Download FFA Accretion in Neonate Baboon CNS

Clinical Pathologic Conference
R1曾敏華 / 洪志興主治醫師
Chief complaint

A 5 year-old boy was admitted because of fever off and
on with chillness, cough with whitish sputum and chest
pain for 3 days.
Present illness

About 1 week before this episode (10 days before
arrival), he suffered from several times of watery
diarrhea.

He had chest wall injury while he was playing with his
friend.

3 days before admission, fever off and on with
chillness, cough with whitish sputum and chest pain
were noted.
Present illness



The pattern of chest pain:
-No relieve or aggressive factor
-No radiating pain.
-Did not improved despite of medication.
1 day before admission, dyspnea after climbing
upstairs and palpitation was also noted.
He was brought to ER on the day of admission, and
short of breath, pale lips, pale conjuntivae were found
and vomiting for 3 times at ER.
Present illness


Throughout the whole course of present illness, he had
no skin rash, headache, abdominal discomfort and
urinary change.
His appetite and activity were good.
Past,Personal and Family History

Past history
-Allergic rhinitis
-Hydronephrosis, left.
-Asthmatic bronchitis
-Urethritis
-Acute gastritis
Past,Personal and Family History




Birth history:
-GA: 38 weeks via C/S, Birth weight: 3700 gm
Developmental History: normal
No travel history.
Family history: Grandfather: had been working at mine,
(礦物局) driver.
: No any family member has the same
symptoms like him.
Physical examination

Vital sign: PR: ↑ 132 /min (65-110), RR: ↑ 36 /min(2025), BT: 37 ºC

HEENT: Pale conjunctiva/ lip , grade 1/4 of tonsils,
: congested throat
Chest wall: A tender mass 2 × 3-cm in size at his forechest wall.
: Coarse breathing sound

Lab. data
0905(admission)
B/R:
-WBC:14,620 (5,5-15,5 x10 3)
-RBC: 4.72 x10 6 (3.9-5.3 x10 6 ) , Hct:33.4%
-Hgb: 11.3 ( 6mo-6 yr: 10.5 - 14) Nelson 17 ed Table 439-1
-MCV: 70.9 (6 mo-6 yr: 70-74) Nelson 17 ed Table 439-1
-MCH: 24 (24-30)
-MCHC: 33.8(31-37)
-PLT: 244 x10 3 (150-450 x10 3 )
-Neut. ↑ 77.1% (54-62%); LYM.:25% (25-33%); Mon.:4.9 %(3-7%); Eos.:0.5 %(1-3%)
Lab. data
0907(hospitalization)
B/R:
-WBC:10,380 (5,5-15,5 x10 3)
-RBC: 4.65 x10 6 (3.9-5.3 x10 6 ), Hct:33.4%
-Hgb: 11.0 ( 6mo-6 yr: 10.5 - 14) Nelson 17 ed Table 439-1
-MCV: 69.7 (6 mo-6 yr: 70-74) Nelson 17 ed Table 439-1
-MCH: 23.7 (24-30)
-MCHC: 34(31-37)
-PLT: 234 x10 3 (150-450 x10 3 )
-Neut. ↑ 65 % (54-62%); LYM.:25% (25-33%); Mon.:8 %(3-7%); Eos.:2 %(1-3%)
Lab. data







Mycoplasma AB: < 40 (-)
CRP: ↑2.93 (0.17-1.07)
BUN / Cr: 10 / 0.4
CPK: 50 U/L(5-110); CK-MB: 1 U/L: 2 %(1.7-7.9 %)
Glucose: 158 mg/dL
Na/ K/ Cl: 136/↓3.4/ 100
Total Ca: 9.3
Lab. data

Urine routine:
- pH: 6.0
-Protein: +/-RBC: 0-1/ HPF
-WBC: ↑ 5-10/ HPF (Children 0–5/ hpf )
-Spgr: 1.017
Hospital course :


After admission, CxR was taken, and draws blood
samples.
He was discharged to home after a series of studies
and treatment.
Problem list
Major problems:
 Chest pain
 Short of breath/
dyspnea
 Chest wall mass
 Fever, cough
 Vomiting
 Diarrhea
Minor problem
 Pale conjuntivae/ lip
 Hyperglycemia
 Pyuria (U/R) ?
Questions?










