Case report #1

Addis Ababa University

Medical Faculty

Department of Pediatrics and Child Health

Submitted to: [Link]

Name: Alferid Abrar

ID NO: MDR/3430/02
TIKUR ANBESSA HOSPITAL

Identification:
Name: Lensa Fufa Age: 12 yrs sex: female Education: 7th grade

Mother : Etenesh Alemu Age: 51 yrs occupation: house-wife Education: literate

Father : Fufa Guta Age: 55 yrs occupation: Auditor Education:literate

Address: Burayu,oromia Religion: Christian Orthodox

Date of admission: November 05, 2012 GC Bed #: 47/3

Date of clerking: November 12, 2012 GC Yekatit XII Hospital

Department Of Pediatrics and Child Health

Historian:
The Father, without language barrier.

Previous admission:
None

Chief Complaint
Shortness of breath of 2 weeks duration.

HPI
This is a 12 years old female known RVI patient for the last 2 years, who is not on ART. She was relatively
well until 2 weeks ago at which time she developed shortness of breath. It started gradually. It initially
was apparent during playing & later it became evident when she was just walking around the house.
Worsening in the following days, it prevented her from going to school.

She also has history of cough which began insidiously and got worsened in the past 2 weeks. It is of dry
kind of cough, with occasional thick whitish sputum which is odorless and less than half coffee cup per
day. This exacerbates while exposed to cold environment, but with no relation to time and relieved
upon taking unspecified cough syrup. There is stabbing chest pain associated with coughing at middle
part of the chest with no radiation and relieved while not coughing.
There is history of rapid shallow breathing and easy fatigability and she has also intermittent mild fever
which happens whenever there is cough, associated with global headache, but with no sweating, it’s is
relieved by taking paracetamol.

She also has developed multiple dark rashes over the whole body.

She has also lost her apetite and lost unquantified but significant amount of weight from previous
measured weight of 26.5kg.

Previously she was advised to take HAART which her family didn’t allow her to take, she also started to
take cotrimoxazole but after taking for few days her family discontinoued it purposely. She is not
informed of her sero status.

Her family immediately took her to a near by clinic and was told to have typhoid and was given
unspecified IM medication for 5 days. Though Anan didn’t show any improvements, so she was taken to
[Link] hospital and because there was no space she was refered to Tikur Anbessa Hospital.

Otherwise she has no history of palpitations, orthopnea, PND, syncope or leg swelling. There is no
history of nausea, vomiting and abnormal bowel habits. There is no history of contact with chronic
cougher. There is no history of Runny nose, hoarseness of voice. There is no history of mouth ulceration,
difficulty of swallowing, yellowish discoloration of the eyes. There is no history of flank pain and other
urinary complaints including reddish discoloration of urine, urgency, hesitancy or change in amount.
There is no personal and family history of hypertension, DM and known cardiac illness.

She came to the hospital walking supported by her family.

Past medical History

She has no history of childhood diseases like measles, pertussis, mumps or chicken pox

Family history
The mother is a housewife and her father works as an auditor. She lives in a middle income family. Both
her father and mother are sero positive, they knew it 4 years ago and her father has started ART 3 years
back but her mother haven’t started yet. She has 2 older brothers 20 and 18 years old who never tested
for their sero status. They have adequate and clean water supply and live in adequate 4 room house.

Immunization
The patient is immunized according to the EPI, inferred from age at immunization.
Nutritional History
She was exclusively breast fed until 6th months. she was breast fed until the age of 2 and a half
years. She received complementary feeds like cow milk and injera. She was exposed to
adequate direct sunlight. She has grown up eating injera her entire life.

Developmental History
She was able to sit up at 6 months. She started to walk at 12 months and started to call her father and
mother names by 13 months. She is an active child and has got many friends, and plays well with her
peers. She is grade 7 average student in her class.

