Case report BRONCHOPNEUMONIA Presenters Day/Date Supervisor : Kiki Anggrita Sari Mutiara Hutagalung : Thursday/December 23rd 2010 : dr.

Lily Irsa, Sp.A (K) CHAPTER 1 1.1. INTRODUCTION Pneumonia can be generally defined as inflammation of the lung parenchyma, pneumonia is characterized by consolidation of the affected part and a filling of the alveolar air spaces with exudate, inflammatory cells, and fibrin. Most cases of pneumonia are due to infection by bacteria or viruses, although they may also be due to the inhalation of chemicals, trauma to the chest wall, or other infectious agents such as rickettsiae, fungi, and yeasts. 1 Bronchopneumonia is one of two types of bacterial pneumonia as classified by gross anatomic distribution of consolidation (solidification), the other being lobar pneumonia. Bronchopneumonia is an acute inflammation of the walls of smaller bronchial tubes, with varying amount of pulmonary consolidation due to spread of the inflammation into peribronchiolar alveoli and the alveolar ducts.2.3 Although most cases of pneumonia are caused by microorganisms. Pneumonia is an acute infection of one or both lungs that can be caused by a bacterium, usually Streptococcus pneumoniae (also called pneumococcus; see streptococcus streptococcus, any of a group of gram-positive bacteria, genus Streptococcus, some of which cause disease, or by a virus, fungus, or other organism. The causal organisms reach the lungs through the respiratory passages. Usually an upper respiratory infection precedes the disease. Alcoholism, extreme

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youth or age, debility, immunosuppressive disorders and therapy, and compromised consciousness are predisposing factors. 1.4 When one or more entire lobes of the lung are involved, the infection is considered a lobar pneumonia. When the disease is confined to the air spaces adjacent to the bronchi, it is known as bronchopneumonia. Aspiration pneumonia is the pathological consequence of the abnormal entry of fluids, particulate matter, or secretions in the lower airways. Noninfectious causes include aspiration of food or gastric acid, foreign bodies, hydrocarbons, and lipoid substances, hypersensitivity reactions and drug or radiation induced pneumonitis.4 1.2. DEFINITION Bronchopneumonia is a type of pneumonia that is characterized by an inflammation of the lung generally associated with, and following about with bronchiolitis. Bronchopneumonia or bronchial pneumonia or bronchogenic pneumonia is an acute inflammation of the walls of the bronchioles. It is a type of pneumonia characterized by multiple foci of isolated, acute consolidation, affecting one or more pulmonary lobules. It is one of two types of bacterial pneumonia as classified by gross anatomic distribution of consolidation (solidification), the other being lobar pneumonia.2.3 1.3. ETIOLOGY Pneumonia is most often caused by a bacterial infection (bacterial pneumonia) or a viral infection (viral pneumonia). However, pneumonia can also be caused by a fungal infection, yeast infection, trauma, or from inflammation of the lungs due to exposure to toxic substances, such as poisonous gases. Pathogens implicated in pneumonia vary with the age of the child, the underlying patient-specific risk factors, immunization status, and seasonality.8 In the neonate, pathogens that may infect the infant via the maternal genital tract include group B streptococci, Escherichia coli and other fecal coliforms, and C trachomatis. Group B streptococci most often is transmitted to the fetus in utero, usually as a result of colonization of the mother's vagina and cervix by the organism. Affected infants commonly present within the first few

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hours after birth, but if infection is acquired during the delivery, the presentation may be delayed. The usual presenting symptoms include tachypnea, hypoxemia, and signs of respiratory distress. Physical examination may reveal diffuse fine crackles, and the chest radiograph may demonstrate a ground-glass appearance and air bronchograms.6 Newborns may be affected by the bacteria and viruses that cause infections in older infants and children. Risk factors for infection include older siblings, group daycare, and lack of immunization, particularly against pertussis. In the young infant, aged 1-3 months, continued concern about perinatally acquired pathogens mentioned above as well as the unusual Listeria monocytogenes remains. However, most pneumonia in this age group is community acquired and involves Streptococcus pneumoniae, Staphylococcus aureus, and non-typeable Haemophilus influenzae. Streptococcus pneumoniae is by far the most common bacterial pathogen in this age group. Infection with Staphylococcus aureus may be complicated by lung abscess, parapneumonic effusions, and empyema. 6 Young children, viruses are a common cause of pneumonia among toddlers and preschoolers. The usual culprits are those previously discussed. Tsolia et al identified a viral infection among 65% of hospitalized children with community-acquired pneumonia. Streptococcus pneumoniae is by far the most common bacterial cause of pneumonia. Among hospitalized children, Streptococcus pneumoniae accounts for 21-44% of disease. In a recent study to evaluate the effectiveness of heptavalent pneumococcal conjugate vaccine in prevention of pneumonia in children younger than 5 years, Black et al showed a 32.2% reduction in the first year of life and a 23.4% reduction between 1-2 years, but only a 9.1% reduction in children older than 2 years.Children in this age group are also at risk for infection by M pneumoniae.6 Older children and adolescents, M. pneumoniae is a frequent cause of pneumonia among older children and adolescents. Mycoplasma accounts for 1435% of pneumonia hospitalizations in this age group. C pneumoniae can cause pneumonia in this age group.