Correlation between chest injury and chest pain/ chest mass?
Chest mass location ? Rib, costochondritic joint, intercostal
muscle or sternum?
Chest wall mass: Mobile or immobile? Warm/ heat? fluctuant ?
Chest pain: sudden onset or progressive?
Needle aspiration (culture)? Mass biopsy ?
Viral culture (throat)?
CxR ? Patchy infiltration? Hilar lymphoadenopathy?
Body weight loss? Night sweating? FHx of TB? Medication Hx?
EKG ?
Sputum culture?
Chest pain: possible differential diagnosis




Infectious costochondritis: Tietze syndrome
Pleurodynia
Pneumonia: Pyogenic Empyema Necessitatis
Musculoskeletal chest wall pain: Osteomyelitis
Dyspnea: possible mechanism
Pediatric Respiratory Medicine P370




↓Pulmonary compliance: Inflammation
↑Airway Resistance:
Airway inflammation & hyperreactivity
↑Sensory Stimuli: Chest wall
↑Chemical Stimuli: Hypoxemia, CO2, Acidosis
Chest wall lesions in childhood

A wide range of pathologies.
I. Benign lesions: include
a. Lipoma /Lipoblastoma: usually painless, occur in the
first 2 years
b. Neurofibroma: Painless, associated with
neurofibrosis type I
c. Lymphangioma: Painless,associated with a variety
of other syndromes such as
asplenia,Noonan’s syndrome, and
tuberculosis.
Chest wall lesions in childhood
d. Haemangioma and AVM
: congenital lesions.
e. Mesenchymal hamartoma
: benign lesion of infancy with most lesions presenting
before 2 years of age.
Chest wall lesions in childhood
II. Malignant lesions: include
a. Neuroblastoma: occur before 5 years of age,
abdominal mass
b. Rhabdomyosarcoma:common found in head/ neck or
extremities
c. Ewing’s sarcoma, Askin tumour, Primitive
neuroectodermal tumours:
: all belong to the group of small round blue
cell tumor of childhood.
: Usually presenting in the second decade of life.
Chest wall lesions in childhood
II. Manifestations of systemic diseases:
e. Leukaemia/ Lymphoma
: always be excluded in a child
: presenting with multiple bone lesions or
bone pain, hematologic finding.
f. Langerhans cell histocytosis
Chest wall lesions in childhood
III. Infections
a. Tuberculosis:
-TB on the chest wall can occur as an isolated
primary infection with no evidence of pulmonary
disease
- Spread to the chest wall from pulmonary infection
may also occur althrough symptoms may be minor
- Presentation may be similar to pyogenic abscess or
simply an enlarging mass.
Chest wall lesions in childhood
b. Actinomycosis : rare, may mimic TB with pulmonary
infiltration and spread to the chest wall
c. Aspergilosis: in immunocompromised patients, usually
by local invasion from the lung.
d. Progenic abscess
: Staphylococcus, Klebsiella infection
e. Other infection illness: Strongyloidiasis (Strongyloides
stercoralis)糞小桿線蟲
Chest wall lesions in childhood
IV. Other lesions:
a. Pseudo-lesions: found in cildren of early teenage
years presenting with a hard lump
in costochondral cartilage.
: Usually no specific symptoms.
b. Thoracic cage anomalies,osteochondroma,
hemangiopericytoma
Chest wall mass: possibile DDx




Tuberculosis
Actinomycosis
Pyogenic abscess
Strongyloidiasis (Strongyloides stercoralis)
Differential diagnosis
Chest mass
Chest pain
Tuberculosis
Infectious
costochondritis:
Tietz syndrome
Pleurodynia
Pneumonia- Pyogenic Empyema
Necessitatis
Osteomyelitis
Actinomycosis
Pyogenic
abscess
Strongyloidiasis
Dyspnea
↑Airway
Resistance:
Airway inflammation &
hyperreactivity
↓Pulmonary compliance:
Inflammation
↑Sensory
Stimuli:
Chest wall
↑Chemical Stimuli:
Hypoxemia, CO2, Acidosis
1. Tietze syndrome: infectious costochondritis

