CASE REPORT

Bronchopneumonia
By Anggi Saktina Sari Batubara 080100357 Wahyu Medsa Yeltas Putra Supervisor 080100364 dr. Selvi Navianti, Sp. A (K)
PEDIATRIC DEPARTMENT FACULTY OF MEDICINE HAJI ADAM MALIK HOSPITAL UNIVERSITY OF NORTH SUMATERA 2012

Definition
Bronchopneumonia

Bronchopneumoni is a lower respiratory tract infection involving the bronchus / bronchioles that from of distribution of spots - spots are caused by a wide - range of etiologies such as bacteria, viruses, fungi, and foreign objects.

EPIDEMIOLOGY
Bronchopneumon ia is estimated that 3.9 million of the 10.8 million deaths in children annually world wide occur in the first 28 days of life. Of 150 neonates with respiratory distress presenting to a referral hospital in India, 103 (68.7%) were diagnosed to have pneumonia. Using a different case definition in a teaching hospital in Brazil, of 318 infants presenting with respiratory distress within the first 4 days of life, bacterial infection was proven on culture in 31 (9.7%), and another 62 (19.5%) had radiographic signs of pneumonia.

Age

Etiology Pathogens

Neonates
(< 1 month) 1-3 months

Group B streptococcus, Streptococcus pneumoniae, haemophilus

influenzae type b, Escherichia coli, Klebsiella sp Respiratory syncytial virus, other respiratory viruses (parainfluenza viruses, influenza viruses, adenoviruses), S. pneumoniae, H.

influenzae type b, Chlamydia trachomatis 3-12 months Respiratory syncytial virus, other respiratory viruses (parainfluenza
viruses, influenza viruses, adenoviruses), S. pneumoniae, H. Influenza type b, C. trachomatis, Mycoplasma pneumoniae, group A streptococcus 2-5 yr 5-18 yr Mycoplasma pneumonia, Chlamydia pneumonia M. pneumoniae, S. pneumoniae, C. pneumoniae, H. Influenza type b, influenza viruses, adenoviruses, other respiratory viruses 18 yr M. pneumoniae, S. pneumoniae, C. pneumoniae, H. influenzae type b, influenza viruses, adenoviruses, Legionella pneumophila

Microorganism

Resolution Stage
inhaled to peripheral lung by respiratory track
increasingly fibrin deposit, there is fibrin and PMN cell founded at alveoli, then degeneration cell, thin fibrin, microorganism and loss debrishment

tissue reaction that may easily proliferating and diffusing microorganism to the other tissues

Infected lung area may there consolidation; there were PMN cell, fibrin, erytrosit, swelling fluid, and microorganism founded at alveoli

Red Hepatisation Stage

DIARRHOE A FEVER

HEADACH E

MALAIS E

NAUSEA

GENERA L
CLINICAL MANIFESTATI ON

VOMITTIN G

COUGH

RESPIRATO RY
RETRACTIO N TACHYPN OE

CYANOSIS AIR HUNGER

DYSPNOE

ANAMNESIS PHYSICAL DX
CHES T XRAY
DIAGNOSI S

WBC COUN T

CLINICAL MANIFESTATION

Condition Bronchitis

Differentiating signs/symptoms Differentiating tests Patient with bronchitis often have a lower grade fever than in patient with The chest radiograph may interpretated by normal pneumonia, and may appear less ill, and no rales on lung examination

Bronchiolitis

Infants with pneumonia generally have higher fever (40C) than with An FBC may demonstrate leukocytosis and neutrophilia in bronchiolitis. pneumonia than in patient with bronchiolitis
Wheezing is not a common finding in pneumonia. While in bronchiolitis is The presence of a focal infiltrate on chest x-ray would more common. increase the suspicion of pneumonia.

Bronchiectasis

Patients with pneumonia describe symptoms of short duration (7 to 10 days), CXR and chest CT results in pneumonia are quite variable as opposed to years in bronchiectasis. and often depend on aetiology. Auscultation findings (rhonchi, wheezing, crackles) may be similar in In bronchiectasis, there is characteristic dilation of bronchiectasis and pneumonia, especially multi-lobar pneumonia. Bronchial bronchi with or without airway thickening. breath sounds, which are characteristic of pneumonia, are not present in bronchiectasis. Consolidation, which is seen in pneumonia, is not seen in bronchiectasis.

