatric Posting
Year 3 MBBS

Student Name: KHOO ER HAU

ID No.: 16UMB05703 Year: 3

Name of lecturer: Dr. Veronica Poulsaeman

Marks allocated for each section of Case Write-up

Chief complaints /5 Investigations (with indications, /10

results & interpretation of
results)

History of present illness is /20 Basic principles of management, /7

chronologically clear with clinical course of patient in the
relevant positive & negative ward and final diagnosis at
findings discharge or death

Other history (Birth, feeding, /10 Discussion on lessons learned /10

immunization, development,
family history, social history,
past history, drug history,
allergy history, etc)
from the clinical features ,
investigations and management
of this case, including issues on
professionalism, ethics, patient
safety and communications.

Physical Examination findings /15 References /3

clearly documented

Summary of case clear and /5 Proper use of English language, /5

concise and clear and logical write-up
Discussion of /10 Total score /100
diagnosis/Differential diagnosis

Signature of Lecture: ________________Date:___________________________

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PATIENT IDENTIFICATION
Patient’s Initial: XY
Gender: Female
Date of admission: 25/7/2018
Date of clerking: 27/7/2018
R/N: AM00627557 Age: 1 year 4 months
Ethnic group: Chinese
Date of discharge: 15/8/2018
Source of History: Parents, referral letter, case notes

CLINICAL FINDINGS & DISCUSSION

Chief Complaint:
Fever, cough, running nose for 4 days, and increased work of breathing for 1 day.

History of Present Illness:

XY was apparently well until 4 days before admission when her mother felt she was
warm to touch. Her temperature was 37.8oC when measured at home. She has no chills, rigors
or convulsion. Then on the same day she started having cough and runny nose. Her cough was
chesty and productive, but not barking-like in nature. Her mother had denied any prolonged
cough, any history of posseting, nor any witnessing of foreign body ingestion, or cough after
feeding. As for her running nose, her nasal discharge was always clear. On the next day, she
was brought to Tung Shin Hospital to seek medical attention when her documented temperature
at home reached 38oC. Afterwards, she was discharged with syrup paracetamol, nasal drop and
azithromycin to which she took for the following 3 days, however her symptoms had not
relieved. On the same day itself, she started tolerating less solid food, taking only 3 ounces of
formula milk instead of her usual amount of solid food intake and her average daily 10 ounces
of milk. She also appeared lethargic and became more irritable. According to the mother, she
started becoming less active and slept more than usual. Then on the 3rd day of illness, XY
started breathing rapidly and her mother had noticed chest wall recession. However, her mother
could not describe if there was grunting, nasal flaring, or any other signs of respiratory distress.
Hence on the 4th day, she was brought to Tung Shin hospital again, and on presentation she
appeared very lethargic and tachypneic. Her respiratory rate was 66 beats per minute with blood
oxygen saturation at 95% under room air. Her temperature was 39.4oC. Examination of lungs
revealed diminished breath sounds over the left lateral and lower zone with no adventitious
sounds, while other systemic examination was unremarkable. A chest x-ray immediately done
later showed a left pleural effusion from the middle zone to the lower zone with a mild shift of
mediastinum to the right. Peribronchial opacities are also seen in the left perihilar region and
to lesser extend in the right side as well. There is notable collapse consolidation of left lower

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lobe in addition to the left pleural effusion. Initial blood investigation showed normal blood
cell count however C-reactive protein was 146 mg/L.

Below are the details of the full blood count obtained from Tung Shin hospital on
25/7/2018.
Blood component Results Reference range
Hb 13.8 g/ dL 9.8- 13.2
Hematocrit 29.2 % 40.1- 50.6
Platelet count 255 K/μl 142- 350
RDW Width (RDW-CV) 13.2 % 12.0- 14.8
WBC 6.0 K/μl 4.1- 11.4
% of Neutrophils 84% 30-45
% of Lymphocytes 9% 40-55
% of Monocyte 6% 1-8
% of Eosinophil 1% 1-8

Both dengue specific antibody and mycoplasma antibody testing yield negative results.
Subsequently, she was stabilised with IV ceftriaxone 435mg and placed under supplemental
oxygen NPO2 1L/min, and her condition slightly improved. However due to her chest x-ray
appearance and parents inability to afford continuous private medical care, she was referred to
Hospital Ampang.
On admission, patient is still febrile with temperature of 39oC, appears lethargic and
was completely unable to tolerate any food or liquid orally. She was also breathing rapidly and
still persistently having intermittent cough and running nose. Mother reported XY previously
had been in contact with her 3 year-old elder brother who had cough and runny nose as well.
Otherwise, she has normal urine output, no abnormalities in her bowel movements, no rashes,
weight changes or other abnormal behaviour.
Upon admission, she needed 3 days of high-flow nasal cannula oxygen therapy and was
weaned to NPO2 up til discharge. From admission til now, XY had 3 weeks of persistent fever
despite several courses of antibiotics.
On examination wise, her respiratory rate had slowed down to 40-45bpm. She was more
active and playful. There was no recession. On auscultation, posteriorly, the whole left lung

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field was reduced in breath sounds, with improving aeration over the left upper zone.
Anteriorly, her lungs were clear.

Systemic Review:
Cardiovascular: No sweating, no color changes with feeding, no history of murmur, no edema,
no cyanosis

Respiratory system: No wheezing, no epistaxis, no hemoptysis

Gastrointestinal: No constipation, no diarrhea, no hematemesis, no abnormal passing of gas

Genitourinary: No history of UTI, no increase in frequency, no hematuria

Dermatological: No itchiness, no rashes or eczema, no bruising or petechiae, no other abnormal

skin lesions

Central nervous system: No unexplained cry, no loss of consciousness

HEENT: No change in vision or hearing, no eye discharge / itchiness or excessive tearing, no

ear discharge

Musculoskeletal: No history of fracture or recent trauma, no redness or swelling at joints, no

cramping or weakness

Antenatal History:
During the antenatal period, XY’s mother was healthy with no complication. There
were also no intrauterine infection or perinatal infections. No abnormalities were seen during
her scheduled check-up and antenatal ultrasound showed no anomaly.

Birth History:
XY was born termed at 38 weeks via spontaneous vaginal delivery at Hospital
Selayang. Her birth weight was 3.67kg. There were no complication during and after the
delivery. APGAR’s are unknown but according to mother, XY was pink, cried at birth, did not
need resuscitation and was active in flexing his arms and legs. Newborn screening and
assessment revealed normal results.

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Neonatal History:
XY did not have any jaundice, respiratory distress or complication after delivery to
which XY was discharged together with her mother one day after birth. She was not admitted
into the neonatal intensive care unit.

Feeding History:
After birth, XY was breastfed exclusively for 6 months. Subsequently ever since 7
months old, she took formula milk every day and weaned with solid diet. Her current diet
include 9 ounces of formula milk daily with adult diet comprising of rice, vegetables, chicken,
fish and eggs. She is not a picky eater, takes almost 4 meals per day with continuous milk
intake and no other supplementation.