Inflammation of the costal cartilages (Costochondritis) with a
large, tender, fusiform (spindle-shaped), nonsuppurative
swelling at the costochondral or chondrosternal junction.
Principles and Practice of Pediatric Infectious Diseases, 2nd ed

Etiology:
-Exact cause unclear
-Most often idiopathic
-Associated with excessive exercise, chest injury or a preceding
viral respiratory illness (postinfectious)
1. Tietze syndrome



Epidemiology
-Generally occurs in late teens to early twenties, but has been
described in young children.
S/s: sharp pain in anterior chest wall, may radiate to
back or upper abdomen.
: varies in intensity and quality.
PE: Tender by palpation at local site or movements of
the arm or shoulder.
:May show evidence of tachypnea, tachycardia or
systolic HTN.
: Distortion of local soft tissue.
1. Tietze syndrome
Diagnostic workup
-Made with historical and physical clues.
-Biopsy: increased cartilage and lack of inflammatory
fibrosis.
 Management:
NSAIDs, Injections into the painful area with
triamcinolone are sometimes curative.
Question: Fever ? preceding viral respiratory illness?

2. Pleurodynia
Nelson 17ed p1045, Principles and Practice of Pediatric Infectious Diseases, 2nd ed P1183


Etiologic agents are most frequently coxsackieviruses B3 and
B5, as well as coxsackieviruses B1 and B2 and echoviruses 1
and 6.
Nelson 17ed p1045
Sex: Males are affected more than females. Half of these
patients are younger than 5 years, and 30% are younger than 1
year.

Coxsackievirus B usually causes an asymptomatic or brief
upper respiratory tract or gastroenteric infection. Nelson 17ed p1045

The virus has an incubation time of 1 week in the GI tract and
subsequently involves the target organs through hematogenous
dissemination.
2. Pleurodynia
Nelson 17ed p1045, Principles and Practice of Pediatric Infectious Diseases, 2nd ed P1183

Prodromal symptoms such as malaise, myalgias, headache
and diarrhea are followed by sudden onset of fever and pain.
Principles and Practice of Pediatric Infectious Diseases, 2nd ed P1183

Involvement of the intercostal and other muscles of respiration
results in enhanced pain with deep breathing and a sensation of
“pleuritic” pain that can result in splinting of the chest and rapid,
shallow breathing.
Principles and Practice of Pediatric Infectious Diseases, 2nd ed P1183


Pain, typically located in the chest or upper abdomen, and is
spasmodic and can be excruciatingly severe. Nelson 17ed p1045
During spasms, respirations are usually rapid, shallow, and
grunting, pale, sweaty, and shock-like appearance.Nelson 17ed p1045
2. Pleurodynia
Nelson 17ed p1045, Principles and Practice of Pediatric Infectious Diseases, 2nd ed P1183



Causes necrosis of the striated intercostal muscles in patients
with pleurodynia.
Muscle tenderness can be detected by direct palpation; less
commonly, localized swelling is observed ( Sylvest, 1934 )
Associated symptoms related to the viral infection may include
the following:
-Upper respiratory tract symptoms, including sore throat, rhinitis,
and cough.
-Constitutional symptoms, including headaches (50%), fever,
and malaise
2. Pleurodynia
Nelson 17ed p1045, Principles and Practice of Pediatric Infectious Diseases, 2nd ed P1183
-GI symptoms, including nausea, vomiting, diarrhea (50%), and in
children, abdominal pain (usually in the epigastric area)
 Diagnosis:
-Viral cultures(throat) isolation of coxsackievirus B in cell
cultures .
-RT-PCR(throat)
-Histologic Findings: Necrosis of the striated intercostal muscles
is visible .
-Serum creatine kinase is usually elevated because of muscle
necrosis.
-CxR: reveals clear lung fields; less than 10% of patients have a
pleural friction rub or pleural fluid evident on chest radiographs.
2. Pleurodynia
Nelson 17ed p1045, Principles and Practice of Pediatric Infectious Diseases, 2nd ed P1183