Asthma

Patients with asthma have bilateral wheezing; In asthma, bronchospasm is PFT may be useful to diagnose asthma in patients who recurrent and progressive. have residual obstructive findings. Dyspnoea and tachypnoea are common before intubation. If ARDS is The ratio of FiO2 to PaO2 <200 supports ARDS in the secondary to an infection, a fever will be present. Furthermore, fever is a context of a diffuse opacity. feature of fibroproliferative ARDS. Patients are typically intubated and sedated and therefore a common method of diagnosis is generalised pulmonary opacity seen on CXR. A viral infection of the upper airways, often caused by parainfluenza viruses. Characterised by fever, inspiratory stridor, and a barking cough. Symptoms often worsen at night. Diagnosis is usually clinical. Sub-glottic narrowing may be seen on an AP neck radiograph; however, this investigation is rarely indicated.

ARDS

Laryngotracheobronchitis (croup)

Tuberculosis

A history of immunosuppression or prolonged course that is not responding to Sputum cultures and acid fast bacilli stains positive. A antibacterial therapy suggests tuberculosis. cavity on the CXR may be observed.

Atelectasis

Usually not hypoxic or febrile, although a low-grade fever may be present.

Leukocytosis and sputum production may or may not be present.

Opacities on a CXR tend to be more linear than lobar

Treatment
ANTIBIOTIC THERAPY

1st Line : -lactam 2nd Line: Cephalosporin 3th Line : Carbapenem 4th Line : Aminoglycosides Fluid Therapy Oxygen Therapy Antitussive Remedies Chest Physiotherapy

SUPPORTIV E THERAPY

Prognosis
Most children recover from pneumonia rapidly and completely

The prognosis for varicella pneumonia is somewhat more guarded. Staphylococcal pneumonia, although rare, can be very serious despite treatment.

Prevention
Breast feeding to prevent viral infections get limit the spread of viral infections (e.g., hand washing)

VACCINATION
Haemophilus influenza type B vaccine Influenza vaccine is recommended for high-risk children conjugated pneumococcal vaccine

CASE
CH, 2 months old girl, weight 2,7 Kg, height 42 cm, was admitted to Haji Adam Malik Hospital at the Infection Unit Pediatric Department on February 2nd 2012 with the main complaint of difficulty breathing. It started 2 weeks old and was not associated with weather or activity. Cough was found, since 2 weeks ago, phlegm was found, and was not easily let out. Fever not found but was having history for recurrent fever and decreased with fever medicines. History of seizures was not found. History contact with long-term coughing adult was not found. History for drinking dropouts not found. Atopy in the family was not found.

 History of previous disease: This baby was reconciliation

from Pirngadi Hospital with diagnosis Bconchopneumonia and hospitalization fot 1 day.\ History of medication: Ceftazidine 100 gr/12 hour (IV) and Nebule Ventolin Fls + Ambroxol 1 cc/8 hour History of pregnant : Never take drugs, Hypertension (-), Diabetes Melitus (-) History of birth: SC birth, with the help of doctor in RSU Dr. Pirngadi Medan, and have a birth weight 2300 gram. Never have a immunization till now

Physical Examination: Sensorium : Compos mentis, BW= 2,7 Kg, BL= 46 cm, BBI= 3900, Temp. = 36.6 0C Head circumfence: 34 cm Anemia (-), edema (-), cyanosis (-), icteric (-), dyspnoe (+) Head : Eye: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra(-/-). Edema palpebra (-/-). Ear/Nose: nasal flare (+), mouth: normal Neck : Lymph node enlargement (-) Thorax : bulging (+), retraction (+), epigastrial suprasternal and intercostal HR= 142 bpm, regular, murmur (-) RR= 52 rpm, reg, rales(+) on the right side, Long expiration, wheezing (-) Abdominal : Soepel, peristaltic (+), liver and spleen not palpable Extremities : Pulse =142 bpm, regular, adequate pressure/volume, BP=110/60 mmHg. Warm Acral, CRT < 3

Chest X-Ray:

CTR < 55% , heart is dilated, costa well, not widened superior mediastinum. Trachea in the middle, two hilus is not widened. Inhomogen consolidations view on the both side of lung. Sinus and costofrenikus good. The bones of the chest either.