Vaccination History:
Vaccination was up to date as her last vaccination was at 12 months old. According to
the mother, she has not received any additional vaccination shots from private hospitals. The
table below shows the list of vaccination she has received to this day:
Age Vaccination
At birth BCG (scar can be seen) (Single dose)
Hepatitis B (1st dose)
1 month Hepatitis B (2nd dose)
2 months Haemophilus influenza B (Hib), Diphtheria, Tetanus and
Pertussis (DTaP), Inactivated poliovirus (IPV) (1st dose)
3 months Hib, DTaP and IPV (2nd dose)
5 months Hib, DTaP and IPV (3rd dose)
6 months Hepatitis B dose 3
9 months Mumps, Measles, Rubella (1st dose)
12 months Mumps, Measles, Rubella (2nd dose)

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Developmental Milestones:
Gross motor XY is able to crawl, able to stand without support and walk
steadily. She can creep upstairs. Her gross motor function is
corresponding to more than 12 months, appropriate for 16 months
of age.
Fine motor and vision XY is able to reach out to grasp object, transfers from one hand
to another, has both mature and immature pincer grip, able to
scribble to and fro, able to build blocks of 3, however she is unable
to draw circle or straight line. Her fine motor skills are up to par
with age of 16 months.
Speech, hearing and She is able to understand and speak simple terms like “mama,
language papa, mum-mum, don’t want”. She is able to respond to her name
and positively to hearing distraction test. She is able to point out
her mother when asked to. Her hearing, speech and language is
appropriate for 16 months.
Social, emotional and She likes to smile and laugh, and responds when played “peek-a-
behavioral boo”. She’s able to wave bye-bye and clap her hands. She’s able
to feed herself with cup and spoon. Sometimes she displays
stranger awareness. She has complete object permanence or
rapprochement. Her social, emotional and behavioural
development corresponds to more than 12 months, which is
appropriate for her age.
Remark: Patient’s developmental milestone is appropriate for her age of 16 months.

Past Medical and Surgical History:

Prior to this hospitalisation, she has no medical illness. She has no history of
hospitalisation or surgery.

Medication history & history of allergy:

Apart from mentioned prescribed syrup paracetamol, azithromycin from GP and IV
ceftriaxone given by Tung Shin hospital, XY was not on any long term medication nor has she
taken any over-the-counter drugs. No traditional herbal medication or health supplements was
taken. There are no known allergy towards food and medication.

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Family History:
Father Mother
40 years old 22 years old

Male

Eldest 2nd brother XY Female

7 year old 3 year old 16 months

Both her parents are currently well and healthy. Her father is G6PD deficient and her
mother is a Hepatitis B carrier. There were no history of consanguinity in the family. She is the
youngest out of 3 siblings and all her siblings are healthy. They’re all screened for Hepatitis B
and G6PD which all turn out negative.

Environmental History:
XY lives with her parents and brothers, in total 5 people under a roof in an apartment
house at Pandan Perdana.

Social History:
Her father works as a salesperson whereas her mother works as an office administrator.
Usually when her parents work, she’s taken care by babysitter along with another 3 year old
boy. The other boy is currently not ill. Currently her mother has stopped working to take care
of her full time. At home, her father smokes but does not do so within close vicinity. There are
also no recent travel history.

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Physical Examination:
Anthropometric measurements
Height: 76 cm
Weight: 9.2 kg
Head circumference: 46cm

(Refer behind for growth charts)

Interpretation: According to her growth chart, she is thriving on the 25th to 50th percentile for
weight, 75th percentile for height. Her weight-for length is between 10th to 25th percentiles.
Overall height and weight are satisfactory. As for head circumference, it is between the 25th
and 50th percentile.

Vital signs:
Temperature: 38°C (high)

Blood Pressure: 92/50mm Hg (normal)

Pulse rate (Awake): 138 beats/ min (normal)

Respiratory rate: 56 breaths/ min (tachypneic)

SpO₂: 98% on high flow nasal cannula oxygen therapy

Interpretation: She is currently febrile. Based on the respiratory rate, XY is tachypneic. Other
vital signs are normal.

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10
11
General Examination:
The patient was lying on the bed, playing with her mother. She looks pink, lethargic
and tachypneic. Branula was seen on the left dorsum of the hand. The general appearance of
XY looks normal and she was febrile to touch. Glasgow Coma Scale (GSC) was assessed and
XY achieved a score of 15/15. Her eyes were able to open spontaneously (4 points). There’s
good verbal response (5 points), and she was able to move spontaneously and purposefully (6
points).

Hydration status
XY did not present with any signs of dehydration - no sunken eyes seen, skin turgor is
good, anterior fontanelle is soft, non-bulging and not sunken. There is no peeling or scaling of
the skin and her lips are moist. Her hydration status is good.

Nutrition
Her hair is well black, has good amount and was not frail, could not be easily plucked.
She appears to have good muscle bulk with no muscle wasting. There is no angular stomatitis,
bitot spots or macroglossia.

Skin
There are no rashes seen at the upper limb and lower limbs, trunk, back and face. No
signs of bleeding tendencies such as petechiae, purpura or ecchymosis are observed. No scars
or marks are seen on the limbs.

HEENT
There are no scleral icterus or conjunctival pallor. There are no dysmorphic features
e.g. upslanted palpebral fissures, low set ears, flat nose bridge, epicanthic folds or
hypertelorism. There’s no facial asymmetry. Ears and nose are normal appearing with no
deformity, discharge or congestion. Throat was normal, not injected, and tonsils are not
enlarged. Other than that, the teeths and gums look healthy with no bleeding. No central
cyanosis observed from the tongue.

Lymph nodes
There are no palpable submental, submandibular, pre-auricular, post-auricular,
occipital, anterior or posterior cervical, supraclavicular lymph node.

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Respiratory System
On inspection, there’s no nasal flaring and nasal septum is not deviated. There’s no
pursed lip breathing. There’s no head bobbing. The chest is normal in shape bilaterally,
however moving asymmetrically with respiration. There’s intercostal and subcostal retraction.
Evidence also is the use of accessory muscles in breathing with paradoxical inward motion of
abdomen during inspiration when patient is supine. Apart from that, the anterior posterior
diameter of the chest was less than the lateral diameter. There is no deformity, Harrison’s sulcus
or dilated veins. Respiratory rate was 56 breaths per minute, tachypneic. There’s no tracheal
deviation, no tracheal tug and as chest expansion on the left hand side was slightly reduced.

On percussion, there’s dullness over the left lung while resonance is heard over the right
lung. Upper border of liver percussed to be at the right 5th intercostal space. On auscultation,
normal vesicular breath sounds are heard with diminished sound over the left upper zone to the
lower zone. There’s crepitation over the left lung field as well.

Cardiovascular System
There was no koilonychia, no leukocynia, no peripheral cyanosis, no Janeway lesion,
no Osler’s node and no splinter haemorrhage seen. Peripheries were warm. Capillary refill time
was less than 2 seconds. Pulse rate measured was 140 bpm with regular rhythm, good character
and volume. There was no radioradial delay or radiofemoral delay. Jugular venous pulsation
was not prominent and thyroid was not enlarged. Carotid pulse were felt bilaterally on the neck.
There was no edema and clubbing on both hands and feet. Both the dorsalis pedis and posterior
tibial pulse could be felt.

