CASE PRESENTATION

MORBILI COMPLICATED WITH

BRONCHOPNEUMONIA
Preceptor:
dr. Ulynar Marpaung,
Sp.A
Presenter:
Rinto Nugroho1102010244
DEPARTMENT OF PEDIATRIC R. SAID SUKANTO POLICE CENTER HOSPITAL
FACULTY OF MEDICINE YARSI UNIVERSITY
PERIOD DECEMBER 2015 FEBRUARY 2016

PATIENT IDENTITY

Name
: Shaafiyah
Birth Date : December 12th 2013
Age
: 2 years old
Gender : Female
Address
: Ketapang, Munjul
Nationality : Indonesia
Religion
: Islam
Admission : December 21th 2015
Examination : December 21th 2015

PARENTS IDENTITY

Father

Mother

Name

Mr.Agus

Mrs. Aini

Age

30 years old

26 years old

Job

Entrepreneur

Housewife

Nationality

Javanese

Javanese

Religion

Islam

Islam

Education

High School (graduated)s High

Earning/mo

Approximately

nth
Address

Rp.2.000.000,Ketapang,Munjul.

(graduated)s
-

School

HISTORY TAKING
Taken on December 21th 2015
by Alloanamnesis (from patients
mother)

Chief
Chiefcomplain
complain: :
Shortness of breath 8 hours before admission to hospital

Additional
Additional
complain
complain: :
High fever, productive cough, runny nose, hoarseness, red
patches all over the body, loss appetite

HISTORY OF PRESENT
ILLNESS

S
O
H
E
R
O
F
BE

S
S
I
M
D
A
L
A
T
I
P

5 DAYS

HOSPITAL
December 21th 2015

ION

8 HOURS

1 DAYS

Shortness of breath,
Rash spreading to thrunk
and chest

rash appeared on her face and neck, she

also present with poor feeding and
irritable.

Sudden high fever, never been measured,

productive cough, runny nose with clear and mucoid
secret and redness watery eye.
Hoarseness occurs at night after.
She was taking paracetamol, but there was no

HISTORY OF PAST ILLNESS

Pharyngitis/Tonsilit
is
Bronchitis

Bacillary
Dysentry
Amoeba Dysentry

Pneumonia

Diarrhea

Morbilli

Thypoid

Pertussis

Worms

Varicella

Surgery

Diphteria

Brain Concussion

Malaria

Fracture

Polio

Drug Reaction

Enteritis

Prenatal History
Antenatal care
Antenatal check ups performed at
the doctor in the hospital. There was
no problems during pregnancy.
No maternal illness during pregnancy
Drugs consumption:
Vitamins every antenatal care

Birth History

Labor
: Hospital
Birth attendants
: doctor
Mode of delivery : pervaginam
Gestation
: 38 weeks
Infant state
: healthy
Birth weight
: 3400 grams
Body length
: 50 cm
According to the mother, the baby started
to cry and the baby's skin is red, no
congenital defects were reported

Post Natal History

Examination by midwife
The state of the infant: healthy

Development History

First dentition: 6 months

Psychomotor development
Head Up
: 1 month old
Smile
: 1 month old
Laughing
: 1- 2 month old
Slant
: 2,5 months old
Speech Initiation
: 4 months old
Prone Position
: 4 months old
Food Self
: 5 6 months old
Sitting
: 6 months old

Mental Status: Normal

Conclusion: Growth and development status is still in the
normal limits and was appropriate according to the patients
age

History of Eating

Breast Milk

Exclusively 6 month..

Formula milk

Biscuits milna

Baby biscuits
Fruit and vegetables

Banana, Papaya

History of Immunization

Immunization

Frequency

Time

BCG

1 time

1 month old

Hepatitis B

3 times

0, 1, 6 months old

DPT

3 times

2, 4, 6 months old

Polio

4 times

0, 2, 4, 6 months old

Hib

3 times

2, 4, 6 months old

Measles

Family History
Patients both parents were married
when they were 26 years old and 24
years old, and this is their first
marriage.
There are not any significant
illnesses or chronic illnesses in the
family declared.

History of sibling

Childbirth

Spontan
pervaginam,
gestation aterm

Gender

Age Died

Sumption Died

Age

girl

2 years

old

History of the disease people

around the patient
There is no one living around their
home known for having the same
condition as the patient.

Social and Economic History

The patient lived at the house with size 20m x 10 m
together with father and mother.
There are 1 door at the front side, 1 toilet near the
kitchen and 3 rooms, in which 1 room is the
bedroom of three of them and 1 room is for guest.
There are 4 windows inside the house. The windows
are ocassionaly opened during the day.
Hygiene:
The patient changes his clothes everyday with clean
clothes.
Bed sheets changed every two weeks.