Review of systems

HEENT: -
Head - No history of head injury.
Eyes - No history of discharge, eye redness or blurred vision
Ears- No history of ear aches, discharges, or hearing loss
Nose- No history of epistaxis, stuffy or runny nose or persistent sneezing
Mouth- No history of ulcerations, bleeding gums, dental carries
Throat- No history of hoarseness of voice, or difficulty of swallowing, please refer to HPI
RS: - mentioned on the HPI
CVS: - mentioned on the HPI
GIS: - mentioned on the HPI
GUS: - mentioned on the HPI
IS: , mentioned on the HPI
MSS: - Mentioned on the HPI
CNS: - No history of paralysis, numbness, urine incontinence, headaches, seizures, speech
defects

Physical examination
General appearance:
The patient is on nasal O2 supply and NG tube. She is acutely sick looking. She is on respiratory
distress(flaring of ala nasae, and with use of accessory muscles).she is cyanosed but with no
gross deformities. She is awake and alert.
Vital signs:
Blood pressure: 120/90 mmHg right arm, supine,
Systolic- 120-between 75th and 80th percentile.
Diastolic- 90-above 95th percentile.
Respiratory rate: 40 breathes /min,regular tachypenic
Pulse rate: 124 beats /min (right radial artery),regular, tachycardic
Temperature: 38.2⁰c, axillary hyperthermia
O2 saturation: 84% with oxygen hypoxic

Anthropometry
Weight: 26.5kg Weight for age: less than 3rd percentile on NCHS curve: Underweight
Height: 147cm Height for age: between 25 and 50th percentile on NCHS curve: appropriate
for age.
Head Circumference:53cm on the mean: appropriate for age.
MUAC: 15cm : on the mean : appropriate for age.

H.E.E.N.T
Head: No skull deformity, no areas of tenderness, normal hair distribution.
` Ears: No low set ears or any discharge. No swelling or tenderness of the mastoid
process.
Eyes: The conjunctivae are pink. The sclera is white and non icteric, the pupils are
normal and equal in size. No periorbital edema, ptosis, strabismus, or nystagmus.
Nose:The nasal septum is not deviated. The nostrils are patent. There is no tenderness
over maxillary and frontal sinus. There is no discharge.
Mouse and throat: The breath has no bad odor. No Oral trush & mouth ulceration..
cyanosis of lips and the tongue. No cleft lip or palate. No tooth caries.

Lymphoglandular System
No swelling on the neck. No palpable lymph nodes in all accessible areas.
Respiratory system
Inspection:
Tachypnic with shallow breathing, intercostal retraction, flaring of ala nasae, central and
peripheral cyanosis present, moderate clubbing is also present. Symetrical chest [Link]
chest deformities

Palpation—chest expansion is 7mm,no area of tenderness or subcutaneous creptation.

centrally placed trachea. Tactile fremitus decreased on right lower 1/3 rd lung field.

Percussion—resonant percussion note all over the lung fields except dullness on the right
1/[Link] excursion is 2cm.
Auscultation—decreased air entry over right lower 1/3rd and bronchial breath sound on right
middle lung field other wise vesicular breath sounds on the other lung [Link] are bilateral
coarse creptations. No wheeze,stridor or pleural friction rub.

Cardiovascular system
Inspection: There is no bluish discoloration of lips, tongue and hands.
Arteries: radial, femoral, carotid, and dorsalispedis arteries were palpable.
Precordium:
Inspection: no precordial bulge. The precordium is Quiet. The apical impulse is not
visible.
Palpation: The point of maximum impulse is felt in the 4 th intercostal space 3
centimeters lateral from the midline and is localized. There is a no parasternal
heave, apical heave or thrill.
Auscultation: S1 and S2 are appreciated. There are no murmurs or additional
heart sounds.

Gastrointestinal system
Inspection: The abdomen is symmetrically flat and moves with respiration. There are no visible
dilated veins, scars or masses. Hernia sites are free. The umbilicus is inverted. There is no visible
peristalsis.
Auscultation: The bowel sound is normo-active. There is no bruit over renal artery, abdominal
aorta or liver areas. No friction rub over the liver & spleen areas.
Palpation:
Superficial: No muscle spasm, tenderness, or superficially palpable mass.
 Deep: The spleen and liver are not palpable . There is no deep mass or tendernes. The
kidneys are not bimanually palpable.

Percussion: No shifting dullness. No flank dullness. The total vertical span of the liver couldn’t
be accessed because of the dullness over the right lung field.