On inspection of the chest, the chest wall is symmetrical on both sides, no deformity,
no surgical scars and no precordial bulge. Apex beat is not seen but palpable at the left 5 th
intercostal space medial to the midclavicular line. There is a palpable thrill on the pulmonic
area. No thrills on other areas of the heart could be felt. There’s no parasternal heave

On auscultation, both S1 and S2 hearts could be heard, with no murmurs. There’s no

carotid bruit.

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Abdominal:
Upon inspection, the abdomen is not distended, protuberant and moves with respiration.
Umbilicus is centrally located and inverted. There’s no flank fullness, abdominal straie,
surgical scars, visible peristalsis, or dilated veins over the abdomen. On palpation, the abdomen
is soft, non-tender and there is no guarding, rigidity or mass felt. The liver and spleen are both
not palpable. Kidneys were not ballotable. On percussion, there is normal liver dulless heard
at right 5th intercostal space in the midclavicular line. On percussion across the Traube’s space,
it produces a tympanic sound. Shifting dullness or fluid thrill was not demonstrable. On
auscultation, there’s normal bowel sound with no liver or renal bruit.

Musculoskeletal System
On inspection, there are no bone deformities over the upper and lower limbs. There’s
no abnormal curvature of the spine. All four limbs are able to move freely without limitations
during passive movement. On palpation, there’s no swelling, tenderness or redness over the
joints. There’s no limb length discrepancy. Muscle bulk is normal with no atrophy. Peripheries
are warm and equal for all four limbs.

Neurological Examination
Kernig’s sign and Brudzinski’s sign were elicited and both were negative. There is no neck
stiffness. Cranial nerves examination was done based on observation.
The tested cranial nerve functions were:
Cranial Nerves Findings
Optic nerve (II) Direct and consensual light reflex were normal
Oculomotor, trochlear, Movement of eyes in all direction following direction of toy
abducens nerve (III, IV, VI) moving
Direct and consensual light reflex were normal
Trigeminal nerve (V) Able to chew bread
Facial nerve (VII) No facial asymmetry
Able to smile and close eyes
No drooping of eyelids or angle of mouth
Vestibulocochlear nerve Turn to noise elicited
(VIII) Able to hear and answer upon calling her name

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 Glossopharyngeal, vagus
nerve (IX, X)
Spinal accessory nerve (XI)
Hypoglossal (XII)
Able to swallow food and water
Uvula not deviated
No wasting of trapezius or sternocleidomastoid muscle
No wasting, tremor, atrophy or inability to protrude the
tongue

Sensory examination was not performed as XY was unable to close her eyes for the
testing period. The tone on all four limbs were normal. Normal reflex were seen at the
brachioradialis, biceps, triceps, knee-jerk and Achilles tendon. Power on both upper and lower
limbs are good, either 4/5 or 5/5. Babinski sign was downgoing on plantar reflexes. There’s no
ankle clonus. Coordination test was unable to be carried out due to inability to understand given
command.

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Summary of the case:
XY, a 1 year 4 months old girl was referred to Hospital Ampang from Tung Shin
Hospital due to a complaint of fever (unresolved by syrup paracetamol), chesty cough and clear
runny nose for 4 days, rapid breathing for 1 day, reduced oral intake for 3 days, lethargy for 2
days prior to admission. She was referred to Hospital Ampang because her respiratory rate was
66 breaths, oxygen saturation at 95% under room air, with notable pleural effusion and collapse
consolidation over the left lung on chest x-ray in Tung Shin hospital. She has ill contact at
home.
On physical examination, her height, weight and head circumference are satisfactory.
She is febrile and tachypneic, while other vital signs are normal. She has subcostal and
intercostal recession, with notable accessory muscles breathing. Chest expansion was
asymmetrical as it is slightly reduced on the left side. On percussion, the left lung was dull
from the left upper zone to the lower zone. Breath sounds were diminished on the left side with
crepitation. There was also no neck stiffness, Kernig’s and Brudzinski’s signs are negative.
Otherwise, all other systems are normal.

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Differential Diagnosis
Pneumonia with left parapneumonic effusion

The diagnosis of pneumonia in XY is indisputable. Evidence by the signs and

symptoms of lower respiratory tract infection such as fever, cough, and rapid breathing. The
high index of suspicion also arises from the non-specific signs such as lethargy and poor
feeding. Prior to admission, XY’s chest x-ray also shows parenchymal effusion with collapse
consolidation on the left lung. On physical examination, there’s evidence of respiratory distress
including tachypnea (56 breaths per min), subcostal and intercostal retraction and in drawing.
Oxygen saturation improved from 95% under room air in Tung Shin hospital to 98% under
high flow nasal cannula oxygen therapy. Chest expansion was reduced in the left side,
prompting the idea that possibly there’s build-up of mucus, pus or fluid in the left lung.

On percussion, there’s dullness over the left lung suggesting consolidation or effusion.
On auscultation, diminished breath sound over the left upper zone to the lower zone. There’s
crepitation over the left lung field as well. All the findings both in physical examination and
chest x-ray point towards parapneumonic effusion.

Bronchiolitis

Bronchiolitis serves a differential to pneumonia as XY presents with fever, cough and

rapid breathing. On physical examination, evident are chest wall recession and tachypnea.
However bronchiolitis is unlikely because patient with bronchiolitis typically has milder
presentations (less tachypneic and lower grade fever) which do not typically require hospital
admission. On chest X-ray, there’s also no hyperinflation or segmental collapse / consolidation
present. Hence this diagnosis is excluded.

Meningitis

Meningitis must be considered in XY’s case as well as she appeared lethargic and
irritable. This could be due to infection / sepsis causing meningeal irritation. Meningitis could
result in the prolonged course of fever, which typically would not resolve without proper
antibiotic treatment. On physical examination however, there’s no nuchal rigidity, and both
Kernig’s and Brudzinski’s sign are negative.

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Other causes of unresolved fever and rapid breathing

Typically in XY’s case, her slow or incomplete resolution of pneumonia despite

treatment is a problem to be discussed. There are a variety of reasons that a case of pneumonia
might resolve slowly or incompletely, including those relating to the etiology of the pneumonia
(misdiagnosis of the pathogen or the presence of a resistant pathogen); those relating to the
host, including mechanical processes; and the development of complications from the initial
infection. In addition, noninfectious etiologies of pulmonary infiltrates can mimic infectious
pneumonia, thus making it appear that resolution is not following the expected course. Below
are an elaboration of causes to exclude in XY’s case, where her pneumonia is nonresolving.

1. Development of complication from initial pneumonia.

XY’s pneumonia could have progressed to develop empyema, lung abscess or

atelectasis. Sequestered foci of infection may prevent adequate concentrations of antibiotic
agents from reaching the site of infection. Empyema is particularly possible, as XY’s chest x-
ray shows significant amount of pleural fluid. In addition, anaerobes are the dominant flora of
the upper airways and common pathogens in aspiration pneumonia and its sequelae:
necrotizing pneumonia and lung abscess. As XY presents with high grade fever, cough,
dyspnea, the possibility of lung abscess should not be missed. In the case of lung abscess,
infection could be due to Peptostreptococcus, Bacteroides melaninogenicus, and
Fusobacterium nucleatum, which causes patients to present with symptoms that subtle in onset
and relatively slow in progression, but despite so, in the long term causing unresolving fever
and rapid breathing,

2. Influence of specific bacterial pathogens

Infection caused by streptococcus pneumoniae, mycoplasma pneumoniae,

streptococcus group B, hemophilus influenza must not be missed. These organism represent
some of the most common cause of community acquired pneumonia. it also is responsible for
most cases of nonresolving pneumonia syndromes that are due to infection. Although XY has
been vaccinated against hemophilus influenza B, however one cannot rule out possibility of
vaccination failure, as her course of fever is so prolonged. There might also be nontypeable
strains of hemophilus influenza to be considered in this case where her pneumonia cannot reach

18
resolution. XY has not gotten any pneumococcal vaccination as well, hence increasing the risk
that her nonresolving pneumonia was a result of streptococcus pneumoniae infection. Although
generally, in normal individuals without predisposing illness, clinical improvement is relatively
rapid. The maximum temperature generally decreases over the first 48 to 72 hours in patients
with lobar pneumonia but may not resolve completely for several more days; Some patient will
have a more severe presentation.

