Bugs in the Lungs
Bacteria causes abrupt onset of fever, cough with wheezing, joint pains, and rash in a 15 year-old boy.
Mycoplasma pneumonia
Extrapulmonary manifestations include hemolytic anemia, splenomegaly, erythema multiforme (and Stevens-Johnsons syndrome), arthritis, pharyngitis, tonsillitis, and neurologic changes especially confusion.
3-month-old male infant presents with, Progressive tachypnea over 5 days, Dry, non-productive cough, Poor feeding, History of oral thrush, O2 saturation: 86% on room air, No fever. Chest X-ray: Bilateral, diffuse ground-glass opacities with hyperinflation. His mother is HIV-positive and recently diagnosed. The infant has not yet received antiretroviral therapy or prophylaxis.
Pneumocystis jirovecii pneumonia (PJP)
Classic presentation of PJP pneumonia in HIV-exposed but untreated infants, typically between 2–6 months of age.
Dry cough, progressive respiratory distress without fever, and hypoxia out of proportion to exam are hallmark features.
CXR typically shows bilateral diffuse interstitial (ground-glass) infiltrates, sometimes with hyperinflation.
May present with oral thrush, as seen in advanced immunosuppression.
Treatment: High-dose TMP-SMX (trimethoprim-sulfamethoxazole) ± corticosteroids if hypoxic.
In October, a 2 year old boy presents with High-pitched, barking cough, Inspiratory stridor, Subglottic narrowing on AP neck x ray.
•Croup (Laryngotracheabronchitis)
•It commonly occurs in children between the ages of 3 months and 3 years, within an average of 2 years.
•Boy are nore likely to be affected than girls. Most incidents occur in fall and early winter.
•Parainfluenza viruses cause most cases of croup.
Most likely trigger of asthma exacerbation in a kindergartner who is admitted to the hospital.
•Viral infection
2 year old boy presents acutely with Choking, Coughing, Wheezing, Diminished breath sounds on the right. Normal CXR.
•Aspiration of a foreign body
•Promptly consider aspiration of a foreign body when a child <2 years old acutely presents with choking, particularly if this is followed by the classic triad of cough, wheezing, and diminished breath sounds on physical exam.
•CXR may show asymmetric inflation but is commonly normal.
•The most commonly aspirated objects are seeds, nuts, coins, hot dogs, balloons, jewelry, batteries and firm vegetables.
Bacteria causes sore throat, hoarseness in a 13 year old girl. Throat swab culture negative for Group A Streptococcus. Now, 2-3 weeks later, she develops pneumonia.
Chlamydia Pneumonia
Causes epidemic pneumonia in older children and adolescents. It is the cause of up to 10% of community acquired pneumonias. The biphasic course is classic for pneumonia infection.
17 year old boy from northwest Arkansas who hunts frequently presents with 1 month history of low grade fever, cough with occasional hemoptysis, chest pain, 10 lb weight loss, several verrucous lesions with irregular borders and micro abscess formation at the periphery of left arm. CXR upper lobe infiltrates with a cavitary lesion.
•Blastomycosis
•Classic description of Blastomycosis that causes chronic pneumonia with dissemination to the skin. Most cases occur in Arkansas, Mississippi, Illinois, Wisconsin and states bordering there areas.
3 year old boy presents with a history of Waking up in the middle of night with a barking cough Mild stridor. The next day, the child is perfectly healthy. That night, the symptoms reoccur. The next day, the child is again healthy. The family says this has occurred for 3 nights.
•Spasmodic Croup (noninfectious)
•This is a cycle of waking up with croupy cough and mild stridor and then being normal the other day without issues. Then, that night the croupy cough returns and resolves the next day with a normal appearing child.
•This is noninfectious may be related to gastrointestinal reflux.
17 year old girl with known asthma presents with Cough, wheezing, chest tightness with URI and exercise ED visit 2 years ago for asthma exacerbation. PFT: FEV1=74%, FEV1/FVC=79%, Change in FEV1 Postbronchodilator=35%.
•Moderate persistent asthma
•Age>12:
•FEV1>60%, but 80% predicted is the defined range for moderate persistent asthma
•8 year old girl presents with Iron deficiency anemia that was initially diagnosed 1 year ago, Progressive dyspnea, Fatigue, Recurrent cough with new onset hemoptysis. Sputum that shows hemosiderin-laden alveolar macrophages.
•Idiopathic Pulmonary Hemosiderosis (IPH)
•Iron deficiency anemia followed by cough hemoptysis
•Diagnosis with sputum or BAL shows hemosiderin laden alveolar macrophages.
Bacteria causes abrupt onset of fever, tachypnea, tachycardia, cyanosis in 15 year old boy with current history of influenza. CXR shows distinct pneumatoceles.
Staphylococcus Aureus
Classic for pneumonia following Influenza URI.
Pneumatoceles are classic for S. Aureus, but can also be seen in Strep pyogenes pneumonia –Influenza history helps to differentiate these two.
17 year old boy was visiting his grandparents in Indiana over the summer. Two months after cleaning out his grandfather’s chicken coop, he presents with Mild respiratory symptoms. Low grade fever. CXR shows a few focal infiltrates with hilar adenopathy
•Histoplasmosis
•Most cases of Histoplasmosis are asymptomatic or only mild symptoms. Some may have severe respiratory symptoms.
•Classically, this is seen in Mississippi and Ohio River valleys. It is associated with droppings of chicken and bats.
2 year old girl presents with High fever, Brassy cough, Stridor. She is given treatment for croup but does not respond and she deteriorates rapidly. She is intubated in the emergency department.
•Bacterial tracheitis
•Appears like has viral croup but after receiving appropriate therapy for viral croup, the child continues to deteriorates rapidly and may require intubation or tracheostomy.
