SC1 PAEDIATRICS CASE REPORT

NAME: Thatchiayani A/P Sweneson

ID NUMBER: 14923343

REPORT: Case Report 1

Presenting Complaint

My patient MZ, a 6 month old Malay boy brought in by his mother to Accident and Emergency
Department of Hospital Tuanku Jaafar Seremban (HTJS) on 16th of April 2018 complaining of 6 days
history of fever and cough and 1 day history of shortness of breathing.

History of Presenting Complaint

He had insidious onset of high grade fever, which was intermittent in pattern for 6 days. There was
no aggravating and relieving factors. Fever was associated with non-productive chesty cough with no
diurnal variation. There was no history of barking cough or prolonged bouts of cough.

Patient also had shortness of breath 1 day prior to admission which was insidious in onset,
progressively worsening and was aggravated by cough. He also had clear nasal discharge. However,
no bluish discolouration or wheezing were noted.

He also had poor feeding. He usually takes 5 ounces of milk 5-6 times per day, but only taking 2-3
times now. He is less active at home. His urine output also has reduced. Otherwise, there is no rash,
vomiting and diarrhoea. There is no history of sick contact, antibiotic exposure and recent travelling.
No seizure, ear or eye discharge, cloudy or foul smelling urine. Not from dengue prone area or had
recent fogging. This is the first episode.

Past Medical and Surgical History

He has underlying eczema diagnosed at the age of 3 months old. He has no allergic rhinitis. This is his
second admission to hospital. First admission was for his neonatal jaundice. He was admitted in sick
care nursery HTJS for a week for phototherapy. There is no past surgical history.

Birth history

He was born at 39 weeks of gestation via spontaneous vaginal delivery in HTJS. The mother had
anaemia during pregnancy and was on Obimin tablets. There was no intrapartum and postpartum
complications. His birth weight was 2.89kg and his Apgar score was 8 in 1 minutes and 9 in 5
minutes. He has been exclusively breastfed till now. He has not weaned yet.

Development and Growth

Gross motor : sits without support, able to roll over

Fine motor / vision : mouth objects, transfers objects, has palmar grasp

Hearing / speech : says vowels and syllables

Personal / social : laughs and screams

His developmental age is 6 months which corresponds to her age that is 6 month old. Some of the
key past milestones are sits momentarily, transfers objects, shows likes and dislikes, and babbles.
Immunizations

He took immunization up to 5 months. His last immunization was pentavalent vaccine. He did not
get any optional vaccine from any private sector.

Medications and Allergies

He is currently on syrup paracetamol, co-amoxiclav, normal saline nasal drop, oxygen supply,
nebulised salbutamol and aqueous cream for eczema. He has no known drug or food allergy. No
history of traditional medication.

Family History

Father is a 34 year old businessman. Mother, 29 year old manager of a convenient store. Both
parents have no known medical illness. It was not a consanguineous marriage. There is no known
genetic disorder running in the family. No family history of asthma and atopic disorders such as
eczema and allergic rhinitis.

Social History

He is the third child out of 3 siblings. He has a 5 years old and 4 years old elder brothers. They live in
Ampangan. 6 occupants in the house including maternal uncle. Maternal uncle is a smoker. But he
smokes outside the house. No pets or carpets at home.

34y 29y

5y 4y 6m

Summary

MZ, a 6 month old Malay boy with underlying eczema presented with 6 days history of high grade
fever and cough and 1 day history of shortness of breath which is not associated with wheezing and
cyanosis.
Physical examination

Vital signs Heart rate : 160 beats/min

Respiratory rate : 52 breaths/min
Temperature : 39.0˚C
Blood pressure : 84/47 mmHg
SpO2 : 98%

Anthropometry Height : 68cm (50th-75th centile)

Weight : 7kg (10th-25th centile)
There was no past records to be compared

General examination Alert, comfortable, pink

Has rashes over cheeks, neck and hand
Has subcostal recession
But no nasal flaring, grunting, use of accessory muscle, head nodding and
Harrison sulcus
No noisy breathing such as wheeze and stridor
Not connected to any medical devices such as IV cannula, nasal prong,
inhaler and pulse oximetry

Hands :
No pallor of palmar creases, no peripheral cyanosis
Good pulse volume and warm peripheries
Capillary refill time : < 2 seconds

Face :
No conjunctival and oral mucosal pallor
No central cyanosis

Respiratory Inspection : symmetrical movement of chest with respiration, no skeletal

examination abnormality, no scars
Palpation : trachea was in midline, apex beat was at left 5th intercostal
space at midclavicular line
Percussion : dullness over right middle lobe and left lower lobe
Auscultation : bronchial breathing, generalised rhonchi heard

Investigations

Full blood count
White cell count : 12.79 ( 4 - 11.7 x 109/L ) High
Lymphocyte : 51.1 ( 10.8 - 45.4% ) High
Haemoglobin : 11.9 ( 8.8 - 16.5g/dL )
Platelet : 319 ( 97 - 390 x 109/L )
Haematocrit : 33.61 ( 26.10 - 49.60% )
MCV : 70.7 ( 76.4 - 102.0 fL ) Low

Chest X-ray Perihilar haziness

 Nasopharyngeal aspirate Positive for Parainfluenza 1
immunofluorescence (NPAIF)
Blood culture + sensitivity No growth seen