3. Misdiagnosis of pathogens

Alternative pathogens in addition to the usual bacterial causes of pneumonia need to be

considered in the patient who fails to respond to treatment. Particularly important pathogens in
this category include mycobacteria (either Mycobacterium tuberculosis or atypical
mycobacteria), fungi, Nocardia, and Actinomyces. Although it is highly unlikely in young
patients like XY, but tuberculosis is of significant concern as the clinical presentation of
tuberculosis as a cause of nonresolving pneumonia is often atypical. Both opportunistic and
endemic fungal infections can mimic bacterial pneumonia. In the patient with an apparent
nonresolving pneumonia, Aspergillus is a particularly important pathogen, presenting either as
chronic necrotizing or as invasive aspergillosis.

4. Resistant bacterial pathogens

The presence of a resistant pathogen is an important consideration for any pneumonia

that is not responding appropriately to antibiotic therapy. Although penicillin-resistant
Streptococcus pneumoniae (pneumococcus) is the organism of most concern, multidrug-
resistant H. influenzae and Pseudomonas aeruginosa as well as methicillin-resistant
Staphylococcus aureus are increasingly recognized in the community setting as possible causes
of a nonresolving or recurrent pneumonia. XY may have contracted these resistant organisms
when she was transferred from Tung Shin hospital or not to deny, possibility of an outbreak of
these resistant organisms in Hospital Ampang as well.

19
 5. Other non-infectious etiologies
A variety of noninfectious etiologies of pulmonary infiltrates can mimic pneumonia
and therefore represent causes of presumed nonresolving pneumonia. Hence suggesting here is
that XY’s case could be misdiagnosed as well, and her presentation could be due to underlying
neoplastic disorders (e.g. bronchogenic carcinoma, carcinoid tumor), inflammatory disorders
(e.g. systemic vasculitis, bronchiolitis obliterans, eosinophilic pneumonia), pulmonary
embolism, sarcoidosis, unrecognised metastatic focus of infection (e.g. subacute bacterial
endocarditis).

Investigations:
1. Full blood count and white blood cell differential count: Routine investigation to
determine white blood cell count for current infection and also to determine the
severity of infection present. The differential white count allows to differentiate viral
infection and bacterial infection. A rise in platelet count is also useful in identifying
platelet aggregation in the setting of inflammation.
2. Renal profile: To monitor the hydration status and electrolyte imbalance, and
detection of any impairment in renal function
3. Liver function test – To identify any impairment in liver function from long standing
inflammation, antibiotic and paracetamol intake
4. Special tests on uric acid, calcium, cholesterol, glucose and inorganic phosphate – To
identify metabolic response of patient to pneumonia and drug treatment, also identify
exposure of harmful inhaled particulate which may linked to metabolic alterations
5. Venous Blood Bases – To monitor the ventilation and perfusion of lungs and to
identify acid-base status of XY
6. C-reactive protein test – Act as marker of inflammation
7. 24 hours blood culture and sensitivity – To identify the microorganism present which
causes the unresolving pneumonia
8. Antimycoplasma pneumoniae IgM antibody testing – To rule out pneumonia caused
by mycoplasma pneumoniae
9. Stool FEME and culture and sensitivity with rotavirus antigen testing – To rule out
cause of long standing fever due to underlying infection in the gastrointestinal tract
10. Bacterial antigen test – To identify the organism responsible for the unresolved
pneumonia

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 11. Cerebrospinal fluid culture and sensitivity with cytology– To rule out meningitis as
cause of long standing fever
12. Gastric lavage for Acid Fast Bacteria test – To rule out mycobacterium tuberculosis as
cause of unexplained long unresolved pneumonia
13. Nasopharyngeal aspirate for Respiratory Synctial Virus – To rule out respiratory
syncytial virus as the cause of severe pneumonia
14. Streptococcus pneumonia PCR testing – To rule out streptococcus pneumonia as
cause of severe pneumonia
15. Mantoux test – To rule out tuberculosis as differential of severe pneumonia
16. AFB sputum test - To rule out tuberculosis as differential of severe pneumonia
17. Mycobacterium culture & sensitivity testing – To rule out mycoplasma pneumoniae
as causative organism in severe pneumonia
18. Chest X-ray – To obtain the image of the chest and lung parenchyma to visualise
pneumonia and its severity
19. Ultrasound of thorax – To determine location of pleural fluid and to differentiate
pleural fluid from lung consolidation

Result of Investigations:

1. Full blood count

Blood component Results Reference range

30/7 2/8 6/8 9/8 11/8
RBC (x 106 /μl) 3.6 4.09 3.67 3.47 3.42 4.53- 5.95
Hb (g/dL) 9.7 10.7 9.7 9.1 9.2 13.5- 17.4
Hematocrit (%) 29.2 33.4 30.0 29.5 29.9 40.1- 50.6
MCV (fL) 81.1 81.7 81.7 85.0 87.4 80.6- 95.5
MCH (pg) 26.9 26.2 26.4 26.2 26.9 26.9-32.3
MCHC (g/dL) 33.2 32.0 32.3 30.8 30.8 31.9-35.3
Platelet count (K/μl) 513 991 925 796 670 142- 350
RDW Width (%) 13.2 13.2 13.2 13.6 13.7 12.0- 14.8
WBC (K/μl) 28.5 18.4 20.4 15.8 14.0 4.1- 11.4
Immature granulocyte count 2.40 0.71 0.18 0.08 0.08 -

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 Immature granulocyte (%) 8.4 3.8 0.9 0.5 0.6 -
Absolute Neutrophil (K/μl) 21.9 13.2 16.3 11.6 9.2 3.9- 7.1
Absolute Lymphocyte (K/μl) 2.6 3.4 2.5 3.1 3.5 1.8- 4.8
Absolute Monocyte (K/μl) 3.8 1.8 1.5 1.1 1.2 0.4- 1.1
Absolute Eosinophil (K/μl) 0.1 0.1 0.0 0.0 0.1 0.0- 0.8
Absolute Basophil (K/μl) 0.1 0.1 0.1 0.0 0.0 0.0- 0.1
% of Neutrophils 76.8 71.2 79.8 73.4 65.5 -
% of Lymphocytes 9.2 18.2 12.4 19.3 25.1 -
% of Monocyte 13.3 9.7 7.3 6.7 8.2 -
% of Eosinophil 0.3 0.5 0.2 0.3 0.9 -
% of Basophil 0.4 0.4 0.3 0.3 0.3 -

