CASE-WRITE UP ON PEDIATRIC PNEUMONIA.

PATIENT’S DEMOGRAPHICS.
Patient’s Name: Brave Mutumba.
Patient’s Age: 2 months plus 2 weeks.
Sex: Male
Date of birth: 10/8/2024
Address: Mitooma
Birth place: KIU Teaching Hospital
Nationality: Ugandan
Tribe: Muyankole
Name and relationship of the informant: Immaculate
Kyobutongi, the mother.
Date and time of the admission: 10th OCT 2024, at 2pm.
Date of clerkship: 10th OCT 2024.

PRESENTING COMPLAINTS.
 Difficulty in breathing for 1 day.
 Cough for 2 days.
HISTORY OF PRESENTING COMPLAINT.
A 2 month plus 2 weeks of age male baby who was
previously healthy presented with shortness of breath for 1 day
duration which was sudden in onset, progressive in severity as it
became worsen during the day, not relieved by anything and
interfered with the patient’s daily activity of sleep, and feeding
which was preceded by 3 days of flu like illness of runny nose,
congestion and low grade fever (felt by his mother by tough).
However it was not associated with rigor or chills. Before
admission he also developed non-productive cough for 2days
which was more common in the morning aggravated by cold air
and it was not associated with weight loss, night sweats and sore
throat.

REVIEW OF OTHER SYSTEMS.

Cardiovascular system; there was no chest pain, orthopnea,
palpitation, fainting, fatigue, cyanosis, feeding difficulties,
sweating, or swelling of lower limbs.
Gastrointestinal system; the mother reported no change in
appetite, abdominal pain, abdominal mass, altered bowel motion
(diarrhea or constipation), nausea, vomiting, flatulence,
swallowing difficulties, jaundice, hematemesis, melena, or
bleeding per rectum.
Genitourinary system; there was no dysuria, hematuria,
polyuria/oliguria, change in urine color, character of the urine
stream, bedwetting, urethral discharge.
Musculoskeletal system; the mother reported no joint pain,
joint swelling, joint stiffness, joint locking, muscle weakness,
muscles pain, deformity, bone pain, or disturbance of gait.
Endocrine system; there was no growth delay, neck swelling,
polyphagia, excessive thirst/fluid intake, obesity, or decreased
activity.
Ears, nose, and throat (ENT); there was no earache, tinnitus,
hearing impairment, ear discharge, recurrent sore throat,
epistaxis, sneezing, or snoring.
Neurological system; mother reported no headache, dizziness,
vertigo, fainting, loss of consciousness, postural deformities,
weakness, convulsion, anosmia, tremor, or paresthesia.
BIRTH HISTORY
Prenatal history: Mother is a 28 year old gravida 3 had her first
child conceived naturally; she has two additional children,
pregnancy was planned. The mother made four visits to Kitagata
health center IV for independent prenatal care. Her first
appointment was at 24 weeks, during which she underwent tests
for syphilis, HIV, and malaria which were all negative.
She additionally reported she received folic acid, iron sulphate,
fansidar, and tetanus toxoid vaccine were administered to her.
She claims to have taken some herbal medicine during her
pregnancy, to have slept beneath a mosquito net the entire time,
and to have avoided radiation exposure such as x-rays.
Natal history: With the assistance of a midwife, the mother gave
birth at KIUTH at 38 weeks via spontaneous vertex delivery. The
newborn weighed 3.4 kg. The mother doesn't know the Apgar
score.
The woman's membranes burst during birth, she spent a few
hours in labour, and no medication was administered to hasten or
halt labour. Minimal bleeding occurred during delivery, there was
no need for an episiotomy, and the cord was delivered via
carefully managed cord traction without any complications.
Postnatal history: After birth, the infant's health was fine; there
was no fever, breathing difficulties, yellowish or bluish skin
discoloration of the mucous membranes, or cord haemorrhage.
Breastfeeding was started as soon as the baby was delivered, and
the hospital stay lasted for 24 hours. The infant received
tetracycline eye ointment, vitamin K, polio 0 and the BCG vaccine.
No further treatments or medications were administered.