Illness usually lasts 3–6 days, but can last up to a
couple of weeks.
Illness may occasionally be associated with meningitis,
orchitis, myocarditis, or pericarditis.
Management:
-Analgesics and limitation of physical activity are helpful in
reducing pain, which is generally most severe on
presentation and then progressively diminishes during the
course of illness (which is typically 4 to 6 days but which
may last as long as 3 weeks) ( Warin et al., 1953)
Question: Serum creatine kinase within normal range
3. Tuberculosis
Principles and Practice of Pediatric Infectious Diseases, 2nd ed
I. Bony tuberculosis
 Osteomyelitis is otherwise most frequently found in the
metaphysis of long bones, although the ribs, pelvis
and skull may be infected.
 In children in countries in which TB is prevalent,
osteomyelitis is a significant cause of crippling
deformity.
 Trauma does not predispose to tuberculous
osteomyelitis
3. Tuberculosis
Principles and Practice of Pediatric Infectious Diseases, 2nd ed


Bony TB may be accompanied by sinus tracts or soft
tissue masses.
Diagnosis:
-May be difficult because lesions can appear osteolytic
or sclerotic on radiography.
-Biopsy : acid-fast bacilli (AFB) stains, culture or PCR
3. Tuberculosis
Principles and Practice of Pediatric Infectious Diseases, 2nd ed
II. Tuberculous abscesses:
 May form in most soft tissues, including muscle .
 This is usually secondary to contiguous spread of infection but
may follow hematogenous dissemination.
 The classic abscess site is in the psoas muscle, and such an
abscess can occur with or without localizing signs
 Cough, diarrhea and vomiting can be happened, but rare and
chronic when the pulmonary and gastointestinal were involved.
 Question: Contact history? insidious enlarging mass? Chronic
steroid usage? Body weight loss? Night weating?
4. Actinomycosis



Nelson Textbook of Pediatrics, 17th
Actinomyces israelii , a slow-growing, gram-positive bacteria
that are part of the normal oral flora in humans.
Infection caused by these bacteria is termed actinomycosis,
which is a chronic, granulomatous, suppurative disease
characterized by peripheral spread with extension to contiguous
tissue in the formation of numerous draining sinus tracts.
7% of the patients <10 yr of age. The youngest patient in this
series was 28 days old.
4. Actinomycosis




Nelson Textbook of Pediatrics, 17th
Actinomycosis is usually not an opportunistic infection, disease has been
described in patients receiving corticosteroids and those with leukemia,
renal failure, congenital immunodeficiency diseases, and HIV infection
three important sites of Actinomyces infection in order of frequency are
cervicofacial, abdominal, and thoracic
Pulmonary actinomycosis may present as fever, productive cough, chest
pain, and weight loss.
Infection frequently dissects along tissue planes and may extend through
the chest wall or diaphragm, producing numerous sinuses.
4. Actinomycosis



Nelson Textbook of Pediatrics, 17th
Diagnosis : confirmed by examining purulent sinus tract
drainage for sulfur granules, and by appropriate cultures.
The differential diagnosis of pulmonary actinomycosis includes
lung abscess and tuberculosis.
Tx: mainstay of treatment for actinomycosis is prolonged
antibiotic therapy (Penicillin) and an appropriate surgical
approach to sinus tracts and abscesses.
4. Actinomycosis
Nelson Textbook of Pediatrics, 17th
Question: Chronic process, underlying
immunocompromise status; diarrhea? Vomiting?
5. Pneumonia- Pyogenic Empyema Necessitatis



Pyogenic Empyema Necessitatis:
A rare complication of empyema; is a collection of
inflammatory tissue that usually extends directly from
the pleural cavity into the thoracic wall forming a mass
in the extrapleural soft tissues.
The hallmark of empyema necessitatis is a mass
The most common etiologies are tuberculosis and
actinomycosis.
5. Pneumonia- Pyogenic Empyema Necessitatis