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Streptococcus pneumoniae (pneumococcus) and Mycoplasma pneumoniae both are the common bacterium which causes bronchopneumonia in the adults and children.1.6 1.4. EPIDEMIOLOGY The WHO Child Health Epidemiology Reference Group estimated the median global incidence of clinical pneumonia to be 0.28 episodes per childyear.1 This equates to an annual incidence of 150.7 million new cases, of which 11-20 million (7-13%) are severe enough to require hospital admission. Ninetyfive percent of all episodes of clinical pneumonia in young children worldwide occur in developing countries.7 The insiden of pneumonia is 10 times higher in developing than in developed countries, with as many as 5 million deaths occurring yearly in children younger than 5 years. Such variable as nutritional status, age, and the presence of an underlying condition influence morbidity and mortality rafes due to community acquired pneumonia.8 In the United State, In a randomized double-blind trial, the heptavalent pneumococcal vaccine reduced the incidence of clinically diagnosed and radiographically diagnosed pneumonia among children younger than 5 years by 4% and 20%, respectively.7 1.5. PATHOPHYSIOLOGY Pneumonia results from inflammation of the alveolar space and may compromise air exchange. While often complicating other lower respiratory infections such as bronchiolitis or laryngotracheobronchitis, pneumonia may also occur via hematogenous spread or aspiration. Most commonly, this inflammation is the result of invasion by bacteria, viruses, or fungi, but it can occur as a result of chemical injury or may follow direct lung injury.7 Four stages of lobar pneumonia have been described. In the first stage, occurring within 24 hours of infection, the lung is characterized microscopically by vascular congestion and alveolar edema. Many bacteria and few neutrophils are present. The stage of red hepatization (2-3 d), so called because of its similarity to the consistency of liver, is characterized by the presence of many

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erythrocytes, neutrophils, desquamated epithelial cells, and fibrin within the alveoli. In the stage of gray hepatization (2-3 d), the lung is gray-brown to yellow because of fibrin purulent exudates, disintegration of red cells, and hemosiderin. The final stage of resolution is characterized by resorption and restoration of the pulmonary architecture. Fibrinous inflammation may extend into the pleural space, causing a rub heard by auscultation, and it may lead to resolution or to organization and pleural adhesions.7 Bronchopneumonia, a patchy consolidation involving one or more lobes, usually involves the dependent lung zones, a pattern attributable to aspiration of oropharyngeal contents. The neutrophilic exudates are centered in bronchi and bronchioles, with centrifugal spread to the adjacent alveoli. 7 In a person suffering from bronchopneumonia, bacteria invade the lungs, which results to an inflammatory immune response. This reaction of the lungs leads to the filling of the alveolar sacs with exudates. As a result, consolidation takes place a condition where in the air space in the lungs is replaced with fluids. In pathology, we can found macroscopically multiple foci of consolidation are present in the basal lobes of the human lung, often bilateral. These lesions are 2-4 cm in diameter, grey-yellow, dry, often centered on a bronchiole, are poorly delimited and have the tendency to confluence, especially in children, microscopically, A focus of inflammatory condensation is centered on a bronchiole with acute bronchiolitis (suppurative exudates - pus - in the lumen and parietal inflammation). Alveolar lumens surrounding the bronchiole are filled with neutrophils ("leukocytic alveolitis"). Massive congestion is present. Inflammatory foci are separated by normal, aerated parenchyma.1 1.6. CLINICAL FEATURES ( Signs & Symptoms ) Fever and difficulty in breathing are commonest presenting symtoms, usually preceded by an upper respiratory tract infection. Other symptoms include cough, lethargy, poor feeding, an unwell child. Localized chest, abdominal, or neck pain is feature of pleuralirritationand suggest bacterial infection. 10 The signs and symptoms of pneumonia are often nonspecific and widely vary based on the patients age and the infectious organisms involved.

