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3/M, respiratory distress (onset: 15 days ago)
Chief complaint
or Title
respiratory distress (onset: 15 days ago)
Difficulty For student
Won-Hee Seo, Kang-Mo Ahn, Sang-Il Lee[silee@smc.samsung.co.kr],
Department of Pediatrics, Sungkyunkwan University School of Medicine, Samsung Medical Center
* History
Present illness : A 3 year-old boy was transferred to our hospital because of worsening respiratory distress. He had shown frequent episodes of upper respiratory tract infection and acute otitis media since infancy. Thirty days prior to admission, cough and fever developed. He was hospitalized in a general hospital, where a fourfold increase in anti-mycoplasma antibody titer was found. After the treatment with macrolide antibiotics (roxithromycin) under the diagnosis of mycoplasmal pneumonia, fever subsided, but he presented persistent cough. Eighteen days prior to admission fever and rapid breathing re-developed. Chest computed tomography(CT), which was performed after intravenous antibiotics was given, revealed bronchiolitis obliterans. Although he received corticosteroid treatment for 12 days, he showed respiratory difficulty and oxygen supplementation was required. One day prior to admission respiratory difficulty became worse and high fever developed.

Past history : Gestational age 38 wks, Birth weight 2.84kg, Cesarean section delivery .

Family history: He was born as a second baby of twin. Cardiovascular, autoimmune, or pulmonary diseases in his family were denied.
* R.O.S.& P/Ex
Review of system: tachypnea / dyspnea (+/+), Cough /sputum/ rhinorrhea(+/+/+), Nausea / vomiting /diarrhea (-/-/-) .

Physical examination: At admission day, blood pressure was 140/70mmHg, with pulse rate 125 per min and repiratory rate 62 per min. He was alert but looked acutely ill. Chest retraction was found, and breath sound was decreased with crackles and wheezing heard on whole lung field. There was no digital clubbing nor cyanosis.
* Lab
Laboratory finding

VBGA (O2 3L/min, arrived at hospital) : pH 7.397 pCO2 41.5 mmHg pO2 68.8 mmHg HCO325.0 mmol/l Base Excess 0.1 mmol/l O2 Saturation 93.8 % Hematologic values

AST 40 U/L, ALT 41 U/L, Ca 9.7 mg/dl, P 4.9 mg/dl, BUN 10.9 mg/dl, Cr 0.35 mg/dl, CK 94 U/L, LDH 586 U/L, total protein 7.5 g/dl, albumin 4.2 g/dl, Na 136 mmol/L, K 4.6 mmol/L, Cl 98 mmol/L Mycoplasma ab: >1:1280 Virus culture (RSV, parainfluenza, influenza, adenovirus): negative AFB(-), Tb PCR (-) (specimen; transtracheal aspirate)  Mantoux test: negative Blood culture (at admission day) hemophilus influenzae Follow-up blood culture; no growth Urine culture (-) Peumocystis carinii smear (-) Allergy evaluation: Total IgE 76.2 U/ml Specific IgE by CAP: house dust mite, hen¯s egg, cow¯s milk, soy, wheat, buckwheat - negative Immunology evaluation IgG/A/M/D/E: 763/275/51.5/2.92/94.6 IU/ml C3 90.3㎎/£, C4 17.1 ㎎/£ CH50 22.3 CH50/¢ Lymphocyte subset - T (CD3) 37%, B(CD19)60% NK (CD16+56) 3%, T4 (CD4)23%, T8(CD8)7% Nitroblue Tetrazolium Test: 38 % Dihydrohodamine 123 fluorescence test -decreased phagocytosis, normal respiratory burst function CGD- CYBB gene mutation test - no mutation was found
* Clinical Course
On the 1st hospital day, body temperature was over 38É, respiratory rate was over 60 /min. Initially he was treated with intravenous antibiotics (unasyn, amikin), immunoglobulin and aminophyllin. The chest radiographs showed diffuse bronchial wall thickening bilaterally with ill-defined haziness(Fig.1). On the 3rd hospital day, fever subsided but level of CRP was increased. On the 5th hospital day, Cefotaxim was substituted for unasyn because H. influenzae was isolated from his blood. Respiratory difficulty became worse on the 7th hospital day, when tracheal intubation and ventilator care were started. Open lung biopsy, which was performed on the 9th hospital day, showed acute and subacute inflammation with post inflammatory change, consistent  with organizing pneumonia(Fig.2). When he was weaned from the ventilator, his respiratory symptoms were improved and he maintained 90% oxygen saturation by oxygen supplement 2-3 L/min via nasal prong. Prophylactic bactrim was given on the basis of frequent infection episodes and equivocal result of NBT, although CGD was not confirmed in DHR test and mutation analysis. On the 21st hospital day, the temperature rose to 38.5É and respiratory rate was increased up to 60 per min. Chest x-ray showed increased haziness (Fig.3), and he was reintubated. Aminophylline, antibiotics and antifungal agents were administered intravenously. Chest CT scan showed progression of multifocal patchy consolidations in both lungs and air-trapping in peripheral area, suggestive of BOOP (Fig.4). On 27th hospital day, solumedrol (1mg/kg/d) was given intravenously. As the steroid dose was taperd, he was weaned from the ventilator and endotracheal tube was removed. On the 36th hospital day, wheezing sound was heard on his chest and rapid breahing still remained. His oxygen saturation was kept at 95% by oxygen supplement of 0.5-1 L/min via nasal prong. Before discharge chest CT scan was re-checked, revealing persistent air-trapping with slight improvement of pneumonic consolidation (Fig.5,6). He was discharged at 49th hospital day.

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