Post on 27-Dec-2015
Sunil Kamath MDPost-Doctoral Fellow
Childrens Hospital Los Angeles
Pediatric Pulmonary Case Conference
HPI
6 month old male with no significant PMH3/17
cough, rhinorrhea, nasal congestion, Fever 101cranky and NBNB emesis x 1
3/18 "moaning" while breathingPMD diagnosed a URI and pt. was sent homedeveloped subcostal retractions and taken to outside ED
where he received breathing treatments, improved, and was discharged home
3/19Irritable and had subcostal retractionsReturned to outside ED
ED Course
Persistent retractions and pale
SpO2 71% placed on O2 “pinked up”
Received continuous aerosol treatments
Transferred to outside hospital PICU for further care with
the presumptive diagnosis of bronchiolitis
FT, NSVD, no complications, home on DOL 2Surgical history: noneNKDAImmunizations: has not received 6 month
vaccinationsDiet: Enfamil 6oz TID, baby foodsFamily History: father with bronchitis as a childSocial History: Lives with mother, father and 2
yo sister, no tobacco exposure, no petsAll other ROS negative
Outside Hospital Physical ExamVS:
Temp: 36.7 CHR: 174 bpmRR: 53 breaths per minuteBP: 98/67 mmHgSpO2: 98% on 1.5 LPM via NC
PE:General: Awake in mild/moderate respiratory distress with
subcostal retractionsResp: Coarse breath sounds bilaterally. + Rhonchi. No
Wheezing.Heart: RRR. Normal S1 and S2
Labs
18.3 \ 10.7 / 334
/ 36 \ 149 107 8 149 Ca:9.8
5.1 21 0.4Respiratory culture – Negative for bacteriaRSV DAA – negativeInfluenza DAA – negativeTotal IgG, IgA, IgM, IgE – normalCXR
Outside Hospital Course3/20 Intubated for worsening respiratory distress HFOV x 1
weekStarted on ABX and steroids
3/25 ETT viral culture: Adenovirus (not typed)3/30 DVT of right leg Rx Lovenox4/11Extubated to HFNC and steroids were weanedDeveloped wheezing, prolonged expiratory phase, increasing
distress IV steroids were re-started and patient improved5/4 Changed to Prednisone 5mg BID and transferred to the floor 5/5 MSSA bacteremia Rx oxacillin5/6 Developed increased tachypnea with nasal flaring and
fatigue during feeding5/6 Chest CT
consolidation of RLL and LUL with associated cylindrical bronchiectasis
5/7 Transferred to CHLAVS
Temp: 37.9 deg CHR: 148 bpmRR: 38 Breaths/MinBP: 144/90 mm HgSpO2: 99% on ½ LPM
PEGeneral Appearance: laying in bed, moderate respiratory
distress, becomes fearful with examChest: symmetric chest rise, subcostal retractionsRespiratory: diffuse crackles, wheezing, forceful expiration
with gruntingCardiovascular: RRR, no m/r/g, 2+ pulses
Labs18.72 \ 11.5 / 557
/ 35.9 \ Segs 44, Bands 0, Lymph 42, Mono 13, Baso 0, Eos 1
139 97 11 123 Ca:9.9
5 32 0.2
CBG: 7.46/50//36
“The lungs are hyperinflated. There is streaky perihilar disease with peribronchial thickening bilaterally.”
What is your assessment and plan?
Hospital CoursePlan: chest CT, bronchoscopy, lung biopsy, and iPFT when
stable5/10 SCINTI: normal5/11 ECHO
Small secundum atrial septal defect vs. patent foramen ovale.No evidence of PHTN
5/13 MBSS: normal5/18 Wheezing. Prolonged expiratory phase. Increasing
respiratory distress. Prednisone Solumederol5/21 Admitted to the PICU for stabilization and repeat CT
scan5/24 RV panel: negativeImmunology workup: unremarkable
Template
progression of bronchiectasis and scattered areas of groundglass opacity
What is your management plan?
Management
Bronchiolitis Obliterans:Azithromycin (5mg/kg QMWF)Methotrexate (10-15mg/m2/dose SQ Qwk)Continued IV steroids
5/25 Developed thick secretions and was difficult to ventilateEmpirically started on Vanc and ZosynTrach cult (Many Haemophilus influenzae, Beta lactamase
negative) Ceftriaxone
PICUadmit
Intubated
Azithro
MTX
Extubated
ABX started
IV steroids
Bronchiolitis Obliterans
Rare form of chronic obstructive lung disease that occurs after an insult to the lower respiratory tract
Etiology:
Bronchiolitis Obliterans in Children. Pediatric Pulmonology 39:193-208 (2005)
Pathophsiology:Inflammation and fibrosis of the terminal and
respiratory bronchioles narrowing and/or complete obliteration of the airway lumen
Bronchiolitis Obliterans in Children. Pediatric Pulmonology 39:193-208 (2005)
Kumar: Robbins and Cotran Pathologic Basis of Disease, Professional Edition , 8th ed.
Diagnosis:CXRPFTBronchoscopy - neutrophilia HRCT: mosaic patternOpen lung biopsy:
Sampling error due to patchy airway involvement 2 categories:
proliferative bronchiolitis (intraluminal polyps) constrictive bronchiolitis (peribronchiolar fibrosis)
TreatmentSupportive careSteroidsImmune modulators
Thank You