COMPLETE BLOOD COUNT Hemoglobin (Hb) : 10.5 % Erytrocyes (RBC) : 3.17 x 106/mm3 Leucocytes (WBC) : 8.30 x 103/mm3 Hematocrit : 28.80 % Thrombocyte (PLT) : 233 x 103/mm3 MCV : 90.90 fL MCH : 30.00 pg MCHC : 33.00 g% RDW : 13.00 % MPV : 11.00 fL PCT : 0.08 % PDW : 12.3 Cell count: Neutrophil : 23.20 % Lymphocyte : 65.80 % Monocyte : 10.40 % Eosinophil : 0.10 % Basophil : 0.500 %

BLOOD GAS ANALYSIS pH : 7.483 pCO2 : 32.2 mmHg pO2 : 180.2 mmHg Bicarbonate (HCO3) : 23.6 mmol/L Total CO2 : 24.6 mmol/L Base Excess (BE) : 1.0 mmol/L O2 Saturation : 98.9% LIVER FUNCTION TEST AST/SGOT : 40 U/L ALT/SGPT : 23 U/L RENAL FUNCTION TEST Ureum : 14.00 mg/dl Creatinin : 0.20 mg/dl ELECTROLIT Natrium (Na) : 136 mEq/L Kalium (K) : 4.9 mEq/L Klorida (Cl) : 99 mEq/L

Differential Diagnose:

- Bronchopneumonia + malnutrition - Bronchiolitis + malnutrition - Bronkitis akut + malnutrition

Working Diagnose: Bronchopneumonia + malnutrition

Management: Oxygen 1-2 L/minute IVFD D5% NaCl 0.225% 10 gtt/minute Ampicillin injection 50mg / 6 hours /iv Gentamycin injection 14mg /24hours/iv Parasetamol syrup 3x 40 mg Diet ASI/PASI 30 cc/3 hours via NGT (neosure) Nebule ventolin 1 Respule + Nacl 0,9% 2,5 cc/8 hours Investigation Planning: Complete blood count Blood gases analysis Culture blood and sensitivity test

FOLLOW UP:
Follow Up February 3th 2012 S : Difficulty breathing (+), Cough (+), fever (-) O: Sens: CM, T: 36.9 0C, BW = 2,7 kg, BL = 46 cm Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra (-/-). Edema palpebra (-/-).Nose: nasal flare (+), Ear/ mouth: within normal limit Neck Thoraks : Lymph nodes enlargement (-) : bulging (+), retraction (+), epigastrial, intercostal HR = 140 bpm, regular, murmur (-) RR = 52 tpm, regular, rales (+) on the both side of lung, wheezing (-) Abdominal : Soepel, normal peristaltic, liver and spleen not palpable Extremities : Pulse = 140 bpm, regular, adequate pressure/volume, BP = 110/70 mmHg

A : - Bronchopneumonia + Malnutrition Bronchiolitis + Malnutrition

P: O2 1-2 L/minute

IVFD D5% NaCl 0.225% 10 gtt/minute

Ampicillin injection 50mg / 6 hours /iv Gentamycin injection 14mg /24hours/iv Parasetamol syrup 3x 40 mg Diet ASI/PASI 30 cc/3 hours via NGT (neosure) Nebule ventolin 1 Respule + Nacl 0,9% 2,5 cc/8 hours

Test (03-02-2012)
BLOOD GAS ANALYSIS pH

Result

Normal value

7.353

7.35-7.45

pCO2
pO2 Bicarbonate (HCO3) Total CO2 Base Excess (BE) O2 Saturation

50.2 mmHg
74.3 mmHg 27.3 mmol/L 28.8 mmol/L 0.9 mmol/L 94.2%

38-42
85-100 22-26 19-25 (-2)-(+2) 95-100

Kultur Sensitivity (api 20E) (darah)

Tidak dijumpai pertumbuhan bakteri

Follow Up February 4th 2012 S : Difficulty breathing (+), fever (-) O: Sens: CM, T: 37.1 0C, BW = 2,7 kg, BL = 46 cm

Head

: Eyes: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra (-/-).
Edema palpebra (-/-).Nose: nasal flare (+), Ear/ mouth: within normal limit

