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Case Presentation
Chief HPI:
Complaint:Fever
3 year old female with cough and fever for 6 days Initial mild cough and fever; diagnosed with a viral respiratory illness Cough worsened and fever persisted; diagnosed with acute otitis media and started on amoxicillin
Case Presentation
HPI
cont:
Cough continued to worsen and she was still febrile, now with increased work of breathing Oxygen sats at PCPs 88% on room air, so she was referred to PCMC
Case Presentation
PMHx: Healthy term infant. No hospitalizations or surgeries. SocHx:
Lives with parents and older brother, who was recently ill. Attends pre-school twice a week. No recent travel. No tobacco exposure. No pets.
FamHx: Negative for asthma, congenital heart disease, autoimmune diseases, immunodeficiencies.
Case Presentation
Meds: None regularly All: NKDA Imms: Up to date
Case Presentation
Physical Exam
GENERAL: NAD, appears uncomfortable. HEENT: Conjunctivae clear, TMs clear without erythema, MMM, NP clear, OP w/o exudates. NECK: Supple, no LAD. LUNGS: No grunting or nasal flaring, minimal subcostal retractions, left lung clear to auscultation, right lung with crackles and decreased aeration. CV: Tachycardic, normal rhythm, no M/G, nl perfusion and pulses. ABD: Soft, NT/ND, no HSM, nl BS, no masses EXTREMITIES: No C/C/E. SKIN: No rashes, jaundice, cyanosis or pallor.
Differential Diagnosis
349 BMP: Na 138, K 4.3, Cl 106, CO2 21, BUN 14, Cr 0.36, Glu 113, Ca 8.9 ESR 101, CRP 21.7 VRP: pending Blood cx: pending CXR
Presence of signs and symptoms of pneumonia in a previously healthy child due to an infection acquired outside of the hospital Signs and Symptoms: Best positive predictive value: nasal flaring <12 mo, oxygen saturation, tachypnea Best negative predictive value: absence of tachypnea or other respiratory signs
Blood cultures: Should not be obtained in a nontoxic, fully immunized child with CAP managed in the outpatient setting Should be obtained for patients requiring inpatient admission
Positive blood cultures ranged from 1.4% to 3.4% In Utah, 11.4% had positive cultures In pneumonia complicated by parapneumonic effusion, 13% to 26.5% had bacteremia
Recommended if signs/symptoms consistent Culture and cold agglutinin testing not recommended Recommend using PCR, combined IgG-IgM assays or IgM assay
No widely used available and timely test exists for the diagnosis of C. pneumoniae
Not recommended as false positives are common and may reflect colonization
Viral Testing:
CBC Degree of WBC elevation does not distinguish bacterial from viral infection ESR, CRP, procalcitonin Cannot be used as a sole determinant to distinguish bacterial from viral pneumonia May be helpful in monitoring clinical response in patients with serious or complicated disease
CXR: Rarely affected decisions regarding hospitalization For experienced physicians, CXR supported the diagnosis of PNA in 92% of cases Should be obtained when empyema or effusion is suspected Follow up CXR not indicated in children who have fully recovered
Outpatient Antibiotics
Presumed Bacterial Amoxicillin (90mg/kg/d divided BIDTID) Alt: Augmentin Amoxicillin (90mg/kg/d divided BIDTID) Alt: Augmentin Presumed Atypical Azithromycin Presumed Influenza Oseltamivir
>5 years
Azithromycin
Oseltamivir or zanamivir
Inpatient Antibiotics
Presumed Bacterial Presumed Atypical Presumed Influenza
Fully Immunized
Treatment Duration
Most studies have used a standard 10 day treatment course Shorter courses (3-7 days) are being tested CA-MRSA may require longer require longer treatment courses Complicated pneumonias may require 4-6 weeks of therapy
Moderate: >10mm rim on fluid Large: opacifies more than half of the hemithorax
Low to moderate
High
Management of pneumonia with parapneumonic effusion; abx, antibiotics; CT, computed tomography; dx, diagnosis; IV, intravenous; US, ultrasound; VATS, video-assisted thoracoscopic surgery.
Effusion progressed, did not qualify for VATS Pigtail catheter placed by IR on hospital day #2 Continued to have fevers, hypoxia and stalled CRP CT scan done hospital day #4 revealed complicated right-sided pneumonia with areas of necrosis and pneumatocele formation and complicated moderate sized empyema VATS procedure on hospital day #5 with placement of two chest tubes Discharged home on IV abx on hospital day #10 Transitioned to oral abx for another 2 weeks (total 6 weeks of abx)
Utah saw a modest decrease in invasice pneumococcal disease after PCV7 introduction PNP has been increasing in Utah since 2001 Cases were associated with nonvaccine pneumococcal serotypes, especially type 3
PCV13 (S. pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F )
4 dose series at 2, 4, 6 and 12-15 months Healthy children 7-59 months (not previously vaccinated with PCV7 or PCV13) should receive 1-3 doses Children 24-71 months with underlying medical conditions should receive 2 doses of PCV 13 Healthy children 24-59 months should receive 1 dose
PPSV23 (S. pneumoniae: 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19A, 19F, 20, 22F, 23F, and 33F)
Children aged 2 and above with chronic heart disease, chronic lung disease, DM, CSF leaks, cochlear implants, sickle cell and other hemoglobinopathies, congenital or acquired asplenia, HIV, chronic renal failure or nephrotic syndrome, immunosuppression, congenital immunodeficiencies
References
Bradley et al. The management of communityacquired pneumonia in infants and children older than 3 months of age: Clinical practice guidelines by the Pediatric Infectious Disease Society and the Infectious Disease Society of America. Clin Infect Dis. 2011;53:617-30. Michelow et al. Epidemiology and clinical characteristics of community acquired pneumonia in hospitalized children. Pediatrics. 2004;113:701-7. Bender et al. Pneumococcal Necrotizing Pneumonia in Utah: Does Serotype Matter? Clin Infect Dis. 2008;46:1346-1352.