1-year-old boy with Streptococcus pneumoniae
empyema necessitatis and review previously
reported . Pediatr Infect Dis J - 01-FEB-2004; 23(2): 177-9
Symptoms: as the underlying disease, fever, chest
pain, chest wall mass,cough and short of breath may
be occur.
Pediatr Infect Dis J - 01-FEB-2004; 23(2): 177-9
The mass might be painful and fluctuant.
5. Pneumonia- Pyogenic Empyema Necessitatis

Diagnosis:
-Chest radiograph:
Pleural effusion, with thickening of the pleura at the
involved site, may be an enlargement of the overlying
ribs with a thick, calcified pleural rind.
-CT scan:
may show a thick-walled, possibly well-encapsulated, pleural
mass that protrudes through the chest wall.(Virtually diagnostic
of empyema necessitatis)
5. Pneumonia- Pyogenic Empyema Necessitatis
Questions: Rare chronic complication of pneumonia,
decreased breath sounds, dull percussion on
physical examination, vomiting, diarrhea?
6. Pyogenic abscess



Pyogenic abscesses involving Staphylococcus or
Klebsiella infection of the chest wall may also occur
and may be due to central line or catheter-related
sepsis in immunocompromise.
Large multifocal lesions may develop .
Question: diarrhea, vomiting? Cough? No predisposing
factor? Not multifocal mass?
7. Osteomyelitis: Rib or sternum




Nelson 17ed P2297
Most cmmon in young children, more common in boy
than girl(2:1)
The majority of infection in otherwise healthy children
are hematogeneous origin.
Long bone is principlly involved in osteomyelitis (2.9%
in chest bones)
Blunt trauma, bacteremia, illness, malnutrition, immune
system deficiency have been described as
predisposing conditions.
7. Osteomyelitis


Etiology: S. aureus is the most frequently isolated
pathogen excluding patients with hemoglobinopathies,
such as SCD, where Salmonella sp. is more likely .
Primary viral infections of bone are exceedingly rare, but
accompanied viral syndrome, suggesting immune-mediated
pathogenesis.
Nelson 17ed P2298
- Extremely rarely, the viruses which cause chickenpox and
smallpox have been found to cause a viral osteomyelitis.
7. Osteomyelitis


Clinical features may including chills, fever,chest
pain,tenderness,swelling and erythema over the
involved bone.
Scand J Infect Dis 1999 ;31: 98–100.
Insidious onset of nonspecific symptoms associated
with gradual painful swelling over the bone area.

Pediatr Infect Dis J 2001; 20: 547–50
7. Osteomyelitis
Diagosis:
-CBC: leukocytosis with left shift, and a thrombocytosis may be
present.Pediatric Clinics of North America 43: 933-947, 1996
-ESR and CRP are the nonspecific sign of inflammation.
-Culture taken from the bone, either surgically or by needle
aspiation.
-CT or Three phases bone scan
 Question: More insidious process? Chickenpox? Smallpox?

8. Strongyloidiasis (Strongyloides stercoralis)

8. Strongyloidosis (Strongyloides stercoralis)

Pulmonary disease secondary to larval migration through the lung rarely occurs and
may resemble Löffler's syndrome (cough, wheezing, shortness of breath, and
transient pulmonary infiltrates accompanied by eosinophilia).
Nelson 17ed P1160
Clinical manifestations of strongyloidiasis in southern Taiwan.
J Microbiol Immunol Infect - 01-MAR-2002; 35(1): 29-36



The most frequent clinical findings were diarrhea (74%), fever
(70%), abdominal pain (59%), cough (37%), dyspnea (33%),
and constipation (26%).
The common initial laboratory abnormalities were leukocytosis
(81%), anemia (67%), liver function impairment (52%), and
eosinophilia (44%).
Most of the patients had comorbid conditions, including
malnutrition in 20 (74%), corticosteroid dependence in 15 (55%),
chronic obstructive pulmonary disease in 9 (33%), chronic liver
disease or cirrhosis in 8 (30%), and peptic ulcer disease in 7
(26%).
8. Strongyloidosis (Strongyloides stercoralis)