Physical Examination
(December 21 2015)
General Status

General condition : mild ill

Awareness : Compos Mentis
Pulse : 109 x/min, regular, full, strong.
Breathing rate : 29 x/min
Temperature : 39C (per axilla)

Antropometry Status
Weight
height

: 10,5 kilogram
: 80 cm

Nutritional Status based

NCHS (National Center for
Health Statistics) year
2000:
a. WFA (Weight for Age):
10,5/12 x 100 % = 87.5 %
(good nutrition)
b. HFA (Height for Age):
80/86 x 100 % = 93 %
(good nutrition)
c. WFH (Weight for Height):
10,5/11 x 100 % = 95.5 %
Conclusion:
The patient
(normal)
has good nutritional
status.

Systematic Physical Examination

Head

Normocephaly, hair (black, normal distributon, not easily removed)

sign of trauma (-), sunken fontanelle (-).

Eyes

Icteric sclera -/-, pale conjunctiva -/-, hyperaemia conjunctiva -/- ,

lacrimation -/-, sunken eyes -/-, pupils 3mm/3mm isokor, Direct and
indirect light response ++/++

Ears

Normal shape, no wound, no bleeding ,secretion or serumen

Nose

Normal shape, midline septum, secretion +/+

Mouth
Lips
Teeth
Mucous
Tongue
Tonsils
Pharynx
Neck

Dry
No caries
Dry
Not dirty
T1/T1, no hyperemia
Hyperemia
Lymph node enlargement (-), scrofuloderma (-)

Symmetric when breathing , suprasternal and intercostal

retraction (+), ictus cordis is not visible

Thorax
Inspection:
Palpation:

mass (-), tactile fremitus +/+

Percussion:

Sonor on both lungs

Auscultation
Cor :
Pulmo:

regular S1-S2, murmur (-), gallop (-)

vesicular +/+, Wheezing -/- , Rhonchy +/+

Abdomen
:
Inspection :
Palpation

Convex, epigastric retraction (-), there is no a widening of the

veins, no spider nevi.
supple, liver and spleen not palpable, fluid wave (-), abdominal
mass (-)

Percussion:

The entire field of tympanic abdomen, shifting dullness (-)

Auscultation:

normal bowel sound, bruit (-)

Vertebra

Scoliosis (-) kyphosis (-) lordosis(-), any mass along the line
of vertebra (-)

Ekstremities

Warm, capillary refill time <2 second, edema (-)

Skin

Good turgor, makulopapular rash spreading on the

face, neck, chest and thrunk

Laboratory Investigation
Hematology (December 21th 2015)
Hematology

Results

Normal Value

Haemoglobin

11.8 g/dL

13-16 g/dL

Leukocytes

6.400/L

5,000 10,000/L

Hematocrits

36 %

40 48 %

Trombocytes

164.000/ L

150,000
400,000/L

Erythrocytes

4,61 million/L 4 5 million/L

Thorax photo (Dec 21th

2015)
Infiltrate (+) at bilateral parahiler
and paracardial, not seen any limfe
nodes enlargement
Cor, Sinus and Diaphragma on a
normal state
Bone and Tissue on normal limits
Conclussion : Bronchopneumonia
very possible

Working Diagnosis
Bronchopneumonia
Morbili

Management

IVFD RL, micro drip 14 dpm 1000cc/24 hrs

Cefotaxim injection 2x 500 mg, IV
Paracetamol syrup 3x1 cth, oral
Cetirizine syrup 3x1 cth, oral
Ambroxol syrup 3x1 cth, oral
Inhalation :
Oxygen 1 L/Mnt
Ventolin (1,25 mg)
Bisolvon 3 drops twice a day
NaCl 1 cc

PROGNOSIS

dubia ad
bonam

dubia ad
bonam

Quo ad
Quo ad vitam
functionam

dubia ad
bonam
Quo ad
Sanationam

Follow Up Dec 22th 2015

S
O

A
P

2nd day of hospitalization, 6th

day
of illness
Fever (+) Productive cough (+) runny nose (+)
Rash spreading from the face, neck, chest, abdomen, thrunk and proximal of
both extremities (+), Lose appetite (+)
General condition: Compos mentis.
Heart rate
= 100 x/min
Respiratory rate = 26x/min
Temperature
= 38.2C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi +/+, wheezing -/Skin : makulopapular eritema on the face, neck, chest, abdomen, thrunk and
hand proximal of both extremities
Bronchopneumonia
Morbili
Pro Urinalysis
IVFD RL, micro drip 14 dpm 1000cc/24 hrs
Cefotaxim injection 2x 500 mg, IV
Paracetamol syrup 3x1 cth, oral
Cetirizine syrup 3x1 cth, oral
Ambroxol syrup 3x1 cth, oral
Vit A 100.000 IV

