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18/10/1390 1 Mostafavi SN. MD Pediatric infectious disease departement Isfahan University of Medical Science 18/10/1390 2 Lower respiratory tract infections Pneumonia: – Viral – Bacterial – Afebrile – Atypical – Aspiration – Nosocomial Bronchiolitis Empyema 18/10/1390 3 Case 1 A 6 months old boy brought with high fever and cough. On physical exam tachypnea and bilateral coarse rales were found. What’s your diagnosis? 18/10/1390 4 Diagnosis of pneumonia What's suggestive symptoms and signs of pneumonia? Which patient has definite diagnosis of pneumonia? 18/10/1390 5 Symptoms/signs of pneumonia All respiratory infections: fever, cough, Lower respiratory involvement: respiratory distress, tachypnea, cyanosis Pneumonia: fine rales, decreasing breath sounds, bronchophonia, … Definite: new pulmonary infiltration in CXR 18/10/1390 6 Case 1-1 A 6 months old boy brought with high fever and cough. On physical exam tachypnea and bilateral coarse rales were found. What’s your diagnosis? 18/10/1390 7 Case 1-2 A 6 months old boy brought with high fever and cough. On physical exam tachypnea and bilateral coarse rales were found. What’s your diagnosis? 18/10/1390 8 Case 1-2 Has the infant need admission? 18/10/1390 9 Admission criteria in pneumonia Inability to intake fluid or medications Cyanosis( o2 sat< 92%) Severe respiratory distress( apnea, …) Toxic appearance Pleural effusion Sometimes < 1 year 18/10/1390 10 Case 1-2 Has the patient need antibiotic? 18/10/1390 11 Type of pneumonia History Physical exam X ray infiltrates ESR, CRP, WBC, PMN 18/10/1390 Viral bacterial Age< 5, gradual onset, mild fever, cough, respiratory distress Bilateral rales, high pitched breath sounds, Bilateral interstitial , peribronchiolar, parenchymal, hyperinflation Abrupt onset, high fever, severe cough, significant respiratory distress Focal rales NL to mild increase Significant increase Lobar, lobular consolidation , dense parenchymal 12 Case 1-3 A 6 months old boy brought with high fever and cough. On physical exam tachypnea and bilateral coarse rales were found. If he need any antibiotic? 18/10/1390 13 Case 1-2 A 6 months old boy brought with high fever and cough. On physical exam tachypnea and bilateral coarse rales were found. If he need any antibiotic? 18/10/1390 14 Which antibiotic should be prescribed for the infant? 18/10/1390 15 Microorganism Outpatient Inpatient S. pneumonia High dose penicilline(85%), high dose ampicilline( 85%), Ceftriaxone( > 95%), ceftriaxon+ vancomycine( 100%) High dose amoxicillin( 85%), macrolides(6080%) H. Inluenza ( < 5 Low dose Low dose yr) amoxicillin( 50%), ampicillin(50%), low dose co ceftriaxone( 100%) Amoxiclav (>95%), macrolids(> 90%) 18/10/1390 16 Case 1-2 What's the clinical course of the patient? 18/10/1390 17 Clinical course of bacterial pneumonia Improve in fever and respiratory signs in 48-72 hours Clearing CXR in 4-8 weeks 18/10/1390 18 Case 2 A 7 years old girl brought with high fever, malaise, protracted cough, mild diarrhea since 5 days ago. On PE she had bilateral fine rales without significant respiratory distress. She received coamoxiclave since 72 hour ago. Whats your diagnosis? 18/10/1390 19 Atypical pneumonia What's the suggestive symptoms and signs of atypical pneumonia? 18/10/1390 20 Atypical pneumonia Age 5-15 yr Severe constitutional signs: high fever, prolonged fever, anorexia, malaise Mild respiratory signs: coryza, protracted prolonged cough, no/mild distress, bilateral mild rales Prominent extrapulmonary signs: rash, diarrhea, abdominal pain, CNS, … Prominent x ray abnormalities: bilateral interstitial, lobar infiltrates specially in lower lobes No response to beta-lactams and dramatic response to azithromycine, clarithromycine, erythromycine 18/10/1390 21 Case 3 A 2 month old boy brought with severe cogh since two days ago and coryza and mild cough since five days ago. His mother has signs of URTI since 7 days ago. On PE RR=70/min, mild cyanosis and diffuse wheezing were found. What's your diagnosis? 18/10/1390 22 Main clues in bronchiolitis Age:<1 yr ( 2-6 mo), peak admission: 1-3 mo Epidemic in Day to Farvardin months Initially coryza, cough then severe cough, wheezing, dyspnea Sometimes fever Hyperinflation, perihilar infiltration in x ray 18/10/1390 23 Case 3- x ray 18/10/1390 24 A 2 month old boy Case 3 brought with severe cogh since two days ago and coryza and mild cough since five days ago. His mother has signs of URTI since 7 days ago. On PE RR=70/min, mild cyanosis and diffuse wheezing were found. Has the patient need admission? 18/10/1390 25 Admission in bronchiolitis O2 saturation< 90-92 Age< 6 wk Reduced intake Underlying heart, lung, immunological disease Severe respiratory distress including apnea 18/10/1390 26 What's the outpatient management of bronchiolitis? 18/10/1390 27 Out patient management of bronchiolitis No effect of salbutamol, theophylline G, corticosteroids, cough suppressants Supine position with the head elevated Small frequent feeding Nose drops and clearing Warning signs Mist therapy 18/10/1390 28 18/10/1390 29