Genitourinary system
No suprapubic mass or tenderness. There is no costo-vertebral tenderness.

Musculoskeletal system
No bone deformities. No joint tenderness, swelling or limitation of movement. No bone
fracture or dislocations. No muscle weakness.

Integumentary system
There are hypo and hyper pigmentd brown to black lesions all over the skin. There is no pallor
in the palms and soles. The skin is warm. There is no edema.

Hair: normal distribution, dark color, soft texture, shiny and thick

CNS
Mental Status: The patient is conscious, oriented in person, place and time. Her memory status
was good.
Cranial Nerves:
N-I: she can identify the smell of alcohol using each nostril.
N-II: Normal visual acuity, good visual fields and color appreciation
N-III, IV & VI: The eyes can move in all directions. There is no nystagmus. The pupils are round
and regular in outline.
N-V: she responded to light touch. Forceful contraction of the temporal and masseter muscles
N-VII: The face is symmetrical at rest, and during voluntary movement. Intact naso-labial folds.
N-VIII: Hears ticking of watch bilaterally
N-IX & X: Soft palate rises in the midline when saying ‘ah’. Uvula is central.
N-XI: There is turning of head and shrugging of shoulders against resistance.
N-XII: No deviation of the tongue. There is also no fasciculation or atrophy.
Motor Function:
Muscle bulk has symmetrically decreased. There is no spontaneous as well as induced
fasciculation. No involuntary movements. The extremities are norm-tonic. Muscle power is 5/5
in all extremities.
Deep tendon reflexes: All biceps, triceps, brachioradialis, knee and ankle reflexes are 2/4
Superficial reflexes: plantar reflex is down-going, abdominal reflex is intact.
Sensory:
Sensation of light touch, pain and position are intact.
Co-ordination
No abnormal gait or ataxia. Rapid alternating , finger to nose and heel to sheen movements are
intact.
Meningeal irritation signs
No neck stiffness, Negative Brudzinski’s and Kernig’s signs

Summary

Subjective
 12yrs old female child
 RVI positive
 Dyspnea of 2 weeks duration
 Productive cough
 Mild fever
 Rapid breathing and easy fatigue
 Loss of appetite and weight loss
Objective
 Acutely sick looking
 Tachypenic
 Tachycardic
 Hypoxic
 Underweight
 Hyperthermic
 Oral trush
 Peripheral and central cyanosis
 Clubbing
 Use of accessory muscles
 Flaring of ala nasae
 Decreased tactile fremitus, dullness and decreased air entry over the right lower 1/3 rd lung field.
 Bronchial breath sound over the right middle lung field.

Differential diagnosis
 Stage 4 pediatrics AIDS with
[Link]
[Link] Pneumonia
[Link] TB
[Link]

Discussion of Differential Diagnosis

[Link]
LIP is the most common chronic lower respiratory tract abnormality, historically occurring in
approximately 25% of HIV-infected children. LIP is a chronic process with nodular lymphoid hyperplasia
in the bronchial and bronchiolar epithelium, often leading to progressive alveolar capillary block over
months to years. It has a characteristic chronic diffuse reticulonodular pattern on chest radiography
rarely accompanied by hilar lymphadenopathy, which allows a presumptive diagnosis to be made
radiographically before the onset of symptoms. There is an insidious onset of tachypnea, cough, and
mild to moderate hypoxemia with normal auscultatory findings or minimal rales. Progressive disease
may be accompanied by digital clubbing and symptomatic hypoxemia. Several studies suggest that LIP is
associated with a primary Epstein-Barr virus infection in the setting of HIV infection.

The age and serostatus of this patient and presence of tachypnea,dyspnea,cough,hypoxemia,clubbing

and rales on history and physical examination support the diagnosis. but the short duration of the
disease is highly against the course of disease which is insidious onset and chronic.

[Link] TB

95% of tuberculosis cases occur in developing countries where HIV/AIDS epidemics have had
the greatest impact, and where resources are often unavailable for proper identification and
treatment of these diseases. The World Health Organization (WHO) estimates that >8 million
new cases of tuberculosis occur and approximately 3 million people die of the disease worldwide
each year. Almost 1.3 million cases and 450,000 deaths occur in children each year. More than ⅓
of the world's population is infected with Mycobacterium tuberculosis.