Treatments

Nasopharyngeal oxygen 2L/min

Syrup paracetamol 40mg 4 hourly

Normal saline nasal drop 1/1 tds

Nebuliser salbutamol 1.1mg 4 hourly

Amoxicillin clavulanic acid 140mg IV tds x5/7

Aqueous cream local application

Differential diagnosis

In favour Against (absence of)

Pneumonia Fever, tachypnea, cough, Coarse crepitation, dullness to percussion
difficulty feeding and
breathing
Subcostal recession, rhonchi,
bronchial breathing

Bronchial asthma Cough, shortness of breath Recurrent episodes of shortness of breath,

Subcostal recession, rhonchi chest tightness, wheeze, family history of
asthma and atopic disorders
Hyperinflation of the chest, prolonged
expiration, crepitation

Acute bronchiolitis <1 year, low grade fever, Vomiting after feeding, irritable,
cough, feeding less, fewer wet Hyperinflation of the chest, prolonged
nappies, shortness of breath expiration, crepitation
Subcostal recession

Tuberculosis Cough, fever History of contact with TB patient, poor

growth, weight loss, night sweats
Lymphadenopathy
Mantoux test : positive
CXR : primary complex or miliary TB

Croup Fever, barking cough, Inspiratory stridor, hoarseness of voice,

shortness of breath cyanosis
Subcostal recession CXR : steeple sign

Diagnosis : Viral pneumonia

Discussion

Pneumonia, defined as inflammation of the lung parenchyma, is the leading cause of death globally
among children younger than age 5 year.1

Based on investigation, it was established that pneumonia in my patient is caused by Parainfluenza 1

virus. In this age group, that is 6 months old, the common causative agents are respiratory syncytial
virus (RSV), other respiratory viruses (rhinoviruses, parainfluenza viruses, influenza viruses,
adenovirus), S. pneumoniae, H. influenza. Chlamydia trachomatis is considered in afebrile patient.1

Pneumonia is frequently preceded by several days of symptoms of an upper respiratory tract

infection, typically rhinitis and cough.1 Tachypnea being the most consistent clinical manifestation of
pneumonia and it was the chief complaint of my patient who also presented with subcostal
recession indicating increased work of breathing.

On examination, crackles on auscultation are classical, and bronchial breathing is a late sign
indicating consolidation.2 In my patient, generalised rhonchi was noted, most probably it was
partially resolved by the time I conducted the examination. Diagnosis of Recurrent

According to the criteria for hospitalization for pneumonia, my patient fulfilled the following criteria;
infants younger than 6 months of age; dehydration, or inability to maintain hydration orally; inability
to feed in an infant; retractions and difficulty breathing.3

The diagnosis of viral pneumonia is done by viral antigen assays which provide rapid results but
often have limited sensitivity (e.g. influenza A rapid antigen assays have ~65% sensitivity).4 The new
generation of rapid immunoassay tests are significantly better which was done in my patient. Chest
X-rays (CXR) do not reliably distinguish between bacterial and viral pneumonias, although interstitial
shadowing or peribronchial infiltrates are said to be more characteristic of a viral infection and lobar
consolidation of pneumococcal disease.2 Perihilar haziness seen on the CXR of my patient suggests
viral pneumonia.

Since it is often difficult to distinguish pneumonia caused by Human Parainfluenza Virus (HPIV) from
pneumonia caused by bacteria, patients with viral pneumonia are sometimes inappropriately
treated with antibacterial antibiotics. In the setting of HPIV infection, antibiotics are used only if
bacterial complications such as otitis and sinusitis develop.5 However, my patient was started on
broad-spectrum antibiotic therapy though no complications were noted in my patient. Other
complications that could arise from pneumonia include parapneumonic effusions and empyema.1
Rare complications of hematologic spread include meningitis, suppurative arthritis, and
osteomyelitis.1

Besides, supportive care was given to my patient in addition to pharmacological treatment. Thick
secretions at the throat was removed by gentle suction, which my 6 month old patient could not
expectorate. Chest physiotherapy also given to assist in the removal of tracheobronchial secretions.
Fever was relieved by syrup paracetamol in my patient. He also received daily maintenance fluids
appropriate for his body weight. Furthermore, breastfeeding and oral fluids were encouraged. Nasal
prong was used for oxygen delivery as it the preferred method in young infants.

My patient can be discharged when he fulfils the following criteria; resolved respiratory distress; no
hypoxaemia (oxygen saturation > 90%); feeding well; able to take oral medication or have completed
a course of antibiotics. Parents should be counselled on signs and symptoms of pneumonia, and the
complications that could arise before discharging the patient.3
Aside from avoiding infectious contacts (difficult for many families who use daycare facilities),
vaccination is the primary mode of preventing respiratory tract infection. Influenza vaccine is
recommended for children aged 6 months and older. The pneumococcal conjugate vaccine (PCV13)
is recommended for all children younger than 5 years old. The 23-valent polysaccharide vaccine
(PPV23) is recommended for children 24 months or older who are at high risk of pneumococcal
disease. However, all these vaccines are optional and not provided by government hospital.

References :

1. Nelson Textbook of Paediatrics, 20th Edition, Volume 1, Community-Acquired Pneumonia pg

2088-93
2. Forfar & Arneil’s Textbook of Paediatrics, 7th Edition, Pneumonia pg 720-723
3. UpToDate - Pneumonia in children: Inpatient treatment
4. Pittsburgh Lung Conference: Pneumonia - Treatment and Diagnosis
5. Medscape - Parainfluenza Virus Treatment & Management. Available from :
https://emedicine.medscape.com/article/224708-treatment