GROWTH AND DEVELOPMENTAL MILESTONES

Gross motor skills: according to the mother, the child is
currently able to raise his head while in prone; starts to lift chest
at 2 months.
Fine motor and vision: Mother reports child is able to follow
object moved vertically, when supine at 2 months.
Speech, language and hearing: At two months, she started
grinning at faces and voices. The child can now speak in complete
sentences. The child currently attends no school and gets along
nicely with other kids. His mother adds that he is quite active.
Social, emotional, and behavioral: Mother reported that the
child could recognize her face in the first 28 days of his life and
smiled spontaneously in his 4th week of life.
HISTORY OF IMMUNISATION:
The mother reported her child his first vaccines of Polio 1
and BCG at birth at KIUTH. The was scheduled for another
vaccination at 6 weeks for which she said the child received Polio
1, DPT-HEP B-HIB 2, PCV 2 and Rotavirus vaccine 2 at Kitagata
General Hospital which were well documented in the child’s
vaccination card.

HISTORY OF NUTRITION
For the past 2 months, the mother claims to have breastfed the
child entirely. At least ten times a day, on demand, she breastfed
her child. She additionally reports that the child breast feeds 2
times in the night and baby suckles from both breasts. According
to the mother, the breast milk is adequate to the child as he is
gaining weight instantly and she hasn’t started complementary
feeding.

PAST MEDICAL HISTORY

The mother reports this his first admission in the hospital. She
reports reported no history of chronic illnesses like diabetes
mellitus, hypertension, sickle cell disease. No known allergies to
penicillins.
PAST SURGICAL HISTORY
She reported no history of blood transfusions. She additionally
reported no history of fractures, head injuries, burns, dislocations
and no history of any surgical procedures performed.
FAMILY AND SOCIO-ECONOMIC HISTORY
Out of her three children, this is the first one. The other children
are well and free of any long-term illnesses. The father owns his
own firm. The mother states that she does not know of any family
members who have sickle cell disease, but she does know that
her grandfather's mother had a history of hypertension. Mother
and father do not drink alcohol or smoke cigarettes. Every
youngster sleeps beneath a mosquito net. The family cooks their
drinking water, which is kept in a clean jerry can, and they reside
in a permanent home with a pit latrine.

SUMMARY OF CLERKSHIP.
A 2 month+2weeks of age male baby presented with
difficulty in breathing for 1 day which was sudden in onset,
progressive in severity and worsens during the day, not relieved
by anything and interfered with the baby’s breast feeding and
sleep. It was associated with low grade fever and flu-like illness of
runny nose and not associated with rigors or chills. There was also
non-productive cough not associated with night sweats, weight
loss and sore throat.

IMPRESSIONS
1. Acute pneumonia in view of cough and difficulty in breathing.
2. Acute bronchiolitis in view of cough and flu like illness of runny
nose

PHYSICAL EXAMINATION.
 On examination, the child was well built and nourished. He
was crying, irritable and dyspneic. The anthropometric
measurements included the length 66 cm (75th centile), the
weight was 3.4 kg (50th centile) and the head circumference was
40 cm. The child was febrile. The pulse was 136 per minute and
respiratory rate was 56 per minute. The blood pressure recorded
was 60/50 mm Hg. Mild subcostal recession and intercostal
indrawing were present. There was no pallor, lymphadenopathy,
cyanosis and no edema.

RESPIRATORY SYSTEM EXAMINATION.

On inspection the chest wall is of normal symmetry moving with
respiration, no therapeutic or surgical scars, no obvious masses,
mild chest indrawing. The respiration was irregular with abnormal
respiratory rate of 65bpm and SPO2 of 89% in room air.
On palpation the trachea was centrally located, no palpable
masses and the chest moves symmetrically and is of normal
expansion. Both tactile and vocal fremitus were normal in all lung
regions and all lung regions were resonant on percussion. Apex
beat was in the 4th intercostal space mid-clavicular line.
On auscultation, there was presence of fine crepitations at the
base of
the lungs.