Urinalysis Dec 22 2015

th

MACROSCO
PIC

RESULT
S

NORMAL

COLOR

YELOW

CLEARNESS

Slightly
Cloudy

Clear

8.0

5-8.5

DENSITY

1.070

1.000-1.030

PROTEIN

NEGATIVE

BILIRUBIN

GLUCOSE

PH

MICROSCO
PIC

RESULT
S

NORMAL

LEUCOCYTE
SEDIMENTATI
ON

NEGATIVE

Leucocyte

1-2

0-5/LPB

Erythrocyte

0-2

1-3/LPB

Epitel Cell

NEGATIVE

Cylinder Cell

NEGATIVE

Crystal

KETONE

NEGATIVE

Etc

BLOOD/HB

NEGATIVE

NITRIT

NEGATIVE

0.1

0.1-1.0 IU

UROBILINOG
EN

Follow Up Dec 23th 2015

3rd day of hospitalization, 7th day of illness

S
O

A
P

Productive cough (+) runny nose (+)

Lose appetite (+) rash on the face, neck, chest, abdomen, thrunk and proximal
of both extremities (+)
General condition: Compos mentis.
Heart rate
= 100 x/min
Respiratory rate = 25x/min
Temperature
= 37.6C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/Skin : makulopapular eritema on the face, neck, chest, abdomen, thrunk and
hand proximal of both extremities, some of it confluens.
Bronchopneumonia
Morbili
Pro Arterial Blood Gas Analysis
IVFD RL, micro drip 14 dpm 1000cc/24 hrs
Cefotaxim injection 2x 500 mg, IV
Cetirizine syrup 3x1 cth, oral
Ambroxol syrup 3x1 cth, oral
Vit A 100.000 IV

Blood Gas Analysis Dec 23 2015

th

PARAMETE
R
PH

RESUL NORMAL
TS

VALUE

7.47

7.35-7.45

PCO2

26

35-45

mmHg

PO2

114

85-95

mmHg

O2
SATURATIO
N

100

85-95

HCO3

19

21-25

Mmol/L

BE

-3

-2.5 to
+2.5

Mmol/L

SBC

22

22-26

Mmol/L

TOTAL CO2

20

21-27

Mmol/L

-4

-2.4 to
+2.3

Mmol/L

alkalosis respiratorik
IBE

Follow Up Dec 24th 2015

4th day of hospitalization, 8th day of illness

S
O

A
P

Productive cough (+)

Rash on the face, neck, chest, abdomen, thrunk and proximal of both
extremities (+)
General condition: Compos mentis.
Heart rate
= 100 x/min
Respiratory rate = 25x/min
Temperature
= 37.2C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/Skin : maculopapular eritema on the face, neck, chest, abdomen, thrunk and
proximal of both extremities (+) some of it confluens.
Bronchopneumonia
Morbili
Alkalosis Respiratorik
Pro stool analysis test
IVFD RL, micro drip 14 dpm 1000cc/24 hrs
Cefotaxim injection 2x 500 mg, IV
Ambroxol syrup 3x1 cth, oral
Vit A 100.000 IV

STOOL ANALYSIS TEST

(Dec 24th 2015)
MACROSCOPIS

RESULTS

MICROSCOPIS

RESULTS

COLOR

Brown

LEUCOCYTE

1-2 /LPB

CONSISTENCY

Solid,
smooth

ERYTHROCYTE

0-1 / LPB

MUCUS

NEGATIVE

HELMINTH EGG :

BLOOD

NEGATIVE

ASCARIS SP

NEGATIVE

ANCHILOSTOMA
SP

NEGATIVE

TRICHIURIS SP

NEGATIVE

OXYURIS SP

NEGATIVE

Follow Up Dec 25th 2015

5th day of hospitalization, 9th day of illness

S
O

Still have very few rash and cough

Bronchopneumonia
Morbili
Patient can go home
IVFD RL, micro drip 14 dpm 1000cc/24 hrs
Cefotaxim injection 2x 500 mg, IV
Ambroxol syrup 3x1 cth, oral
Vit A 100.000 IV

General condition: Compos mentis.

Heart rate
= 100 x/min
Respiratory rate = 25x/min
Temperature
= 36.6C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/Skin : maculopapular eritema on the skin still visible

TERATURE
ITERATUREREVIEW
REVIEWAND
AND
DISCUSSION
DISCUSSION

CHARACTERISTIC OF MORBILI
Known as : Measles, Rubeola
It is an acute highly contagious viral disease
It has 3 stages of progression; catarrhal, eruption
and convalescence
The latest stage characterized by maculopapular
rash erupting succesively over the neck, face,
trunk, arms and legs.

