/

General Data
Name:
Birth day: 85/04/24
Age: 6 y/o
Chart number: 15213493
Admission day: 91/05/03
Discharge day: 91/05/20
BW: 22 Kg
Chief Complaint
Fever off and on for 8 days
Present Illness
A 6 year-old boy suffered from fever off
and on for 8 days. He also complained of
cough, rhinorrhea and difficult to
expectorate sputum. He was taken to LMD
twice and our OPD on 91/04/30, but the
symptoms persisted in spite of drugs use.
So he was taken to our OPD again on
91/05/03. Physical examination revealed
decreased breathing sound on right chest.
CXR showed lobar pneumonia.
Brief history
Birth Hx: GA: 39 Wks, BBW:3050 gm, NSD
Previous admission: Denied
Vaccination: As schedule
Allergy Hx: Denied
Food exposure: Denied
Drug exposure: Denied
Recent travel: Denied
Family Hx: Non-contributory
Physical Examination:
Vital sign: BT 39.9, PR:120 bpm, RR 32/min
General appearance: Acute-ill looking
HEENT: No gross anomaly
Conjunctiva: not injected
Throat: mild injection
Chest: Symmetric expansion
Retraction: no
decreased breathing sound: right lung,
fine moist rales(+)
percussion: dullness of right chest

CBC/DC
5/3 5/7
WBC 9100 10110
Hgb 11.9 10.6
Hct 32.9 29.7
MCV 72.6 75.2
PLT
190000 206000
Neut 92.3 89.5
Lym 3.3% 5.5%
Mono 2.3% 1.6%
Eos 0.3% 0.5%
Urinalysis
5/3 5/4
Appearance Y-CLEAR Y-CLEAR
SP. Gr. 1.010 1.015
PH 6.0 6.0
Protein 1+ 1+
Glucose - -
OB - -
Bilirubin - -
Nitrate - -
RBC 0-2 8-10
WBC 4-6 40-50
Bacteria + +
Biochemistry
Glu BUN Cr AST ALT Na K
5/3 94 6.0 0.5 117 39 125 4.5
5/4 129
5/7 93 3.0 0.5 85 179 137 4.0
Blood culture

5/3 NO GROWTH
5/7 NO GROWTH

Urine culture
5/5 NO GROWTH

Serology
CRP
5/4 163 mg/l
5/7 126 mg/l

Mycoplasma Pneumoniae Antibody
5/4 NEGATIVE

Hospital Course (I)
Initially (5/3), empiric antibiotics with
Cefuroxime 500mg IV q6h and
Erythromycin 250mg PO q6h were used,
but intermittent high fever up to 39C was
still noted.
Gentamicin was added on 5/4 due to
pyuria of urinalysis and suspected UTI

Hospital Course (II)
On 5/5, multiple fine, discrete, rubella-like
skin rashes developed on the face, trunk
and extremities with itchy sensation.
Vena infusion and Sinbaby lotion were
used for symptom relief.
Serology
5/7 IgA 126 (70-400)
IgM 105 (40-230)
IgG 778 (700-1600)

5/8 Measles IgM (-)
Rubella IgM (-)
Hospital Course (III)
On 5/7, followed CXR showed massive
amount of pleural effusion, right lung. So
we do chest CT, and erythromycin was
changed to 220mg IV q6h

On 5/8, thoracocentasis was done and
showed exudate effusion. So we do chest
tube insertion. About 200ml of yellow-
reddish fluid was drained.
Chest CT
Date 91/05/07
Impression:
Consolidation of right lower lobe
and medial segment of middle lobe,
pneumonia is likely. Moderate amount
of right pleural effusion and scanty
amount of left pleural effusion.
Abdominal echo
Date 91/05/07
Ultrasonic Impression:
Negative finding of abdominal
ultrasonography
Pleural Effusion Study (I)

5/8 Pleural fluid
Appearance cloudy
Color reddish-yellow
Bloody (+)
Chylous (-)
Coagulation (+)
Sp. Gr. 1.025


Pleural Effusion Study (II)

WBC 630 cumm
Polynuclear cells 55.0%
Mononuclear cells 45.0%
Abnormal cells (-)
Pleural, Acid-Fast Stain: Not Found
Pleural, Grams Stain: Not Found
Pleural Effusion Study (III)
Pleural Effusion
Glucose 71 mg/dl
LDH 3149 IU/L (H)
Protein 3.30 g/dl (L)


Pleural Effusion Study (IV)

Pleural effusion culture
on 5/8 no growth
on 5/13 no growth
Pleural Effusion Study (V)

5/8 Pleural effusion cytology:
No evidence of malignancy
5/14 Pleural PCR assay for mycobacteria
result: Negative

Hospital Course (IV)
On 5/10, followed CBC/DC showed
leukocytosis with left shift (WBC 19570,
Neu 92.9%). Persistent high fever was
noted. So Cefuroxime was changed to
Ceftriaxone 1g IV q12h
High fever up to 40C persisted in spite of
Ceftriaxone + Gentamicin + Erythromycin
combined use