Red blood cell count, haemoglobin and haematocrit are consistently lower than
normal range of limit from the first day til 18th day of admission, this suggests that the patient
is anemic. However, red blood cell indices suggest that there is no reduction in size or
haemoglobin concentration per red blood cell, XY is having normochromic normocytic
anemia. Possible differential diagnosis include haemolytic anemia, hyperplastic marrow,
renal failure, or recent blood loss. The MCHC level on the last two occasions are negligible
as it is only slightly reduced, most likely not due to hyperchromasia.
Her high WBC count on multiple occasion suggest that she is having prolonged
infection. In combination with the features, it could be confirmed that there was a lower
respiratory tract infection. However, throughout her course, her WBC is decreasing,
suggesting to us that her infection is slowly resolving. Similarly, XY is also having
thrombocytosis, very high platelet count most likely as a result of her chronic infection and
inflammation. Her platelet count has also seen a decreasing trend, as with her white blood
cell count, occurring with improvement of her condition.
High neutrophils and monocyte count show that there is a high chance that her
nonresolving pneumonia is of bacterial cause.

22
 2. Renal profile

Components Results Reference range

25/7 26/7 27/7 28/7 2/8
Urea (mmol/L) 13.3 13.1 9.2 13.3 2.4 2.76 - 8.07
Sodium (mmol/L) 134 130 129 134 137 136 - 146
Potassium (mmol/L) 4.4 4.3 4.0 4.4 4.0 3.4 - 4.5
Chloride (mmol/L) 91 95 93 91 97 98 - 107
Creatinine umol/L 85 72 56 85 29 21 - 36

From her renal profile from 25/7/2018 to 28/7/2018, her high urea, creatinine and low
chloride count suggest that XY is having renal impairment. Her renal insufficiency could be a
result of the multiple side effect with the antibiotics or antipyretic agent XY is taking.
However, her renal function was restored on 2/8/2018.

3. Liver function test

Components Result Reference range

25/7 6/8
Total bilirubin (µmol/L) - 5.70 <21
Total protein (g/L) 64 85 64-83
Alkaline phosphatase (U/L) - 197 150-420
Albumin (g/L) - 37 35-50
Globulin (g/L) - 30 28-34
Albumin / Globulin ratio - 0.77 -
Alanine Transaminase (U/L) 9 7 5-45

Her liver function is optimal and unaffected by her course of infection.

23
 4. Special test (28/7/2018)

Components Result Reference range

Uric acid (µmol/L) 538 143-339
Calcium (mmol/L) 2.33 2.02-2.6
Inorganic phosphate (mmol/L) 1.18 1.1-2.0
Total cholesterol (mmol/L) 1.75 <5.20
Glucose (mmol/L) 4.8 3.3-5.6

Her high uric acid maybe a result of her renal insufficiency, due to the inability of her
kidneys to filter waste. Other parameters such as calcium, inorganic phosphate, total
cholesterol, glucose are within normal range.

5. Venous blood gases (on NPO2 2L/min)

Blood gas values Results Reference range

pH 7.358 7.35-7.45
pCO2 (mmHg) 33.9 35.0-48.0
pO2 (mmHg) 51.8 83.0-108
Oximetry values
tHb (g/dl) 11.1 11.9-15.9
sO2 (%) 86.4 ~ 75%
FO2Hb (%) 85.7
FHHb (%) 13.5
Metabolite values
Lac (mmol/L) 1.6 0.5-1.6
Oxygen status
tO2 13.4 -
P50 26.67 -
Acid Base Status
Base(Ecf)c (mmol/L) -5.9 -4 to +2
HCO3 (mEq/liter) 19.6 22-27

24
 XY blood pH is neither acidic or alkalotic. Both the decrease in partial pressure of
CO2 and O2 suggest that there is decrease in ventilation, less CO2 is exhaled and less O2 is
inhaled. The change in CO2 is thus compensated by the change in HCO3 and Base(Ecf),
resulting in respiratory alkalosis. This maybe a result of the infection and fever, possibly
causing sepsis. The decrease in HCO3 maybe a result of excess acid accumulation reflecting
on the renal impairment.
6. C-reactive protein test

Components Result Reference range

25/7 30/7 2/8 6/8 9/8 11/8
CRP (mg/L) 146 118.01 104.19 101.59 62.58 45.75 0 - 3.0

There is a marked elevation of CRP indicating presence of inflammation in the body.

Over the course of her hospital stay, her CRP level is decreasing, showing an improvement of
her condition, providing insight that she might be responding to the antibiotics given.

7. 24 hours blood culture and sensitivity

Date Results
26/7/2018 No growth
30/7/2018 No growth
2/8/2018 No growth

On multiple occasion of blood culture and sensitivity testing, results show that there is
no growth after 1 day of incubation showing that there is no bacteria in the blood.

8. Antimycoplasma pneumoniae IgM antibody testing

Date Results
26/7/2018 Negative

The lung infection was not due to mycoplasma pneumoniae.

25
 9. Stool FEME and culture and sensitivity with rotavirus antigen testing (28/7/2018)

Components Results
Macroscopic Yellow, soft
Microscopic No ova or cyst
C&S No enteric bacterial seen
Rotavirus antigen Not detected

No pathogenic bacteria, viruses, fungi or parasites, as there were no ova or cyst,

indicating patient’s prolonged course of fever was not due to infection of the gut. Rotavirus
antigen was also not detected, ruling out gastroenteritis due to rotavirus.

10. Bacterial antigen test (28/7/2018)

Components Results
Haemophilus influenza B Not detected
Neisseria meningitidis (ACY W135) Not detected
Neisseria meningitides (B/E coli K1) Not detected
Streptococcus Group B Not detected
Streptococcus Pneumoniae Not detected

Bacterial antigen for the above organisms are not detected, suggesting that those are not
the causative organism for patient’s prolonged course of fever.

11. Cerebrospinal fluid culture and sensitivity with cytology (28/7/2018)

Components Results Interpretation

Glucose ratio 0.6 -
Gram stain No organisms seen -
Macroscopic Clear -
Microscopic (cytospun) No white blood cell seen -
Glucose (mmol/L) 3.46 Normal
Chloride (mmol/L) 114.5 Normal
Proteins (0.15g/L) 0.15 Normal

26
 Globulins Negative -
Clarity Clear -

There is no infection or inflammation in the nervous system as no organisms was found in

the cerebrospinal fluid, ruling out meningitis or encephalitis.

12. Gastric lavage for Acid Fast Bacteria test

Date Results
9/8/2018 No growth
10/8/2018 No growth
11/8/2018 No growth

Patient’s prolonged course of pneumonia was not due to atypical infection by

mycobacterium tuberculosis.

13. Nasopharyngeal aspirate for Respiratory Synctial Virus

Date Results
8/8/2018 Not detected

Patient is not infected by respiratory syncytial virus.

14. Streptococcus pneumonia PCR testing

Date Results
9/8/2018 Not detected

The lung infection was not due to streptococcus pneumoniae.

27
 15. Mantoux test

Date Results
10/8/2018 2mm

Mantoux test of less than 2mm suggest patient is negative for tb infection.

16. AFB sputum test

Date Results
9/8/2018 Not detected

XY’s lung infection was not caused by acid fast bacteria.