EPIDEMIOLOGY OF MORBILI
(WHO, 2015)
Leading cause of death in children worldwide
Globally there are 30 million people suffering from
measles.
In Indonesia it is estimated 30.000 children die every
year due to its complications.
Most often in :

Children of school age who have not been immunized

Immunized adolescents and young adults

RISK FACTORS OF MORBILI

(WHO, 2015)
Immunodeficiency, such as HIV/AIDS, leukemia, on
steroid therapy
Travel to endemic morbili area, or contact with
immigrants from endemic area
Infants who lose passive antibody or have not been
immunized
Malnutrition

ETIOLOGY OF MORBILI
Measles virus
RNA virus
From Paramyxoviridea of
genus Morbilivirus

Has envelope with

2 protrusion :
F (fusion) protein,
H (hemoagglutanin)
protein

Transmission : droplets spread, direct contact

through nasal or throat secretions of an

PATHOPHYSIOLOGY OF MORBILI

ERUPTION
CONVALESCENCE

SIGNS AND SYMTOMPS

CATARRHAL

(PRODORMAL)

Occurs for 4-5 days

It starts with sudden high fever (38.5-40 C )
reaching its peak at 5-6 days of illness
Sore throat, cough, runny nose and nasal
congestion (coryza) and conjunctivitis
(redness and watery eye)
Kopliks Spots appear as white spot with
erithematous base on buccal mucosa
It will fading as the appearance of
makulopapular rash on skin

Kopliks Spots

Conjunctivitis

Kopliks Spots

SIGNS AND SYMTOMPS

ERUPTION

The rash begins

first appear on the
forehead (around the
hairline), behind the ears,
as a red maculopapular
eruption, spreads toward
to the neck, torso &
extremities
More confluent on the
upper part, discrete on the

2-4 days post

prodromal
stage

SIGNS AND SYMTOMPS

CONVALESCENCE

In the next 3 -4 days after eruption

The rash fades in the order of
occurrence with hyperpigmentation
Hyperpigmentation is pathognomonic
At this stage the temperature
decreases to be normal unless there
are complications.

DIAGNOSTIC INVESTIGATION
ONLY IF COMPLICATIONS
SUSPECTED

Chest
If bacterial bronchopneumonia
Chest
is suspected
Radiography
Radiography
Complete
CompleteStool
Stool If bacterial enteritis is
Test
Test
suspected
Lumbar
Lumbar
If encephalitis is suspected
Puncture
Puncture
CSF examination reveals : ioncreased protein, normal
glucose, mild pleocytosis with a predominance of
lymphocytes

COMPLICATIONS OF MORBILI
CROUP

Acute
Laryngitis

Bronchopneumonia

Otitis Media

Enteritis

Myocarditis

Tuberculosis

Encephalitis

TREATMENT
SUPPORTIVE
SUPPORTIVE
CARE
CARE

Vitamin
VitaminAA

ANTIVIRAL
ANTIVIRAL
THERAPY
THERAPY
ANTIBIOTIC
ANTIBIOTIC
THERAPY
THERAPY

Maintenance of good hydration

and replacement of fluids lost
continue feeding
Antipyretics for fever at 10-15
mg/kg/dose given every 4 hours

Severe measles, doses :

50 000 IU <6 months
100 000 IU 611 months
200 000 IU 12 month
repeat the next day.
NOT recommended.
Only if there is a sign of bacterial
infection

PREVENTION
Measles vaccine to increase
active immunity
The vaccine contains life
attenuated measles viral
Usually given in combination with
mumps and German measles ( MMR )
first dose : age 12-15 months of age
second dose : age 4-6 years
Vaccine Effectiveness
1-dose: ~93%
2-dose: ~97%

PROGNOSIS
Case Fatality rate higher among
patients :
Younger than 5 y.o.
Malnutrition
Vitamin A Defficiency
Immunodeficiency disease
Inadequate vaccination or
unvaccinated
Low socio-economic

REFERENCES
Chen S. Measles. Available online at :
http://emedicine.medscape.com/article/966220-overview#a6. (Last
update on March 30, 2015).
WHO. Measles. Available online at :
http://www.who.int/immunization/diseases/measles/en. (Last update
on Augustus 13 2015).
Centers for Disease Control and Prevention. Measles (Rubeola).
Available online at : http://www.cdc.gov/measles/about/history.html.
(Last update on November 3, 2014).
Measles Y. Maldonado . In : US Wahab ( editor ) . Nelson Health
Sciences Children , edition to -15 . Jakarta : EGC , 2000. 1608-71.
Jawetz , Melnick JL , Adellberg 's EA . Measles Virus Infection . In :
Brooks GF , Ornston LN , Irawati ( editors ) . Medical Microbiology ,
20th edition Jakarta : EGC , 1996. 542-47
Soegijanto Pediatrics S. Tropical and Infectious diseases . Jakarta :
Agency IDAI Publishers , 2000. 125-40
Tumbelaka AR , et al . Standards of Medical Care Child Health .
Jakarta : Agency IDAI publishers , 2004. 95-98