•Child with epiglottitis would have drooling due to severe sore throat and difficulty swallowing and would not have prominent cough, as seen in croup and bacterial tracheitis.
15 year old girl with asthma presents with Malaise, Coughing up brownish mucous plugs, Occasional hemoptysis, Peripheral eosinophilia, High IgE. Improves with corticosteroid therapy, but 2-3 months later, the signs and symptoms reoccur.
•Allergic Bronchopulmonary Aspergillosis (ABPA)
•Classic presentation of ABPA.
•In addition the patients with asthma, it commonly occurs in patients with CF.
•Clues: Recurrent, associated with eosinophilia and very high IgE.
17 year old African American girl presents for evaluation after receiving a CXR in the ED for possible pneumonia that turned out to be a viral infection. However, CXR shows that she has significant bilateral hilar and mediastinal adenopathy. She is completely asymptomatic and denies fever, night sweats, or weight loss. CXR shows no infiltrates. Tuberculosis, fungal diseases, and malignancy have been ruled out.
•Sarcoidosis
•Bilateral hilar lymphadenopathy and no parenchymal infiltrates. Many patients with sarcoidosis asymptomatic, in which case there is nothing therapeutically to do.
•If she had eye or CNS involvement, heart conduction abnormalities, severe pulmonary or skin signs and symptoms or persistent hypercalcemia, then you would intervene with systemic steroids.
•Erythema nodosum is associated with this and is a good prognostic factor.
Bacteria causes abrupt onset of high fever, chills, chest pain with dyspnea, blood tinged sputum in an 8 year old boy. A pleural friction rub audible in exam.
Streptococcus pneumoniae
Classic presentation with high fever, chills, chest pain with dyspnea.
Blood tinged or rust colored sputum is also common.
In some cases, you can detect a pleural friction rub.
Children with pneumococcal pneumonia appear ill and have tachycardia and tachypnea.
2 weeks ago, 17 year old girl visited her grandfather in California. Today presents with Fever, Cough, Several pounds weight loss, Chest pain, Marked fatigue, Erythema nodosum.
•Coccidioidomycosis (a.k.a. Valley Fever)
•Symptoms generally occur 1-3 weeks after visiting an endemic area and are very non specific. The findings of erythema nodosum or erythema multiforme makes this diagnosis highly likely in someone who has visited the desert southwest of Arizona or southern California.
•3 year old girl, abrupt onset of High fever, Sore throat, Drooling, Stridor. She is given treatment for croup but does not respond. She deteriorates rapidly and is intubated in the emergency department. Her parents do not believe in immunization.
•Epiglottitis
•Classic presentation of epiglottitis on the background of no Hemophilus influenzae type b immunization.
•Initially appears that patient has viral croup, but after receiving appropriate therapy, the child continues to deteriorate rapidly and requires intubation.
•17 year old boy
Sinusitis
Bronchiectasis
Situs inversus
•Primary Ciliary Dyskinesia (PCD, Kartagener Syndrome)
•OR, can be sporadic or familial
•3 findings: Sinusitis, Bronchiectasis, Situs inversus
•Male infertility
18 year old young man presents with History of hemoptysis for several months Iron deficiency anemia New onset chronic kidney disease. Biopsy shows linear deposition of IgG and C3 on alveolar and glomerular basement membranes. ANCA is negative.
•Good Pasture Syndrome (Anti-glomerular basement membrane antibody disease)
•Male/Female is 3:1
•Hemoptysis precedes with renal abnormalities
•Patients presents with dyspnea, hemoptysis, iron deficiency anemia and glomerulonephritis but without the upper airway signs that are seen in granulomatosis with polyangiitis.
Most likely diagnosis in 15 year old boy with cerebral palsy and seizure disorder with recurrent choking presents with fever, tachypnea, tachycardia, cyanosis. CXR shows diffuse infiltrates.
Aspiration Pneumonia
When there is predisposition to aspiration, such as history of seizure, neurologic disease, dysphagia, pneumonia may be caused by aspiration of oral anaerobic flora and gram negatives.
15 year old girl with asthma presents with Malaise, Coughing up brownish mucous plugs, Occasional hemoptysis, Peripheral eosinophilia, High IgE. Improves with corticosteroid therapy, but 2-3 months later, the signs and symptoms reoccur.
•Allergic Bronchopulmonary Aspergillosis (ABPA)
•Classic presentation of ABPA.
•In addition the patients with asthma, it commonly occurs in patients with CF.
•Clues: Recurrent, associated with eosinophilia and very high IgE.
2 week of infant presents with inspirational stridor. It is much worse when the child is upset.
•Laryngomalacia
•Most common cause of stridor in the newborn period
•Laryngeal cartilage is just not stiff enough, and inspiration causes significant luminal narrowing.
•The stridor can occur at birth, but it most commonly presents at 2 weeks of age. Most children outgrow the disorder by 12-24 months of age.
•3 year old girl
Rectal prolapse
Nasal polyps
•Cystic Fibrosis
•Nasal polyps occur in up to 50% of CF patients.
•About 50% of CF have rectal prolapse in early childhood.
•At birth, 10-20% of CF patients present with bowel obstruction, which is manifested by meconium ileus.
6 year old newborn presents with following Respiratory distress, Heart failure. Abnormalities of pulmonary venous drainage
•Scimitar Syndrome
•Congenital Pulmonary Venolobar Syndrome (a.k.a. scimitar syndrome) is a rare disorder in which the pulmonary venous blood from all or past of the right lung returns to the inferior vena cava just above or blow the diaphragm.
•CXR may show the shadow of the veins involved as they course, giving a scimitar-like (Turkish sword) appearance.