CARDIOVASCULAR EXAMINATION

On inspection the pericardium was normative, no chest

deformities, no surgical scars and chest was of normal symmetry.
The pulse rate was 110bpm which was regular, strong, of full
volume with radial- radial synronicity and no femoral-radial delay.
There was no finger clubbing, no splinter hemorrhage, no
Osler nodes and no edema.
On palpation, there were no heaves, thrills.
On auscultation the apex heart beat was in the left 4th intercostal
space midclavicular line and both 1st and 2nd heart sounds were
heard with no added sounds and murmurs. The child was
tachycardic.

CENTRAL NERVOUS SYSTEM EXAMINATION

On inspection the child is alert and conscious, oriented well

in time, place and person. The child is not wasted and has no
dysmorphic features and GCS is 15/15.
The child flexes the neck without complaint; the child was
able to stand and move normally. The pupils constrict in response
to shinning of the eyes with torch light.

PLAN

1. Do CBC with differentials, ESR, CXR.

2. IV Ceftriaxone 170 mg OD for 3 days
3. Tabs azithromycin 35mg OD for 2 days
4. Tabs paracetamol 35mg 6 hourly for 2 days
5. IV fluids NS:D5 in a ratio of 30mls:7mls 8 hourly for 3 days
6. Review with lab results.

Investigation results.
CBC revealed Hb of 13mg/dl, WBC was 25000mls per mm3, CXR
revealed increased vascular marking with bilateral patchy
pneumonitis and ESR was 26 mm in the 1st hour.

FOLLOW-UP

1st day after admission review:

Reviewed a 2 months old male infant being managed for
neonatal pneumonia. Today the mother reports that the child is
improving, fever has subsidized and there is mild cough.
O/E: An acutely sick looking male infant baby, lying supine on the
bed, not in respiratory distress, breast feeding well. There is no
pallor of lower conjunctival palpabrae, no yellowing of sclera, no
central cyanosis, finger clubbing, no lymphadenopathy and not
dehydrated.

R/S: Mild crepitations on auscultation.

P/A: Abdomen is of normal fullness, no scars, and not distended

and non-tender.

Plan
1. IV azithromycin 35mg OD for 2 days
2. IV ceftriaxone 170mg OD for 1 day
3. 5. IV fluids NS:D5 in a ratio of 30mls:7mls 8 hourly for 3 days

3rd day after admission review:

Reviewed a 2 months old male infant being managed for
neonatal pneumonia. Today the mother reports that the child is
improving, fever has subsidized and there is no cough.

O/E: Fairly looking male infant baby, lying supine on the bed, not
in respiratory distress, breast feeding well. There is no pallor of
lower conjunctival palpabrae, no yellowing of sclera, no central
cyanosis, finger clubbing, no lymphadenopathy and not
dehydrated.

Plan
Continue with the above plan.

CASE DISCUSSION:
 Child was having fever, cough, and breathlessness. On
examination, there was fever, tachycardia, tachypnea.
Respiratory system revealed the presence of crepitation at the
basal of lungs. Investigation reports showed the presence of the
increased white blood cell count suggests the pneumonia.
Definition:
Pneumonia is defined as inflammation of lung tissue may result
from a noninfectious or an infectious cause.
Bronchopneumonia is primarily a spreading inflammation of
the terminal bronchioles and their related alveoli.
Lobar pneumonia or consolidation is a pathological state
where the alveolar air has been replaced by cellular exudate and
transudate.
Pneumonitis is localized inflammation of lung parenchyma
due to noninfectious causes.
Interstitial pneumonia is characterized by massive
proliferation and desquamation of alveolar cells and thickening of
alveolar walls.
Chest X-ray reveals a diffuse hazy, ground-glass appearance,
usually at lung bases with poorly defined hilar densities.
Recurrent pneumonia is defined as two episodes of
pneumonia in 1 year or more than three episodes at any time
with radiographic clearance between two episodes of illness.

Classification:
Pneumonia can be classified anatomically as lobar or lobular
pneumonia, bronchopneumonia and interstitial pneumonia.
Pathologically there is consolidation of the alveoli or infiltration of
tissue with inflammatory cells.