17. Mycobacterium culture & sensitivity

Date Results
13/8/2018 Not detected

Patient’s long course of unresolving pneumonia was not due to infection by

tuberculosis.

28
 18. Chest X-ray (26/7/2018)

Interpretation: There is reduced opacity over the left lung. The left heart border,
costophrenic angle and hemidiaphragm are obscured. Slight blunting of the left costophrenic
angle indicates moderate pleural effusion on the left side. The mediastinum and apex of the
heat is not shifted.

29
 19. Ultrasound of thorax

Ultrasound thorax (26/7/2018)

Interpretation: Minimal pleural effusion seen at left hemithorax with maximum thickness of
0.5cm. No debri or internal septation seen. There is associated adjacent collapsed consolidative
changes seen. No pleural effusion seen at right hemithorax

Ultrasound thorax (2.8.2018) - To look for worsening effusion

Interpretation: There is presence of effusion in the left hemithorax. In comparison with

previous USG findings, the effusion appears slightly more in current findings. Presence of
echogenic foci within the visualised effusion. Collapse consolidation of the adjacent lung
noted.

Impression: Worsening left complex pleural effusion with adjacent collapsed consolidative
changes

30
Management

Due to patient’s prolonged course in the hospital, and frequent changes in her
management, below is a summary of her condition from day 1 til day of discharge with all the
necessary treatment.

Due to XY’s poor feeding, an intravenous drip (IVD) was set up for her with infusion
of 5% normal saline and 0.5g KCL. Initially on the first day she was on 2/3 maintenance
(23ml/hr), subsequently on the 2nd day of admission she was placed on half maintenance
(18ml/hr) when her mother claimed that she was able to start taking 3 ounces of formula
milk. However on the same day itself at night, her mother complain that she is tolerating less
food again, hence switching back to full maintenance at (35ml/hr). On the 3rd day, she was
placed back on half maintenance when she was able to start feeding again. And subsequently
on the 4th day, when she was able to take in solids, she was put off IVD maintenance.

Date IVD maintenance

25/7/2018 23ml/hr
26/7/2018 18ml/hr -> 35ml/hr
27/8/2018 35ml/hr -> 18ml/hr
28/8/2018 18ml/hr -> off IVD

She was started on antibiotics since day 1 of admission. Initially, she was put on IV
C-penicillin 500,000U QID. Subsequently after 1 day, in view that her fever was not
resolving, her IV C-penicillin was increased from 500,000U to 850000U QID and she has
been taking it from day 2 of admission. On the 2nd day, she was actually scheduled for chest
tube insertion. However, after ultrasound imaging on the 3rd day and her chest ultrasound
show that her pleural effusion was not very severe, chest tube insertion to infuse fibrinolytic
was taken out of management in favour of pleural fluid natural reabsorption. From admission
up til the 3rd day, she appeared very leth

argic, hence prompted the lumbar puncture to investigate whether if XY is having

meningitis. As meningitis was suspected in view of her lethargic and irritable state, she was
stated on IV cefotaxime 420mg QID (50mg/kg/dose). And upon starting IV cefotaxime,
according to the mother, XY started becoming more active, waking up more often and taking
more food orally. On day 6 of illness, she was started on chest physiotherapy as well to

31
optimize her lung functions. A one-day course of magnesium sulphate was attempted to find
out if her symptoms of tachypnea could be resolved, however no improvement was seen. Her
renal impairment resolved spontaneously after stopping IV C-penicillin as evidence by the
normalizing renal profile.

After culture and sensitivity of her CSF fluid came back negative, IV cefotaxime was
stopped. Her mother started chest percussion to help XY to remove the pus accumulated in
her lungs while she remains on nasal prong. On day 9, in view that she was not responding to
her antibiotic treatment, she was stopped on IV C-penicillin and started on cefuroxime 420mg
tds. Over the course of cefuroxime treatment, her fever pattern has seen a reducing trend.
However, on day 12, she is still febrile and according to her mother, she vomited once after
taking the antibiotic. On day 13 there was a temperature spike at night, in view that her fever
was still not under control, IV cloxacillin 210mg QID was started.

After she was started on cloxacillin, XY became more active. On day 13, as her
mother complained that she started taking less orally since started on IV cloxacillin, she was
given a slower infusion of the antibiotic. And subsequently over the next two days, her
temperature started resolving (refer to temperature chart below). However, her condition
made a dramatic change again and as she started having temperature spikes again starting day
16, she was later placed on a higher dose of cloxacillin (50mg/kg/QID). Her antibiotics
summary:

1. IV ceftriaxone 435 mg stat (Tung Shin)

2. Azithromycin (from private – not completed course, unsure dose and duration)
3. IV C-penicillin 500000 U QID from 25/7/2018
4. IV C-penicillin 850000 U QID from 26/7/2018 – 2/8/2018
5. IV Cefotacime 420mg qid 27/7/2018 – 30/7/2018 (cover for meningitis)
6. IV Cefuroxime 420mg tds from 2/8/2018 – 14/8/2018
7. IV Cloxacillin 210 mg QID from 6/8/2018 – 14/8/2018 (increase to a higher
dose of 50mg/kg/qid)

In her 22 days of hospital stay, her temperature has been fluctuating, intermittent with
intervals of afebrile and febrile state. Almost every day she’s been having at least 1 episode
of fever, mostly occurring at night, which is relieved by tepid sponging or syrup paracetamol
subsequently. On certain days, she has seen some temperature spikes, reaching up to 39.6oC

32
(e.g. on 8th day of admission). But overall, her temperature was unsettling, ranging from 36.7
o
C to 39.6 oC. Below is a summary of her temperature chart measured from the axillary area.

Date Morning Evening Night Relieved by

25/7/2018 38.7 - 36.8 Syrup PCM
26/7/2018 37.6 37.4 37.9 -
27/7/2018 38.3 - 37 -
28/7/2018 37.6 38.1 38.5 Syrup PCM
29/7/2018 38.2 - - Tepid sponging
30/7/2018 38.0 37.8 38.0 Syrup PCM
31/7/2018 38.4 39.1 38.7 Syrup PCM
1/8/2018 36.9 38.3 39.6 Syrup PCM
2/8/2018 39 37.9 37.5 Syrup PCM
3/8/2018 37.8 37.8 37 Syrup PCM
4/8/2018 37 36.4 38.8 Tepid sponging
5/8/2018 38.5 37.9 38.8 Syrup PCM
6/8/2018 37.3 38 36.5 Tepid sponging
7/8/2018 36.7 36.9 37.4 -
8/8/2018 36.9 36.9 36.7 -
9/8/2018 36.7 38.0 36.5 Syrup PCM
10/8/2018 36.8 38.2 36.5 Syrup PCM
11/8/2018 37 38.1 37.2 Syrup PCM
12/8/2018 37 37 36.4 -
13/8/2018 37.9 38 36.5 Syrup PCM
14/8/2018 36.5 - - -
15/8/2018 38.5 - - Syrup PCM

She was kept hospitalised in the ward as her fever did not resolve despite the several
courses of antibiotic (mentioned above). Apart from fever, generally she looks pink, alert, and
not appeared to be in any respiratory distress. She also has good hydration and nutrition.
However throughout the 22 days of hospitalisation, she’s mostly tachypneic. Initially on the
first few day, she was maintained with high-flow nasal cannula oxygen supplement, later
after 3 days substituted with NPO2 2L/min. Occasionally she was attempted to weaned off