Common symptoms of pulmonary tuberculosis in children include chronic, unremitting cough

that is not improving and has been present for more than three weeks, fever of more than 38ºC
for at least two weeks, other common causes having been excluded,weight loss or failure to
thrive. However the symptoms are non specific. Physical exam findings may suggest the
presence of a lower respiratory infection, but there are no specific clinical signs or findings to
confirm that pulmonary tuberculosis is the cause.

The age of the patient and her serostatus, and the prevalence of TB in pediatrics AIDS patients
with the additions of respiratory symptoms including dyspnea, cough, weight loss and loss of
appetite and fever may support TB. However the short duration of the symptoms strongly
contradicts TB which is a chronic disease. Also she has no contact with chronic cougher The
physical findings might support TB which doesn’t have specific signs as such.. So pulmonary TB
is a probable diagnosis.

[Link] pneumonia
Childhood pneumonia is an important cause of morbidity in the developed world, and morbidity and
mortality in the developing world. [Link] is the most common [Link]’s most common cause
of respiratory infection in HIV patients. No single symptom or sign is pathognomonic for pneumonia in
children. Symptoms and signs of pneumonia may be subtle, particularly in infants and young children.
The combination of fever and cough is suggestive of pneumonia; other respiratory findings (eg,
tachypnea, increased work of breathing) may precede cough. Cough may not be a feature initially since
the alveoli have few cough receptors. Cough begins when the products of infection irritate cough
receptors in the airways. The longer fever, cough, and respiratory findings are present, the greater the
likelihood of pneumonia. Finding of tachypnea, signs of respiratory distress, creptations decreased breath
sounds Bronchial breath sounds, egophony, bronchophony, Whispered pectoriloquy and dullness to
percussion are some of the signs.
The Epidemology of the disease in our country and in AIDS patients, and the presence of signs of
pneumonia including Fever,cough,Dyspnea,chest pain plus the short duration of the symptoms are
highly suggestive of pneumonia. In addition the physical examination findings starting from the
deranged vital signs(elevated Temprature,tachypnea) and presence of cyanosis,accessory muscle
usage,respiratory system findings including decreased tactile fremitus,dullness to percussion,decreased
air entry and bilateral creptations support pneumonia. But the fact that the cough is not productive,and
fever is of low grade may not support our [Link] this differential is so likely, so we have to do
investigations to rule out this disease.

[Link] Pneumonia(PCP)

Pneumocystis jirovecii pneumonia (PCP) accounts for approximately one-half of all AIDS-defining
conditions diagnosed during the first year of life. The median age at diagnosis of PCP in children is five
[Link] develops in individuals with CD4 counts <200 cells/microL, CD4 percent <15, or in patients
with poor virologic control. In infants, PCP can develop with CD4 counts >200 cells/microL.

PCP should be suspected in patients with low-grade fever, tachypnea, nonproductive

cough(some times can be productive of scanty sputum), and progressive shortness of breath. The onset
of symptoms may be insidious, with nonspecific symptoms of mild cough, dyspnea, poor feeding,
diarrhea, and weight loss. On physical examination, lung auscultation may be normal even in the
presence of severe clinical disease and hypoxemia; rales and rhonchi may not become apparent until
late in the clinical course.

In this patient,she is presenting mainly with shortness of breath which is major complaint of children
with PCP, and the fact that she has dry cough,tachypnea,low grade fever,weight loss are all very
consistent with this disease entity. Also the physical findings of creptations all over the lung field and
signs of pleural effusion can also be complications of PCP.

This patient seems to have oropharyngeal candidiasis, finger nail fungal infections, and pneumocystis
pneumonia. And the presence of Pneumocystis pneumonia makes it Stage 4.

Investigations
 CBC with differentials…. Check for anemia, infection
 CD4+ count
 Chest X-ray
 Blood culture
 Sputum culture
 Urine analysis
 Pulmonary function test
 Lung biopsy—to diagnose LIP

Final Diagnostic impression

 Stage 4 Pediatrics AIDS + Pneumocystis pneumonia with superimposed fungal

infection(candidiasis)