Factors predisposing to bacterial pneumonia

Include increased number of siblings, parental smoking,
preterm delivery, urban residence, poor socioeconomic status,
impaired immune response, congenital and anatomic defects,
lungs and tracheobronchial tree defects, cystic fibrosis, and
congestive heart failure.

PATHOPHYSIOLOGY
Pathogens reach lungs either by hematogenous
dissemination or by aspiration. Viruses are often responsible for
bacterial infection. Following invasion of pulmonary tissue, an
acute inflammatory response causes exudation of fluid and
provide key diagnosis. Tachypnea out of proportion to the degree
of fever may be the only sign in infant. Grunting respiration in
young child arouse a suspicion of pneumonia. Polymorphonuclear
cells with eventual fibrin deposition and consolidation.
Consolidation of lung tissue decreases the vital capacity (VC) and
compliance of lungs. Intrapulmonary right to left shunt and
ventilation perfusion (V/Q) mismatching can cause hypoxia; even
pulmonary hypertension may occur, which with added
hypercapnia, can result in cardiac overload.

CLINICAL FEATURES
Cough is common symptom, for which this child presented
with for 2 days. It may be absent in infants and newborns.
Mere observation will Congestive cardiac failure Tachypnea
is the most sensitive index of disease severity.
The diagnosis of pneumonia is defined as respiratory rate
more than 60/min in children below 2 months of age, more than
50/min in children between 2 or 12 months of age and more than
40/min in children 1–5 years of age. Pneumonia may present with
acute abdominal pain which is attributed to referred pain from the
pleura. Apical pneumonia may be associated with meningismus
and convulsions.

DIAGNOSIS
Acute phase reactants, like complete blood cell (CBC), C-
reactive protein (CRP), erythrocyte sedimentation rate (ESR) was
elevated for this case, have poor sensitivity and specificity. They
do not distinguish between viral and bacterial etiology, north help
in making decision of antibiotic choice; however, may be useful
tools for monitoring the course of the disease.
Complete blood count helps for the evidence of septicemia.
White blood cell (WBC) count more than 15,000 cells/cu mm,
polymorphonuclear leukocytosis or count less than 5000/cu mm,
or febrile neutropenia are bad prognostic signs. There was
leukocytosis for this child’s CBC.
Nasopharyngeal aspirate is investigated for viral antigens,
e.g., cytomegalovirus (CMV) and adenovirus.
Radiology is not routinely required in non-severe pneumonia
to confirm the diagnosis. At times correlate with the clinical signs;
there is also wide variation in the interpretation by radiologists.

MANAGEMENT
It includes specific treatment and supportive treatment:
Specific Treatment It includes specific antimicrobial agent.
Antibiotics are selected on the basis of age of the child, and
epidemiology, clinical features, radiological features and
extrapulmonary manifestation.

Specific Antimicrobial Therapy in Pneumonia

■ 5 years first-line; Ampicillin/Penicillin G co-amoxiclav/Macrolide
(if mycoplasma suspected); second-line; ceftriaxone/Cefotaxime
and Macrolides
■ Suspected staphylococcal infection; Cefuroxime or Co-
amoxiclav or IV 3rd generation Cephalosporins + Cloxacillin;
second-line; ceftriaxone/Cefotaxime and Vancomycin
Teicoplanin/Linezolid.

Supportive Treatment
Paracetamol (10–15 mg/kg/dose) every 4–6 hourly for the
treatment of fever is recommended. In the presence of
tachypnea, cyanosis or chest indrawing, oxygen should be
administered.
Intravenous fluid is given if the child is not tolerating orally.
Oral fluids/food is encouraged as soon as tachypnea or chest
retractions are under control.

Duration of Treatment
Pneumonia (outpatient) - 5–7 days Pneumonia (inpatient) - 10–14
days Atypical organism - 10 days Staphylococcus pneumoniae -
3–4 weeks

COMPLICATIONS
These include empyema, pneumothorax, bronchogenic
dissemination, septicemia, osteomyelitis, multiple system
abscesses, septic arthritis and meningitis which the child never
developed due to prompt treatment.