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Newborns, newborns with pneumonia rarely cough; they more commonly present with tachypnea, retractions, grunting, and hypoxemia. Grunting in a newborn is due to vocal cord approximation as they try to provide increased positive end-expiratory pressure (PEEP) and keep their lower airways open. Grunting suggests a lower respiratory tract disease. Retractions result from the effort to increase intrathoracic pressure to compensate for decreased compliance. Older infants, grunting may be less common; however, tachypnea, retractions, and hypoxemia are common and may be accompanied by a persistent cough, congestion, fever, irritability, and decreased feeding. Toddlers and preschoolers, these children most often present with fever, cough (productive or nonproductive), tachypnea, and congestion. They may have some posttussive emesis. Older children and adolescents, this group may also present with fever, cough (productive or nonproductive), congestion, chest pain, dehydration, and lethargy. Extra pulmonary signs and symptoms include (1) abdominal pain or an ileuses accompanied by emesis in patients with lower lobe pneumonia, (2) nuchal rigidity in patients with right upper lobe pneumonia, or (3) a rub caused by pericardial effusion in patients with lower lobe pneumonia due to Haemophilus influenzae infection. All children, many children present with nasal flaring, which increases airflow to respiratory surfaces.7 Auscultation of the lung fields may yield rales, wheezing, diminished breath sounds, tubular breath sounds, or pleural friction rub. The affected lung field may be dull to percussion. Decreased tactile and vocal fremitus, as well as egophony, may be appreciated over the area of pneumonia.10 1.7. LABORATORY STUDY Identifying the causative infectious agent is the most valuable step in managing a complicated case of pneumonia. Unfortunately, an etiologic agent can be difficult to identify. Therefore, in most patients with community-acquired

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pneumonia who are treated on an outpatient basis, treatment is empiric and based primarily on patient age and clinical presentation. a. CBC count Testing should include a CBC count with differential and evaluation of acute-phase reactants (ESR, CRP, or both) and sedimentation rate. The total WBC and differential may aid in determining if an infection is bacterial or viral, and, together with clinical symptoms chest radiography and ESR can be useful in monitoring the course of pneumonia. In viral pneumonia, the WBC count may be normal or elevated . Bacterial pneumonia is often associated with an elevated WBC count in the range of 15,00040,000/mm3 and a predominance of granulocytes.1.3 b. Sputum culture Sputum is rarely produced in children younger than 10 years, and samples are always contaminated by oral flora. An adequate sputum culture should contain more than 25 polymorphonuclear (PMN) cells per field and fewer than 10 squamous cells per field. The common agents that cause pneumonia may be normal oral flora. For these reasons, sputum cultures are not useful in most children with pneumonia, although a Gram stain may help. An example of a positive Gram stain for S pneumoniae is shown in the image below.3.8

(A) Gram stain demonstrating gram-positive cocci in pairs and chains and (B) culture positive for Streptococcus pneumoniae.

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c. Blood culture Although blood cultures are technically easy to obtain and relatively noninvasive and non traumatic, the results are rarely positive in the presence of pneumonia and even less so in cases of pretreated pneumonia. In a study of 168 patients with known pneumonia, Wubbel et al found only sterile blood cultures. In general, blood culture results are positive in 10-15% of patients with streptococcal pneumonia. The numbers are even less in patients with Staphylococcus infection. A blood culture is still recommended in complicated cases of pneumonia.3 d. Skin tests Tuberculosis should always be considered as possible diagnose, especially in endemic areas.8 These tests are used in diagnosing TB. Mantoux skin test (intradermal inoculation of 5 TU of purified protein derivative) results should be read 48-72 hours after placement. In children older than 4 years without any risk factors, test results are positive if the indurations (not the area of erythematic, which may be larger) is 15 mm or larger. Among children younger than 4 years, those who have an increased environmental exposure to TB or other medical risk factors (eg, lymphoma, diabetes mellitus, malnutrition, renal failure), results are positive if the indurations is 10 mm or larger. In immunosuppressed children or those in close contact with others who have known or suspected cases of TB, test results are positive if the indurations is 5 mm or larger. Even if the child has received the Bacillus Calmette-Gurin (BCG) vaccine, Mantoux test results should be interpreted using the criteria outlined above.3 e. Bronchoscopy Flexible fiberoptic bronchoscopy is occasionally useful to obtain lower airway secretions for culture or cytology. This procedure is most useful in immunocompromised patients who are believed to be infected with unusual organisms (Pneumocystis, other fungi) or in patients who are severely ill.3

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1.8.