CBC/DC
5/3 5/7 5/10 5/13 5/15
WBC 9100 10110 19570 26450 12270
Hgb 11.9 10.6 8.8 8.4 8.9
Hct 32.9 29.7 25.2 24.2 25.1
MCV 72.6 75.2 85.7 76.2 74.1
PLT
190000 206000 378000 551000 707000
Neut 92.3 89.5 92.9 92.8 87.1
Lym 3.3% 5.5% 4.2% 3.5% 6.9%
Mono 2.3% 1.6% 2.2% 1.9% 2.6%
Eos 0.3% 0.5% 0.4% 0.8% 1.8%
Urinalysis
5/3 5/4 5/11 5/14
Appearance Y-CLEAR Y-CLEAR Y-CLEAR Y-CLEAR
SP. Gr. 1.010 1.015 1.010 1.020
PH 6.0 6.0 5.0 6.5
Protein 1+ 1+ - -
Glucose - - - -
OB - - - -
Bilirubin - - - -
Nitrate - - - -
RBC 0-2 8-10 0-2 0-1
WBC 4-6 40-50 0-2 8-10
Bacteria + + -- --
Biochemistry
Glu BUN Cr AST ALT Na K Alb
5/3 94 6.0 0.5 117 39 125 4.5
5/4 129
5/7 93 3.0 0.5 85 179 137 4.0
5/9 5.0 0.4 46 99 131 5.2
5/11 136 3.0
5/14 11.2 0.4 85 175
5/16 71 146 3.5
Blood culture

5/3 NO GROWTH
5/7 NO GROWTH
5/11 NO GROWTH
Urine culture
5/5 NO GROWTH
5/10 NO GROWTH
5/12 NO GROWTH

Serology (I)
CRP
5/4 163 mg/l
5/7 126 mg/l
5/14 113 mg/l
Serology (II)
5/13 Direct Coombs test: positive
Indirect Coombs test: positive
5/14 RA< 10.2 IU/ML (<40.0)
C3 166.0 mg/dl (90.0-180.0)
C4 21.4 mg/dl (10.0- 40.0)
Serology (III)
5/14 Heterophil Ab: Negative
ANA Negative
5/14 Legionella Ab: Negative
Chlamydia Ab: Negative


Ga-67 Inflammation Survey
Date 91/05/15
A patch of abnormal tracer uptake at
the right lower lung field, may be
inflammatory focus.
Diffusely increase uptake of liver. This
phenomenon can be found in iron
deficiency anemia
Serology (I)
Mycoplasma Pneumoniae Antibody
5/4 Negative
5/7 160X
5/14 320X
Pleural Effusion Study (II)
5/8 Pleural fluid for Mycoplasmal
pneumonia antibody: 80X


Serology (III)

5/16 Cold hemaglutination: 512 X (<32X)


Hospital Course (V)
Chest tube was removed on 5/13
We used prednisolone (2mg/kg/day in 4
divided doses) on 5/14. Fever subsided on
the night of 5/14.
Steroid was tapered gradually
On 5/20, patient was discharged under
stable condition.

CBC/DC
5/3 5/7 5/10 5/13 5/15 5/23
WBC 9100 10110 19570 26450 12270 9780
Hgb 11.9 10.6 8.8 8.4 8.9 10.1
Hct 32.9 29.7 25.2 24.2 25.1 30.2
MCV 72.6 75.2 85.7 76.2 74.1 78.9
PLT
190000 206000 378000 551000 707000 377000
Neut 92.3 89.5 92.9 92.8 87.1 66.1
Lym 3.3% 5.5% 4.2% 3.5% 6.9% 22.3
Mono 2.3% 1.6% 2.2% 1.9% 2.6% 10.0
Eos 0.3% 0.5% 0.4% 0.8% 1.8% 1.0
Biochemistry
Glu BUN Cr AST ALT Na K Alb
5/3 94 6.0 0.5 117 39 125 4.5
5/4 129
5/7 93 3.0 0.5 85 179 137 4.0
5/9 5.0 0.4 46 99 131 5.2
5/11 136 3.0
5/14 11.2 0.4 85 175
5/16 71 146 3.5
5/23 21 30
Serology (I)
CRP
5/4 163 mg/l
5/7 126 mg/l
5/14 113 mg/l
5/30 5.2 mg/l
Final Diagnosis
Mycoplasmal lobar pneumonia,
complicated with prolonged
fever, skin rashes, right lung
pleural effusion, and hemolytic
anemia

Mycoplasma Pneumoniae
In 1944, M. pneumoniae was reported by
Monroe Eaton, originally called the Eaton
agent.

Smallest free-living microorganism,
belongs to the class Mollicutes.

Mycoplasmas lack a cell wall, so tend to
be pleomorphic.

Clinical Manifestations
M. pneumoniae causes approximately 20% of all
cases of pneumonia.

Peak incidence at 6-21 years of age.

Incubation period of 2-3 weeks.

Transmission by inhalation of infected droplet
aerosols.

Pneumonia is the most important clinical
manifestation of M. pneumoniae infection.