Neck Thoraks

: Lymph nodes enlargement (-) : Bulging, retraction (+), epigastrial, intercostal HR = 112 bpm, regular, murmur (-) RR = 36 tpm, regular, rales (+) on right side of lung, Wheezing (-)

Abdominal : Soepel, normal peristaltic, liver and spleen not palpable Extremities : Pulse = 108 bpm, regular, adequate pressure/volume, BP = 110/60 mmHg A : - Bronchopneumonia + Malnutrition

P:

Bronchiolitis + Malnutrition

O2 1-2 L/minute IVFD D5% NaCl 0.225% 10 gtt/minute Ampicillin injection 50mg / 6 hours /iv Gentamycin injection 14mg /24hours/iv Parasetamol syrup 3x 40 mg Diet ASI/PASI 30 cc/3 hours via NGT (neosure) Nebule ventolin 1 Respule + Nacl 0,9% 2,5 cc/8 hours

Follow Up January 5th 2012 S : Difficulty breathing (+), cough (+), fever (-) O: Sens: CM, T: 37.1 0C, BW = 2,7 kg, BL = 46 cm Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra (-/-). Edema palpebra (-/-).Nose: nasal flare (-), Ear/ mouth: within normal limit Neck Thoraks : Lymph nodes enlargement (-) : bulging (+), retraction (+), epigastrial, suprasternal HR = 110 bpm, regular, murmur (-) RR = 34 tpm, regular, rales (+) on the both side of lung. Abdominal : Soepel, normal peristaltic, liver and spleen not palpable Extremities : Pulse = 110 bpm, regular, adequate pressure/volume, BP = 110/60 mmHg A : - Bronchopneumonia + Malnutrition Bronchiolitis + Malnutrition

P:
Head Box 5 L/minute IVFD D5% NaCl 0.225% 4 gtt/minute Ampicillin injection 50mg / 6 hours /iv Gentamycin injection 14mg /24hours/iv Parasetamol syrup 3x 40 mg Diet ASI/PASI 30 cc/3 hours via NGT (neosure) Nebule ventolin 1 Respule + Nacl 0,9% 2,5 cc/8 hours

Follow Up January 6th 2012

S : Difficulty breathing (+), cough (+) fever (-)

O: Sens: CM, T: 37.1 0C, BW = 2,7 kg, BL = 46 cm Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra (-/-). Edema palpebra (-/-).Nose: nasal flare (-), Ear/ mouth: within normal limit Neck : Lymph nodes enlargement (-)

Thoraks

: bulging (+), retraction (+), epigastrial, suprasternal

HR = 108 bpm, regular, murmur (-) RR = 36 tpm, regular, rales (+) on the both side of lung

Abdominal : Soepel, normal peristaltic, liver and spleen not palpable Extremities : Pulse = 110 bpm, regular, adequate pressure/volume, BP = 110/60 mmHg A : - Bronchopneumonia + Malnutrition P: Head Box 2,5 L/minute Bronchiolitis + Malnutrition

IVFD D5% NaCl 0.225% 4 gtt/minute

Ampicillin injection 50mg / 6 hours /iv Gentamycin injection 14mg /24hours/iv Parasetamol syrup 3x 40 mg Diet ASI/PASI 30 cc/3 hours via NGT (neosure) Nebule ventolin 1 Respule + Nacl 0,9% 2,5 cc/8 hours Chest Fisioterapi

Follow Up January 7th 2012 S : Difficulty breathing (+)

O: Sens: CM, T: 37.1 0C, BW = 2,7 kg, BL = 46 cm

Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra (-/-). Edema palpebra (-/-).Nose: nasal flare (-), Ear/ mouth: within normal limit Neck Thoraks : Lymph nodes enlargement (-) : bulging (+), retraction (+), epigastrial, suprasternal HR = 112 bpm, regular, murmur (-) RR = 40 tpm, regular, rales (+) on the both side of lung Abdominal : Soepel, normal peristaltic, liver and spleen not palpable Extremities : Pulse = 110 bpm, regular, adequate pressure/volume, BP = 110/60 mmHg A : - Bronchopneumonia +Moderate Malnutrition Bronchiolitis + Moderate Malnutrition