IMAGING STUDY Radiography, this is the primary imaging study used to confirm the

diagnosis of pneumonia. Radiography is often performed when diagnosing pneumonia, however, it is not always necessary or useful in determining the etiology of the infection.3 In general, chest radiographs are standart practice with hospitalized children whom a diagnose pneumonia being considered. The sensitivity of the test to diagnose is approximately 75%.8 Viral pneumonias are associated with a patchy perihilar infiltrate, hyperinflation, and atelectasis on chest radiography.In patients with bacterial pneumonia, typical findings include a lobar consolidation with air bronchograms occasionally accompanied by a pleural effusion (see the images below).Photo thorax there bronkopeumoni patches infiltrates in one or several lobes, if the pneumonia lobaris seen a consolidation in one or several lobes. Pneumatoceles and abscesses are less commonly found but may indicate an S aureus, gramnegative, or complicated pneumococcal pneumonia.3 A small propotion of pneumonias are associated with a parapneumonic effusion, where they may be blunting of the costophrenic angle on the chest Xray. Some of this effusion develop into empyema.8 1.9. MANAGEMENT AND TREATMENT Infant and children with mild and moderste low respiratory tract infection can be safely cared for at home. In this situation, the child usually should be reexamined within 48 hours of beginning treatment. According to the British Thoracic Society guideline, an SaO2 of 92% or less, cyanosis, respiratory rate greater than 70 breaths per minute, difficulty of breathing, intermittent apnea, grunting, inability to feed, and family incapable of providing appropriate observation or supervision are indicators for hospital admission among infant.8 General supportive care should include antipyretics, oxygen to keep saturation > 92. Fluids should be given if necessary, ensuring that an excessive volume is not given because of potensial inappropiate ADH secretion.10 Treatment decisions in children with pneumonia are dictated based on the likely etiology of the infectious organism and the age and clinical status of the

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patient. Antibiotic administration must be targeted to the likely organism, bearing in mind the age of the patient, the history of exposure, the possibility of resistance (which may vary, depending on local resistance patterns), and other pertinent history. The initial outpatient treatment of children with pneumonia depends upon the clinical findings and the patient's age.3 A position paper by the U.S Center for Disease and Control and Prevention was recently published supporting the findings that intermediate susceptible strain of pneumococcus respond well to high doses of beta-lactam. High doses of penicillin, ampicillin, and amoxicillin have been recommended whenever intermediate susceptible strain are considered. Some expert suggest an option with third generation cephalosporins such as ceftriaxon or cefotaxime.8 Children in whom pneumococcal disease is suspected initially should be treated with amoxicillin or penicillin. A macrolide antibiotic alone, or in combination with sulfisoxazole or an oral cephalosporin is an alternative.7 The choice antibiotic is determinaned by childs age, newborn require broad-spectrum intrvenous antibiotics. Most older infant can be manage with oral amoxicillin, with broader spectrum antibiotics. For children >5 years of age either amoxicillin or an oral macrolide such as erytrhomycin is the treatment of choice.10 1.10. COMPLICATION Fortunately, most children with pneumonia recover without complications. Persistent effusions and empyemas are the most common serious complications of bacterial pneumonia, others include the following:7

Pulmonary abscess Respiratory distress Sepsis PROGNOSIS Patients who were placed on a protocol-driven pneumonia clinical

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pathway are more likely to have favorable outcomes. The prognosis for most forms of pneumonia is excellent. Most cases of viral pneumonia resolve without

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treatment, common bacterial pathogens and atypical organisms respond to antimicrobial therapy.7 The prognosis for varicella pneumonia is somewhat more guarded. Staphylococcal pneumonia, although rare, can be very serious despite treatment. Immunocompromised children, those with underlying lung disease, and neonates are at high risk for severe sequelae. Some forms of viral pneumonia, particularly adenoviral disease, may cause necrotizing bronchiolitis or bronchiolitis obliterans.7

CHAPTER 2 2.1. OBJECTIVE The aim of doing this paper is to report a case of bronchopneumonia of an 1-year-old girl that was admitted at the Infection Unit of Haji Adam Malik General Hospital. 2.2. CASE N, a 2-year-old girl, 9.5 kg, 82 cm, was admitted to the Infection Unit of Haji Adam Malik General Hospital on September 16th, 2010 at 21.00 pm with chief complaint was shortness of breath. The shortness of breath occurred since 2 days ago and getting worst in 1 day before she admitted to the hospital. The shortness of breath was not related to activity and weather. Cyanosis was not found. Productive cough occurred since 3 day ago. History of contact with TB patient was not found.

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Fever was found since 1 week ago with a characteristic of high fever which relieved with fever relieving medication. Shivers and seizures were not found. History of diarrhea was found since 5 days ago with frequency 5 times a day and the volume was 20cc/diarrhea. Currently the patient is having watery stool. Micturition is in normal range. History of birth, the patient was delivered through caesarian operation and cried instantly. She had a history of complete immunizations. History of previous illness: This patient was referred from pediatrician History of drugs usage :-

PHYSICAL EXAMINATION Generalized Status: Body weight (BW) : 9.5 kg BW/ BL : 84% (mild malnutrition) Body Temperature : 40.5 C Sensorium : Compos Mentis Localized Status: Head : Eye: light reflexes (+/+), isochoric pupil (right=left), pale inferior conjunctival palpebra (-/-), palpebra edema (-/-) Mouth/Ears: Within normal limit, Nose: Nasal Flaring (+) Neck Chest : Lymph node enlargement (-), JVP: R-2cmHO : Symmetrical fusiformic, retraction (+) HR: 180 bpm, regular, murmur (-) RR: 20 rpm, regular, ronchi (+) Abdominal Extremities Urogenital : Soepel, peristaltic (+) normal, Liver/Spleen: within normal limits : Pulse: 180 bpm, regular, pressure/volume = sufficient BP: 90/60 mmHg, warm extremity : Female, within normal limit Body length (BL) : 82 cm