* Bronchopneumonia pattern mostly.
Lobar pneumonia and large amount
pleural fluid are unusual.
Pediat Radiol 1989;19(8):499-503

* Respiratory disease other than
pneumonia: unspecific URI, pharyngitis,
AOM, croup, sinusitis, bronchitis,
bronchiolitis, asthma.


Cutaneous manifestations : common.
* Exanthem and enanthem of Mycoplasma
pneumoniae infection are observed in 5 to
24% of cases
AAP, Report of Committee on Infectious Diseases, 1994:333-5

* Most common with an erythematous
maculopapular rash on the trunk and back;
discrete (rubelliform) or confluent
(morbilliform).

* Most serious presentation: Erythema
multiforme and Stevens-Johnson syndrome.
Clini Pediatrics 1991:30(1),42-9

Hematologic manifestations:
* Hemolytic anemia: usually mild,
however, it may become severe and
result in 50% reduction in hemoglobin
concentration.
Pediat Infec Dis J 1998;17(2):173-7

* Direct Coombs test usually positive.

* Steroid administration may be
beneficial.
South Med J 1990;83(9):1106-8

Hemolytic anemia is presumably
related to the presence of cold
agglutinins in serum which at high
concentration, may agglutinate
erythrocytes at 37

Rev Pneumol Clin 1990,46(2),83-4

Gastrointestinal findings are nonspecific with
nausea, vomiting, abdominal pain, and/or
diarrhea.

Neurologic disease association was reported
2.6-4.8%.
* Encephalitis, meningitis, transverse
myelitis, psychosis, Bell palsy and
Guillain-Barre` syndrome.

Arthritis in association with M.pneumoniae
infection have not been established.

Hepatitis was once thought to be
unusual, but recent studies suggest
that liver dysfunction may be present
in up to 30% of M. pneumoniae
infection.


Pediatr Pulmonol 1990;8:182-7

Liver dysfunction was observed
more frequently in patients with
pleuropneumonia than in simple
pneumonia cases.


Pediatr Pulmonol 1990;8:182-7

Radiographic Manifestation (I)
Interstitial infiltration was more commonly
seen in pediatric than adult patients (46% vs
20%)

Unilateral lesions 80%
Single lobe lesions 77%
Lower lobe predominant 69%
Pleural effusion 7%

1993;9(4):204-11
Radiographic Manifestation (II)
Unilateral infiltration 84%
Lower lobe predominance 60%
Confluent consolidation 56%
Patchy consolidation 33%
Pleural effusion 24%

1991;14(3):156-62
Diagnosis (I)
WBC, CRP, ESR are non-specific, may be
normal or elevated.
Growth of the organism takes weeks,
generally only in expertise laboratories.
PCR is sensitive and specific.
Serologic testing : Cold agglutinins, titer of
>1:64 is suggestive of infection; Anti-
mycoplasmal Ab detection, fourfold or
greater rise are considered diagnostic.
Diagnosis (II)

Imaging : Interstitial infiltrate or
bronchopneumonia pattern. Lobar
consolidation and pleural effusion are
uncommon but may occur.

Treatment

Erythromycin is the drug of choice.
(40-50mg/kg/24hr q6h for 10-14 days).
Newer macrolides:
Azithromycin (10mg/kg on day 1, and
5mg/kg/24hr on days 2-5) or
Clarithromycin (15mg/kg/24hr given in two
divided doses for 10 days).

Empiric Therapy for Lobar Pneumonia
Clinically moderate to severely toxic,
treat empirically for S. pneumonia, S.
pyogens ( and H. influenzae type b in
unimmunized children)

In toxic children, tests for Mycoplasma
should be considered because focal
pneumonia is a rare presentation
Cefuroxime intravenously, ceftriaxone
or cefotaxime intravenously
For anti-staphylococcal coverage, add
to the above, either: nafcillin, oxacillin,
or clindamycin
For Mycoplasma: intravenous
erythromycin or azithromycin; or oral
erythromycin, azithromycin, or
clarithromycin.
Pneumonia, with pleural fluid or empyema
Treat empirically for S. pneumonia, S.
pyogenes, and S. aureus ( and H.
influenzae type b in unimmunized children)

Consider aspiration pneumonia with
anaerobic oral flora as pathogens; needle
or catheter aspiration of pleural fluid, with
drainage, is often required for clinical cure.
Ceftriaxone or cefotaxime

For antistaphylococcal covarage, add to the
above either: nafcillin, oxacillin, or
clindamycin (also covers anaerobes found in
aspiration pneumonia as well as most
pneumoncocci)

Single agent therapy with meropenem, or
ticarcillin/clavulanate (Timentin) both of
which cover both aerobic and anaerobic
pathogens
Presence of pleuropneumonia
appears to be associated with
more severe and prolonged
course of illness


Pediatr Pulmonol 1990;8:182-7
Even in patients with clinically
mild pneumonia, Mycoplasma
pneumoniae may be the cause
of severe anemia

Ann of Hematol 2001;80(3):180-2
Association of exanthem and
pneumonia or of hemolytic
anemia and pneumonia are
considered to be strongly
suggestive for the diagnosis of M.
pneumonia infection

Clin Infec Dis 1993;17(Suppl 1):S47-51











THE END