33
oxygen, reducing therapy to NPO2 1L/min, however she became more tachypneic and her
blood oxygen saturation drops a little. Then she was placed back on NPO2 2L/min, allowing
her blood oxygen saturation to be maintained above 95%. She was also started on nebulizer
salbutamol (4 hourly) and subsequently she was seen becoming more comfortable in her
breathing. Below is a summary of her vitals

Date Respiratory rate Pulse rate Blood pressure SPO2 Oxygen

(breaths/min) (bpm) (mmHg) # (%) supplementation
25/7/2018 52-60 134-173 88/56 97-98 HFNC (10/min)
26/7/2018 46-53 139-142 93/60 96-98 HFNC (5/min)
27/7/2018 42-48 112-120 93/55 97-100 HFNC (3L/min)
28/7/2018 46-48 152-158 89/50 97-100 NPO2 (2L/min)
29/7/2018 48 158 119/68 100 NPO2 (2L/min)
30/7/2018 40-44 157-158 97/61 97-98 NPO2 (1L/min)
31/7/2018 44 168-169 115/75 95-97 NPO2 (1L/min)
1/8/2018 40-46 135-162 108/68 96-99 NPO2 (2L/min)
2/8/2018 40-44 121-141 102/64 96-88 NPO2 (2L/min)
3/8/2018 31-44 123-160 90/52 95-100 NPO2 (2L/min)
4/8/2018 38 134-138 95/60 97-100 NPO2 (2L/min)
5/8/2018 40-44 152-182 - 97-98 NPO2 (2L/min)
6/8/2018 40-48 110-140 96/51 100 NPO2 (2L/min)
7/8/2018 47-49 150-169 - 97-100 NPO2 (2L/min)
8/8/2018 42-48 126-160 95/48 96-99 NPO2 (2L/min)
9/8/2018 40-42 126-161 113/73 96-100 NPO2 (1L/min)
10/8/2018 44 154 129/92 98 NPO2 (1L/min)
11/8/2018 38-44 127-178 118/86 97-98 NPO2 (1L/min)
12/8/2018 40-42 132-140 104/72 97-98 NPO2 (1L/min)
13/8/2018 40-44 160-169 118/61 95-7 NPO2 (1L/min)
14/8/2018 39-42 132-152 96/52 100 NPO2 (1L/min)
15/8/2018 - - - - NPO2 (0.5L/min)
#Taken at night *Three measurements was taken per day, the range is the lowest limit to the
highest limit of the measurements taken

34
 Clinically, from the 1st day of admission to the 12th day of admission, there was mild
subcostal and intercostal recession on her chest. The left lung was stony dull on percussion.
On auscultation, continuously she has diminished breath sound and crepitation heard over the
left side from the upper zone to the lower zone. Over the course of 22 days, it has generally
been getting better, with slight improved breath sound and progressively less crepitation
found on the left side. In fact starting day 14 onwards, the breath sounds on the upper zone of
the left lung could be completely heard. The right side of lung has normal breath sound all
this while. Overall, she was clinically getting better and becoming able to tolerate lower dose
of oxygen therapy.

Over the course, generally her mainstay of management resolves around these principles

- Strict input/output chart while on intravenous drip and after off intravenous drip to
ensure good hydration and urine output
- Making sure XY can tolerate orally after ending intravenous drip
- Encourage mother to perform chest percussion
- Chest physiotherapy
- Initiate and continue medications
- Monitor temperature
- Continue oxygen therapy (NPO2 2L/min)
- Monitor weekly weight to ensure XY is thriving properly

However as her fever is still unresolved up til day 20 (13th August 2018), XY’s mother
expressed to paediatric specialist Dr Tan regarding her concern about how her child is still in
the hospital despite 3 weeks of continuing antibiotics, despite so, showing no improvement,
and that the fever is too prolonged already, thereby stating her wish to transfer to Hospital
Kuala Lumpur (HKL). Dr Tan asked XY and mother to stay for another day by assuring them
that XY’s temperature has been lower this week and regardless of where the treatment is
done, the treatment of antibiotics will be the same. XY is referred to physiotherapy for a more
vigorous optimization of her lung function, in hopes that her recovery will be sped up.

35
 Another chest X-ray was done on the same day (13/8/2018), showing the following.

Bilateral lung parenchymal opacities indicate pneumonia. The obliterated left

costophrenic angle and the loss of opacity in the left lung field suggesting there’s a thick
layer of gas and fluid collection between the 2 layers of pleura.

Despite the chest x-ray finding however, XY’s course, as assured to the mother, is
improving in a lot of ways

1. Fever is occurring much lesser and lower in grade

2. C-reactive protein is dropping steadily and optimally
3. Clinically she appears better with lesser tachypnea and has became more active

Judging by her clinical appearance, XY should be recovering but however her chest x-ray
was not promising. And any delay in further treatment might bring more harm than good to
her course if she’s asked to continue on with antibiotics solely, allowing reabsorption of
pleural effusion.

Originally her management plan include having her stay for 3 more days to observe her
outcome, and by increasing antibiotic dosage and chest physiotherapy frequency with hopes
that she’ll recover. However, on the 22nd day, she had another temperature spike and this
warranted her discharge to Hospital Kuala Lumpur to seek further medical intervention.

Following up with her after discharge, she has been scheduled for an video-assisted
thoracoscopic surgery to remove the fluid collection. She was not longer suitable for pleural

36
tap, which is to insert chest tube for fibrinolysis of the deposit, as the accumulation was
already too thick to allow proper clinical outcome of the procedure.

Final diagnosis

Complicated bronchopneumonia with empyema thoracis, with underlying anemia and resolved
renal impairment

37
Discussion of case:
A) Discuss on what you have learned from the clinical features of this case, the diagnostic
procedures, management and literature review of the case.

In this case of nonresolving pneumonia, subsequently diagnosed to be complicated by

empyema thoracis, is an unusual case in children. According to studies, the term “nonresolving
pneumonia” include those cases of presumed pneumonia that progress, resolve slowly, or fail
to achieve complete resolution despite what is thought to be appropriate therapy. It is a clinical
syndrome in which focal infiltrates begin with some clinical association of acute pulmonary
infection and despite a minimum of 10 days of antibiotic therapy, patients still either
- Don’t improve
- Worsen or
- Radiographic opacities fail to resolve within 12 weeks.

The 2009 British Thoracic Society guidelines for the management of community-acquired
pneumonia suggest that chest radiograph and hospitalization be considered for outpatients with
pneumonia who fail to improve after 48 hours of treatment.

In terms of investigation, only anteroposterior (AP) view of the chest radiograph was
taken. In making the diagnosis of pleural effusion, the lateral decubitus radiograph should also
be taken. Not sure just for better accuracy, but a lateral decubitus chest x-ray can help in XY’s
case to correctly identify the amount of pleural fluid or pus collection, allowing one to
determine the need for thoracentesis and /or chest tube placement earlier. It permits free fluid
to layer out on the dependent chest wall and can help to distinguish fluid from pleural
thickening. The importance of identifying tracheal deviation cannot be denied as well, as
deviation of the trachea away from the involved lung (mediastinal shift) are likely to have a
large pleural effusion, and should be evaluated and treated urgently.