Anemic (-), icteric (-), cyanosis (-), edema (-), dyspnea (+)

Laboratory Findings (September 16th 2010) from Private Lab Test Result Complete Blood Count Normal Value

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Hemoglobin (HGB) Erythrocytes (RBC) Leucocytes (WBC) Hematocrit Thrombocytes (PLT) MCV MCH MCHC RDW Neutrophil Lymphocyte Monocyte Eosinophil Basophil

10,40 g% 4,15 x 106/mm3 10,79 x 103/ mm3 31,50 % 225 x 103/ mm3 75,9 fL 25,1 pg 33 g% 13,8 % Cell Count 75,40 % 13,60 % 10,90 % 0% 0,10 % Arterial Blood Gases 7,515 23,9 mmHg 135,2 mmHg 18,9 mmol/L 19,6 mmol/L -3,0 mmol/L 99,2 % Serum Electrolyte 130 mEq/dL 3,0 mEq/dL 99 mEq/dL

11,3-14,1 4,40-4,48 6,0-17,5 37-41 217-497 81-95 25-29 29-31 11,6-14,8 37-80 20-40 2-8 1-6 0-1

pH pCO2 pO2 Bicarbonate (HCO3) Total CO2 BE O2 Saturation Natrium Kalium Chloride

7,35-7,45 38-42 85-100 22-26 19-25 (-2) (+2) 95-100 135- 155 3.6- 5.5 96- 106

Chest X-Ray (September 16th 2010)

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Chest X-Ray showed infiltrated on right lower lung ( right pericardial), specific process, with differential diagnosis Bronchopneumonia. Differential diagnosis : 1. Bronchopneumonia + GE without Dehydration 2. Bronkiolitis 3. Pulmonary Tuberculosis Working diagnosis Management : O2 1 L/i Nasal Canal Nebule NaCl 0,9% 2,5cc/8 hours IVFD D5% NaCl 0,225% 40 gtt/i Injection Ampicillin 250mg/6 hours/iv skin test Injection Gentamycin 80mg/24 hours/iv skin test Paracetamol 3x100mg, if needed : Bronchopneumonia + GE without Dehydration

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Fasting as the temporary diet

Investigation Plan: - Chest X-Ray (AP) Mantoux Test

Follow Up S O Follow Up November 17th 2010 6:00 am Shortness of breath (+), Cough (+), Fever (-), Diarrhea (+) Sens: Compos Mentis T: 37.4 C BW: 9.5 kg BL: 82 cm BW/BL: 84% (mild malnutrition) Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebral conjunctiva (-/-), Nose: Nasal Flaring (+) Mouth/Ears: Within normal limits Neck Chest : Lymph nodes enlargement (-), JVP: R-2cmHO : Symmetrical fusiformic, retraction (+), HR : 132 bpm, regular, murmur (-) RR : 48 rpm, regular, ronchi (+) Abdomen : Soepel, normal peristaltic, Liver/Spleen: Within normal limits
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Extremities : Pols 132 bpm, regular, Pressure/Volume: sufficient, A P BP : 90/60 mmHg, warm extremity Bronchopneumonia + GE without Dehydration O2 1 L/I Nasal Canal Nebule NaCl 0,9% 2,5cc/8 hours IVFD D5% NaCl 0,225% 40 gtt/i Injection Ampicillin 250mg/6 hours/iv (D-2) Injection Gentamycin 80mg/24 hours/iv (D-2) Paracetamol 3x100 mg, if needed Zinc Kid 1x20mg Lacto B 2x1 sachet Diet M II 900 kkal with 35 grams of protein

Investigation plan : -

S O

Follow Up November 18th 2010 6:00 am Shortness of breath (+), Cough (+), Fever (-), Diarrhea (-) Sens: Compos Mentis T: 37.5 C BW: 9.5 kg BL: 82 cm BW/BL: 84% (mild malnutrition) Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebral conjunctiva (-/-), Nose: Nasal Flaring (+) Mouth/Ears: Within normal limits Neck Chest : Lymph nodes enlargement (-), JVP: R-2cmHO : Symmetrical fusiformic, retraction (+), HR : 140 bpm, regular, murmur (-) RR : 56 rpm, regular, ronchi (+) Abdomen : Soepel, normal peristaltic, Liver/Spleen: Within normal limits Extremities : Pols 140 bpm, regular, Pressure/Volume: sufficient, BP : 90/60 mmHg, warm extremity Bronchopneumonia + GE without Dehydration