Question:, no pruritus, absence of anemia, no
peripheral hypereosinophilia, abdominal pain
(common), chest pain (rare)
Final diagnosis
1. Pleurodynia (Dx. Procedure:viral culture, histiologic examination by biopy)
2. Tietze syndrome (Dx. Procedure: Biopsy; PE: Location)
3. Primary viral infectious osteomyelitis.
(Dx. Procedure: aspiration culture/ virus isolation, CT, bone scan)
4.Tuberculous abscesses (Dx. Procedure: AFS, PCR or culture)
1. Chest pain



Tender mass on fore-chest.
Erythematous change ? Warm sensation?
Precipitating factors: trauma. Acute respiratory
infection (cough, fever).
exrcise? Weight lifting ?foreign body ingestion?caustic
ingestion? Underlying illness: Kawasaki disease, CHD?
Family Hx of cardiac disease? Peptic ulcer disease?
or rheumatoid disease?
1. Chest pain

Cardiac involvement:
- Palpitation, dyspnea after climbing upstair
-Risk factor:
* FHx of myocardial infarction or
hypercholesterolemia (-)
* CHD (-)or acquired heart disease
* Syncope (-)
* Pain with exercise (-)
* Hx of Kawasaki disease(-)
1. Chest pain

Cardiac involvement:
-Physical finding:
Heart murmur(-), Persistent tachycardia(-),
increased intensity of S2 (-), gallop rhythm(-),
friction rub(-), or decreased femoral pulses(-).
1. Chest pain

Cardiac involvement:
-Examination:
*EKG: Ventricular hypertrophy? ST-Twave change?
Arrhythmia?
* CxR: cardiomyopathy?
1. Chest pain

Cardiac involvement: possible idebtify:
-Coronary artery abnormalities
-Arrhythmia
-Cardiomyopathy
-Myocarditis/ pericarditis
-Outflow obstructions
-Mitral valve prolapse
1. Chest pain

Pulmonary involvement:
-Pain of muscle strain (related to cough)
-Pleural irritation or pleurisy
-Diaphragmatic irritation (pneumonia, bronchitis)
-Asthma
-Thoracic tumor
-Foreign body aspiration
-Pulmonary embolism
-Mediastinal causes: pneumomediastinum, mediastinitis,
or tumor
1. Chest pain

Pulmonary involvement:
-S/s: cough, fever, short of breath.
-Exam: CxR?SaO2
1. Chest pain

Musculoskeletal involvement:
Tender on palpation and Hx of chest injury
-Muscle overuse (-)
-Trauma (+) involving the pectoral, upper back or
shoulder muscle.
1. Chest pain

Musculoskeletal involvement: possible identify:
-Muscle sprain.
-Costochondritis
-Slipping rib syndrome
-Xiphoid process
-Tietze syndrome
1. Chest pain

Gastrointestinal involvement:
Watery diarrhea, Vomiting
-Endoscopy ?
-Upper GI series ?
-pH probe study or trial of antacids ?
1. Chest pain

Gastrointestinal involvement: possible identify:
-Peptic ulcer disease
-Esophagitis, esophageal spasm, foreign body in
esophagus
-gastritis
-Caustic ingestizxons.
-Others: pancreatitis, cholecystitis, subdiapragmatic
abscess
1. Chest pain

Other cause of chest pain:
-Hyperventilation or stress
-Lightheadness, dizziness, paresthesia,, chest pain
-High anxiety, psychopathologic process
-Thelarche
-Gynecomastia
-rare: herpes zoster infection, nephrolithiasis, fibrocystic
disease, adenocarcinoma of breast , chest syndrome
of sickle cell disease

cold” chest wall mass may present a diagnostic
challenge. The differential diagnosis of such a chest
wall mass would include actinomyces, cold abscess
due to Mycobacterium tuberculosis, or possibly
malignancy.