P: Head Box 2,5 L/minute IVFD D5% NaCl 0.225% 4 gtt/minute Ampicillin injection 50mg / 6 hours /iv Gentamycin injection 14mg /24hours/iv Parasetamol syrup 3x 40 mg Diet ASI/PASI 30 cc/3 hours via NGT (neosure) Nebule ventolin 1 Respule + Nacl 0,9% 2,5 cc/8 hours Chest Fisioterapi

Follow Up January 8th 2012 S : Difficulty breathing (+) O: Sens: CM, T: 37.1 0C, BW = 2,7 kg, BL = 46 cm Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra (-/-). Edema palpebra (-/-).Nose: nasal flare (-), Ear/ mouth: within normal limit Neck Thoraks : Lymph nodes enlargement (-) : bulging (+), retraction (+), epigastrial, suprasternal HR = 122 bpm, regular, murmur (-) RR = 40 tpm, regular, rales (+) on the both side of lung Abdominal : Soepel, normal peristaltic, liver and spleen not palpable Extremities : Pulse = 110 bpm, regular, adequate pressure/volume, BP = 110/60 mmHg

A : - Bronchopneumonia +Moderate Malnutrition

P: Head Box 2,5 L/minute IVFD D5% NaCl 0.225% 4 gtt/minute Ampicillin injection 50mg / 6 hours /iv Gentamycin injection 14mg /24hours/iv Parasetamol syrup 3x 40 mg Diet ASI/PASI 30 cc/3 hours via NGT (neosure) Nebule ventolin 1 Respule + Nacl 0,9% 2,5 cc/8 hours Chest Fisioterapi Bronchiolitis + Moderate Malnutrition

Test (08-02-2012) BLOOD GAS ANALYSIS pH

Result

Normal value

7.399

7.35-7.45

pCO2
pO2 Bicarbonate (HCO3) Total CO2 Base Excess (BE) O2 Saturation

41.3 mmHg
166.7 mmHg 25.0 mmol/L 26.2 mmol/L 0.1 mmol/L 99.1%

38-42
85-100 22-26 19-25 (-2)-(+2) 95-100

Follow Up January 9th 2012 S : Difficulty breathing (+) O: Sens: CM, T: 37.1 0C, BW = 2,7 kg, BL = 46 cm Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra (-/-).

Edema palpebra (-/-).Nose: nasal flare (-), Ear/ mouth: within normal limit
Neck Thoraks : Lymph nodes enlargement (-) : bulging (+), retraction (+), epigastrial, suprasternal HR = 112 bpm, regular, murmur (-) RR = 40 tpm, regular, rales (+) on the both side of lung Abdominal : Soepel, normal peristaltic, liver and spleen not palpable Extremities : Pulse = 110 bpm, regular, adequate pressure/volume, BP = 110/60 mmHg

A : - Bronchopneumonia +Moderate Malnutrition P: O2 nasal canule 1 L/minute

IVFD D5% NaCl 0.225% 4 gtt/minute

Ampicillin injection 50mg / 6 hours /iv Gentamycin injection 14mg /24hours/iv Parasetamol syrup 3x 40 mg Diet ASI/PASI 30 cc/3 hours via NGT (neosure) Nebule ventolin 1 Respule + Nacl 0,9% 2,5 cc/8 hours Chest Fisioterapi

DISCUSSION
THEORY
fever, productive cough

CASE
weeks ago, having history fever, fever decreased with fever medicines, Cough productive and was not easily let out

Bronchopneumonia is characterized by dyspnea, This patient was dyspnea has been experienced since 2

Physic examination : Head : Nose: nasal flare Thorax : Auskultasion :the voice accompanied by This patient was nasal flare, breath Thorax : Auscultasion : crackle found on the both side of lung This Patient Both sinus and diaphragma are normal, Consolidation inhomegen: infiltrates found on the both side

respiratory hardened Ronchi Radiology : The spotted consolidation in lobe

of lung
Treatment :O2 1-2 l/i, antibiotic (Ampicillin, Treatment : O2 1 L/i, IVFD D5% NaCl 0.225%, Antibiotic Gentamicin), paracetamol mucolitic. for this case are Ampicillin and Gentamycin, Parasetamol, Nebule ventolin 1 Respule + Nacl 0,9% 2,5

SUMMARY
This report is about a case of a 2 months old girl with bronchopneumonia. The diagnosis was established based on history taking, clinical manifestations, radiology and laboratory findings. This patient was given antibiotics in treating the cause, and supportive treatment.