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O2 1 L/I Nasal Canal Nebule NaCl 0,9% 2,5cc/8 hours IVFD D5% NaCl 0,225% 40 gtt/i Injection Ampicillin 250mg/6 hours/iv (D-3) Injection Gentamycin 80mg/24 hours/iv (D-3) Paracetamol 3x100 mg, if needed Zinc Kid 1x20mg Lacto B 2x1 sachet Diet M II 900 kkal with 35 grams of protein

Investigation plan : - Consultation to Respirology Department Respirology Consult : Normal

S O

Follow Up November 19th 2010 6:00 am Shortness of breath (+), Cough (+), Fever (-), Diarrhea (-) Sens: Compos Mentis T: 37.2 C BW: 9.5 kg BL: 82 cm BW/BL: 84% (mild malnutrition) Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebral conjunctiva (-/-), Nose: Nasal Flaring (+) Mouth/Ears: Within normal limits Neck Chest : Lymph nodes enlargement (-), JVP: R-2cmHO : Symmetrical fusiformic, retraction (-), HR : 138 bpm, regular, murmur (-) RR : 48 rpm, regular, ronchi (+) Abdomen : Soepel, normal peristaltic, Liver/Spleen: Within normal limits Extremities : Pols 138 bpm, regular, Pressure/Volume: sufficient, BP : 90/50 mmHg, warm extremity Bronchopneumonia + GE without Dehydration O2 1 L/I Nasal Canal

A P

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Nebule NaCl 0,9% 2,5cc/8 hours IVFD D5% NaCl 0,225% 40 gtt/i Injection Ampicillin 250mg/6 hours/iv (D-4) Injection Gentamycin 80mg/24 hours/iv (D-4) Ambroxol 5mg + Salbutamol 1mg : 3 x pulv I Paracetamol 3x100 mg, if needed Zinc Kid 1x20mg Lacto B 2x1 sachet Diet M II 900 kkal with 35 grams of protein

Investigation plan : - Mantoux Test - Chest Physiotherapy (20/12/2010) - Check for ABG and Electrolyte Follow Up November 20th 2010 6:00 am Shortness of breath (+), Cough (+), Fever (+), Diarrhea (-) Sens: Compos Mentis T: 38.0 C BW: 9.5 kg BL: 82 cm BW/BL: 84% (mild malnutrition) Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebral conjunctiva (-/-), Nose: Nasal Flaring (+) Mouth/Ears: Within normal limits Neck Chest : Lymph nodes enlargement (-), JVP: R-2cmHO : Symmetrical fusiformic, retraction (-), HR : 128 bpm, regular, murmur (-) RR : 36 rpm, regular, ronchi (+) Abdomen : Soepel, normal peristaltic, Liver/Spleen: Within normal limits Extremities : Pols 128 bpm, regular, Pressure/Volume: sufficient, A P BP : 90/70 mmHg, warm extremity Bronchopneumonia O2 1 L/I Nasal Canal Nebule NaCl 0,9% 2,5cc/8 hours

S O

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IVFD D5% NaCl 0,225% 40 gtt/i Injection Ampicillin 250mg/6 hours/iv (D-5) Injection Gentamycin 80mg/24 hours/iv (D-5) Ambroxol 5mg + Salbutamol 1mg : 3 x pulv I Paracetamol 3x100 mg, if needed Diet M II 900 kkal with 35 grams of protein

Investigation plan : Laboratory Findings: ABG : pH/pCO2/pO2/HCO3 = 7.42/40.6/84.7/26.1 Total CO2/BE/SaO2 = 27.3/1.6/96.5% Electrolyte : Na/K/Cl = 132/27/94 Follow Up November 21st 2010 6:00 am Shortness of breath (+), Cough (-), Fever (-) Sens: Compos Mentis T: 37.0 C BW: 9.5 kg BL: 82 cm BW/BL: 84% (mild malnutrition) Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebral conjunctiva (-/-), Nose: Nasal Flaring (+) Mouth/Ears: Within normal limits Neck Chest : Lymph nodes enlargement (-), JVP: R-2cmHO : Symmetrical fusiformic, retraction (-), HR : 124 bpm, regular, murmur (-) RR : 36 rpm, regular, ronchi (+) Abdomen : Soepel, normal peristaltic, Liver/Spleen: Within normal limits Extremities : Pols 124 bpm, regular, Pressure/Volume: sufficient, A P BP : 90/60 mmHg, warm extremity Bronchopneumonia O2 1 L/I Nasal Canal Nebule NaCl 0,9% 2,5cc/8 hours IVFD D5% NaCl 0,225% 40 gtt/i Injection Ampicillin 250mg/6 hours/iv (D-6)
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S O

Injection Gentamycin 80mg/24 hours/iv (D-6) Ambroxol 5mg + Salbutamol 1mg : 3 x pulv I Paracetamol 3x100 mg, if needed Diet M II 900 kkal with 35 grams of protein