Pleura fluid analysis following drainage should have been done too. This is indicated
for some moderate and most large pleural effusion. If a drainage procedure is performed, the
pleural fluid should be sent for microbial analysis and cell count. The pleural fluid sent for
microbiologic analysis can subjected to gram stain and bacterial culture, allowing the organism
to be identified more properly.

38
 C-reactive protein although useful in monitoring the progress of inflammation, but it
has been established as a criterion for hospital discharge and useful enough to correctly predict
antibiotic response. Procalcitonin, although not available right now, serves as a better
inflammatory marker in lower respiratory tract infection compared to C-reactive protein.
According to cross sectional studies, procalcitonin when used was associated with better
antibiotic guidance in prescribing, allowing one to limit or increase the dosage of antibiotic
more correctly when necessary.
However, with all the investigation done, and notable pleural effusion in XY’s chest X-
ray, she should be sent for thoracocentesis to remove the excess fluid accumulated. Chest tubes
can be placed as well to introduce fibronolytics such as alteplase (tPA), which can work to
break down pockets of fluid to allow for better drainage. If she was subjected to intervene for
her parapneumonic effusion earlier, she would not have suffered this prolonged course of
pneumonia and in the end, requiring surgery to decorticate her lungs.

Her prolonged course of fever should have raised suspicions that her pneumonia is not
responding to the course of antibiotics. Although there’s a currently a lack of high quality
evidence to guide the choice of specific antibiotics and the duration of treatment. However, we
know that the top 3 bacterial causes of pneumonia are Streptococcus pneumoniae,
Staphylococcus aureus, and Group A Strep, as she’s not responding to antibiotics, appropriate
antibiotics would be IV Ceftriaxone to cover most pathogens, and IV Clindamycin as
community-acquired MRSA could be possible. Given the nature of infection, XY was not
properly managed.

There are three stages of empyema: At the beginning, the lung parenchyma is inflamed
and becomes leaky, which allows fluid, proteins, and leukocytes to escape into the pleural
space. This first stage is called the exudative stage, where a moderate to large exudative
parapneumonic effusion can develop. The second stage is called the fibropurulent stage, where
invasion of bacteria ensues and loculations develop within the collection. Loculations are
pockets of pleural fluid contained by fibrinous pleural adhesions. In the third stage, called the
organizational stage, the collection becomes more organized and may form a pleural
fibrinous peel. According to her chest X-ray, XY should be in her 2nd or 3rd stage of empyema.
As the pneumonia evolves into the later stages, the fluid forms organized pockets, which are
much more difficult to drain, hence worsening her condition. If earlier intervention such as
draining was performed, it can decrease the amount of days of hospital stay for XY as well.

39
 Hence this raises the issue of prolonged hospital stay. Just being in the hospital can
cause a lot of problems, particularly infection. XY will have a higher risk for hospital acquire
infection. Prolonged hospital stay in long term can jeopardize her overall health, causing
pressure sores, undernutrition, decline in mental function etc. This affects the mother too who
has been in the hospital taking care of her in a lot of ways as well. Prolonged oxygen
supplementation can weaken the lungs, despite chest physiotherapy. According to a Cochrane
review, in children with pneumonia, chest physiotherapy has not showed enough evidence in
proving overall usefulness in improving lung function, there’s no significant improvement in
respiratory rate and oxygen saturation as also evident in XY’s case.

B) Also carry out a discussion on Professionalism, ethical issues, professional judgment,

communication issues, spiritual/traditional/alternative medicine (whichever relevant), and
lifelong learning issues which are relevant to this case.

In this case, as XY was on long term syrup paracetamol and antibiotics, a

professionalism issue revolves around explaining to the mother the need of extended
treatment and why her condition has not improved. In conversation with the mother, the
mother had complained about her suspicion of the paediatrician’s competency in Hospital
Ampang compared to other government and private hospital. The mother felt like the child
was being treated like a rat, attempting different courses of antibiotic just to see if the child’s
condition improved or not. Mother also claimed that she believed her child would have been
treated more efficiently in other hospital and not having to suffer such a prolonged course of
pneumonia.
Perhaps the biggest issue here is the failure of explanation to the mother about how
complicated pneumonia can be and commonly it is not a 1-2 days health issue that can be
treated and resolved immediately. It should be justified to the mother the reason why multiple
antibiotic has to be attempted, as different lines of antibiotic treat different organisms, and
example it would be unwise to start XY on high dose of cloxacillin without proper
investigation. The parents’ concern could be understood, as every parent coming in to the
hospital wishes that the doctors in the hospital provide the best treatment for their child.
Especially like in XY’s case, every parent would be frustrated if his/her child does not show
any improvement in her medical course. As a good paediatrician, the parent’s concern and
frustration must be addressed at all times by having good communication and comprehensive

40
patient education so parents are able to understand better and have more confident in the
hospital’s practice. Quoting from Dr William Withey Gull,
“never forget that it is not a pneumonia, but a pneumonic man who is your patient”
This speaks a lot that while treating a patient, our focus should not be solely in
looking at the disease only, but we have to treat the patient as an entire whole, and at the
background, understanding and approaching the parents well, many people who cared about
this patient depends on the quality of care and confidence one doctor confers.
Moving on, when XY’s fever was still unresolved after many days, different treatment
options were made to possible to the family. One thing I took heed was, it takes a toll on
doctors as well to lay down difficult options to the family, especially when one proposes
watchful waiting vs surgery in such a young age. When the parents expressed their wish to
continue medical care at Hospital Kuala Lumpur, it is every doctors struggle as well to know
that there’s nothing else that can be done, but to let go of their patient to hopefully better
medical care. And perhaps this reality is a common phenomenon among healthcare providers,
to respect patient’s wish in allowing them choose what’s the best treatment for their children.
Especially for XY’s case, the emotional attachment having been with her throughout 22 days
of hospital stay could not be underwhelm.
Seeing how XY has suffered through the course, as a medical student, I felt that I
personally was not doing justice to the patient. I had the propensity of time to join the doctors
in managing the patient, but I was not proactive in wanting to learn more about how to
improve the patient’s course only until 2 days prior to discharge, I joined in the discussion
with Dr Tan and his team. Especially seeing how XY’s condition had not improved, I did not
proactively learn the many things I proposed in the discussion above, only after the patient
had discharged, I took the time to review her clinical case in this case write up. From this I
learned that I must not miss precious learning opportunities, especially when it pops up.

From a professionalism point of view, having the need to go through decortication

surgery at such a young age will bring a huge impact to the patient and her family. It will
potentially scar the patient not just physically, but mentally as well although patient is still
young. Her family will have to bear significant amount of cost as well to put her daughter
through surgery, which all could have been prevented if earlier intervention has been done.

Finally, one thing I learn is the importance of a medical team. Especially in XY’s case
where she had a prolonged course of hospital stay, when her pneumonia was nonresolving,

41
many doctors or healthcare providers’ opinion matter, and had it not been for the frequent
round-the-bed discussion by the doctors and nurses together, pulling all healthcare team
mental resources together, XY’s condition would been a lot worse. Hence the importance of a
medical team must be not understated.

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