Investigation plan : -

S O

Follow Up November 22nd 2010 6:00 am Shortness of breath (+) , Cough (+) , Fever (-) Sens: Compos Mentis T: 36.6 C BW: 9.5 kg BL: 82 cm BW/BL: 84% (mild malnutrition) Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebral conjunctiva (-/-), Nose: Nasal Flaring (+) Mouth/Ears: Within normal limits Neck Chest : Lymph nodes enlargement (-), JVP: R-2cmHO : Symmetrical fusiformic, retraction (-), stridor (+) HR : 120 bpm, regular, murmur (-) RR : 32 rpm, regular, ronchi (+), Prolonged expiration (+) Abdomen : Soepel, normal peristaltic, Liver/Spleen: Within normal limits Extremities : Pols 120 bpm, regular, Pressure/Volume: sufficient, BP : 90/60 mmHg, warm extremity Bronchopneumonia O2 1 L/I Nasal Canal, if needed Nebule Ventolin 2,5 cc + NaCl 0,9% 2,5cc/8 hours IVFD D5% NaCl 0,225% 40 gtt/i Injection Ampicillin 250mg/6 hours/iv (D-7) Injection Gentamycin 80mg/24 hours/iv (D-7) Ambroxol 5mg + Salbutamol 1mg : 3 x pulv I
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Paracetamol 3x100 mg, if needed Diet M II 900 kkal with 35 grams of protein Chest Physiotherapy

Investigation plan : -

S O

Follow Up November 23rd 2010 6:00 am Shortness of breath (+), Cough (+) , Fever (-) Sens: Compos Mentis T: 36.7 C BW: 9.5 kg BL: 82 cm BW/BL: 84% (mild malnutrition) Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebral conjunctiva (-/-), Nose: Nasal Flaring (+) Mouth/Ears: Within normal limits Neck Chest : Lymph nodes enlargement (-), JVP: R-2cmHO : Symmetrical fusiformic, retraction (-), stridor (-) HR : 110 bpm, regular, murmur (-) RR : 36 rpm, regular, ronchi (+), prolonged expiration (+) Abdomen : Soepel, normal peristaltic, Liver/Spleen: Within normal limits Extremities : Pols 110 bpm, regular, Pressure/Volume: sufficient, BP : 100/60 mmHg, warm extremity Bronchopneumonia O2 1 L/I , if needed Nebule Ventolin 2,5 cc + NaCl 0,9% 2,5cc/8 hours IVFD D5% NaCl 0,225% 10 gtt/i Injection Ampicillin 250mg/6 hours/iv (D-8) Injection Gentamycin 80mg/24 hours/iv (D-8) Ambroxol 5mg + Salbutamol 1mg : 3 x pulv I Paracetamol 3x100 mg, if needed

A P

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Diet M II 900 kkal with 35 grams of protein Chest Physiotherapy

Investigation plan : - Discharge (24/12/2010)

CHAPTER 3 3.1. DISCUSSION N, a 2-years-old girl, 9.5 kg, 82 cm, was admitted to the Infection Unit of Haji Adam Malik General Hospital with chief complaint of shortness of breath. The shortness of breath occurred since 2 days ago and getting worst in 1 day before she admitted to the hospital. The shortness of breath was not related to activity and weather. Cyanosis was not found. Productive cough occurred since 3 day ago. Fever was found since 1 week ago with a characteristic of high fever which relieved with fever relieving medication. Shivers and seizures were not found. History of diarrhea was found since 5 days ago with frequency 5 times a day and the volume was 20cc/diarrhea. Currently the patient is having watery stool. This patient was referred to Haji Adam Malik Hospital by pediatrician with bronchopneumonia and gastroenteritis without dehydration. Bronchopneumonia is a type of pneumonia that is characterized by an inflammation of the lung generally associated with, and following about with bronchiolitis. Bronchopneumonia or bronchial pneumonia or bronchogenic pneumonia is an acute inflammation of the walls of the bronchioles. Pneumonia is most often caused by a bacterial infection (bacterial pneumonia) or a viral infection (viral pneumonia). The insiden of pneumonia is 10 times higher in developing than in developed countries, with as many as 5 million deaths occurring yearly in children younger than 5 years. In this case patient is a girl 2 years old.

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In clinical feature, fever and difficulty in breathing are commonest presenting symtoms, usually preceded by an upper respiratory tract infection. In this case patient was admitted with chief complaint shortness of breath, fever was found since 1 week ago and her temperature 40,50C, productive cough occurred since 3 day ago. Pneumonia results from inflammation of the alveolar space and may compromise air exchange. While often complicating other lower respiratory infections such as bronchiolitis or laryngotracheobronchitis, pneumonia may also occur via hematogenous spread or aspiration. Most commonly, this inflammation is the result of invasion by bacteria, viruses, or fungi, but it can occur as a result of chemical injury or may follow direct lung injury. In the young infant, aged 1-3 months most pneumonia in this age group is community acquired and involves Streptococcus pneumoniae, Staphylococcus aureus, and non-typeable Haemophilus influenzae. Streptococcus pneumoniae is by far the most common bacterial pathogen in this age group. Usually preceded by upper respiratory tract infection. This disease usually arises suddenly, the temperature increased 39-40 0C with chills, shortness of breath and rapid, coughing productive "breath sounds" when percussion dim lung examination, breath sounds during auscultation ronchi smooth wet and loud. The laboratory found leukocytosis 15000-40000 / mm3. Photo thorax there bronkopeumoni patches infiltrates in one or several lobes, if the pneumonia lobaris seen a consolidation in one or several lobes. Treatment decisions in children with pneumonia are dictated based on the likely etiology of the infectious organism and the age and clinical status of the patient. Antibiotic administration must be targeted to the likely organism, bearing in mind the age of the patient, the history of exposure, the possibility of resistance (which may vary, depending on local resistance patterns), and other pertinent history. Children in whom pneumococcal disease is suspected initially should be treated with amoxicillin or penicillin. A macrolide antibiotic alone, or in combination with sulfisoxazole or an oral cephalosporin is an alternative.

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Fortunately, most children with pneumonia recover without complications. Persistent effusions and empyemas are the most common serious complications of bacterial pneumonia Patients who were placed on a protocol-driven pneumonia clinical pathway are more likely to have favorable outcomes. The prognosis for most forms of pneumonia is excellent. Most cases of viral pneumonia resolve without treatment, common bacterial pathogens and atypical organisms respond to antimicrobial therapy. This patient N, a 2-years-old girl had shortness of breath, productive cough, high fever, and history of diarrhea was found. Physical examination found nasal flaring, chest symmetrical fusiformic, retraction, ronchi on both left and right lower lungs. From chest X-ray showed infiltrated on right lower lung (pericardial). Thus, the patient was diagnosed as bronchopneumonia.

3.2.

SUMMARY It has been reported a case of a 2-years-old girl with Bronchopneumonia.

The diagnosis was established based on history taking, clinical manifestation, and laboratory findings. Treatment for this patient was only supportive and symptomatic. This patient was discharged after free from any complaint such as shortness of breath, fever, and diarrhea.

REFERENCES

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1. Chernick, V., Boat, T. F., Willmott, R. W., 2006. Kendigs Disorders of the Respiratory Tract in Children Seventh Edition. USA: Saunders Elsevier. Page: 441-451. 2. Lissauer, T., Clayden, G., 2007. Illustrated Textbook of Paediatrics Third Edition. London: Mosby Elsevier. Page: 268-270. 3. Mansjoer, A., Supriohata, Wardhani, W.I., 2000. Kapita Selekta Kedokteran Edisi Ketiga Jilid Kedua. Jakarta: Media Aesculapius. Page: 465-468.
4. Mark I Neuman, MD, MPH, 2010. Pediatrics Pneumonia. Emedicine.

Available from: http://emedicine.medscape.com/ . [Accessed December 6th 2010] 5. Nicholas John Bennett, MB, BCh\ 2010. Pneumonia. Emedicine. Available from: http://emedicine.medscape.com/ . [Accessed December 6th 2010] 6. Wahyuni, N., 2009. Bronkopneumonia. Medpaper. Available from: http://ningrumwahyuni.wordpress.com/2009/08/03/bronkopneumonia/ [Accessed December 7th 2010] 7. Nader Kamangar, MD, 2010. Bacterial Pneumonia. Emedicine. Available from: http://emedicine.medscape.com/ . [Accessed December 6th 2010] 8. Perhimpunan Dokter Paru Indonesia. 2003. Pedoman Diagnosis dan Penatalaksanaan di Indonesia: Perhimpunan Dokter Paru Indonesia. 9. Price, S.A., Wilson, L.M., 2006. Patofisiologi Konsep Klinis Proses-Proses Penyakit Volume 2 Edisi 6. Jakarta: EGC. Page: 804-810. 10. Rahajoe, N.N., Supriyatno, B., Setyanto, D.B., 2008. Buku Ajar Respirologi Anak Edisi Pertama. Jakarta: Badan Penerbit IDAI. Page: 333-365. 11. Theodore C. Sectish, Charles G. Prober. Pneumonia. In: Behrman, Richard E., Kliegman, Robert M., Jenson, Hal B. (eds). Nelson Textbook of Pediatrics 17th ed. USA: Saunders. 2004; Page: 1433-1435.
12. Wickham, H., 2010. Pathophysiology. Creative Commons. Page: 15-19. Available from: http://creativecommons.org/licenses/nc-sa/1.0/.

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