respiratory system final

7/23/2019 Respiratory System Final

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Pyrexia of unknown origin-An unusual cause

N.S.VIGNESHWAR

RMMH

Anna!alai "ni#ersi$y



• 10 months old male infant 2nd born to

nonconsanguineous parents residing atSirkali was brought to casualty by hismother whose reliability was good with

presenting complaints of %e#er x & !on$'

oug' x (wks

)rea$'ing *i+cul$y x (wksRefusal of fee*s x &, *ays

A*o!inal *is$ension x &wk



• Insidious onset• 1 month

• low grade fe#er, in$er!i$$en$

• No chills or rigor

• No H/o rash• No aggravating factors• elieved by antipyretics



• oug' present on o/ throughoutthe day *is$uring $'e slee0

• ! wks duration

• Insidious onset

• Associa$e* with *i+cul$y inrea$'ing " !wk

• #ore during lying down posture

• No H/o foreign body intake

•

No H/o eye congestion•



• H/o refusal of fee*s " 1$ days• H/o weig'$ loss present• A*o!inal *is$ension x &wk

•

No H/o melena• No H/o vomiting, loose stools , %aundice, bleeding per rectum

• No H/o fore head sweating, suckrest suck cycle ,bluishdiscolouration of face

• No H/o sei&ures, loss of



A*!ission a$ 1!on$'sof age for

12 *ays -3R4I

A*!ission a$ 5!on$'s

of agefor &!on$' 63R4I wi$'a*o!in

al*is$ension

A*!i$$e* a$ 7!on$'sof agefor (

weeks-3R4Iwi$'a*o!inal

*is$ension•

%e#er 8 coug'8 rea$'ing *i+cul$y 9a*o!inal *is$ension

• )loo* $ransfusion - ane!ia• :x wi$' 4) A44 s$ar$e* - 7$' !on 8 no

con$ac$ H;o of 4)

S4 HIS4<R=



)IR4H HIS4<R=>-• 'ntenatal (No H/o )*+H

IN-+)I*N• No other maternal risk factors• Natal ( )erm normal delivery. 0wt

20$kg• ostnatal ( 3neventful• 3mbilical cord fell on day 4•

assed #econium on day 1



IMM"NI?A4I<N :- – +5 6Scar present7 – *8 9,1,2,! – :) 1,2,! – Hep; 1,2,! – Hib 1,2,!

• <et to be Immuni&ed with measles

N"4RI4I<N>-

• -;= months then started weaning

Ac$ual Ex0ec$e*

Ga0

+alorie !4$6>cal

7

?996>cal

7

51,@c

alB



:EVE3<PMEN4A3 age appropriate forchronological age

%AMI3= HIS4<R= no H/o similar illness infamily members

S<I<E<N<MI S4A4"S - 5rade I86'ccording to modiAed >uppusamy scale 7

+attle

present

!92

4



HEA: 4< %<<4 ECAMINA4I<N>-

• ' open B Cat

• Eyes 6 Pallor 9

• No evidence of 8it0 :eAciency• •

-ars ,*ral cavity normal• • undus normal

• -ars ; no discharge

• Neck ; no lymphadenopathy.• Dimbs 63D/DD7; normal• Pan*igi$al cluing 9

• A*o!en *is$en*e*

• -"ternal genitalia normal



AN4HR<P<ME4R=A4"A3 ECPE4E:

E-I5H) F0$ >g @0$ >g 5D F(r* cen$ilegra*e IV@IAP7

Dength ==cm 42cm @1GH-':+I+3#--N+-

F!0$cm !rd to 19th centile

Wellcome trust –#arasmus

Waterlow-1° degree stunting

Chronic malnutrition



VI4A3S

• +onscious , alert• )emp;192 •

H;1$2/min. ;@9/=9 mmhg. +)!secs. ;42/min . Sp92;@!G• No e"ternal markers of )•

No signs of liver cell failure

RESPIRA4<R= S=S4EM



RESPIRA4<R= S=S4EM

INSPE4I<N>-

• +hest shape Bmovement symmetrical

• 'pical impulse visible

medial to the D) nipple

• No scar, sinuses

• SR98IR98 Ala nasiaring +

• No bony abnormalities

PA3PA4I<N>-

• )rachea midline0

• 'pical impulse; Dt

Fth intercostalspace J inchmedial to #+D 0

• Vocal fremitus- right

axillar !infra



PER"SSI<N (;• #ullness over $t axillar ! infra

axillar " mammar region

A"S"34A4I<N(;

• reath sounds ; %ronchial %reathsound K R$ axillary 8 infra axillary !a!!ary

• Vocal resonance increased on ta"illary , infra a"illary B mammary

• 'dded sounds ; &'( coarse



ECAMINA4I<N

INSPE4I<N>-

• :istended• 3mbilicus everted B

pushed down•

'll Muadrants moveseMually withrespiration



PER"SSI<N>-

• 3i#er s0an-&2.,c! 6normal=7

•

No Shiftingdullness

A"S"34A4I<N>-

• owel sounds 4/

• No bruit

PA3PA4I<N >-

•No rigidity

•3i#er 0al0ale - 5c! elow RM

–rounded edges –Surface ; smooth

–irm in +onsistency

–No ulsations

•S0leen 0al0ale - (c! 3M

•No Cuid thrill



<4HER S=S4EMSVS >-•

S 1 , S 2 heard• No murmurs• No added sounds

NS>-• Higher mental functions intact•

+ranial nerves intact on t B Dt• No sensory disturbances• #otor system ; intact• No meningeal signs



S=MP4<MS %IN:INGS

- A S"MMAR=

PA33<R

PAN :IGI4A33"))ING

=MP4<MS>-%EVER<"GH)REA4H3ESSNESS

A):<MINA3 *is$ension

4<SP3EN<MEGA3=

RS• V%8VR• )R<NHIA3

)S• )3 <ARSE

REPI4A4I<NS



• yre"ia of unknown origin• t side consolidation,

hepatosplenomegaly , with grade I8-# most probably due totuberculosis 6disseminated )7

PR<VIS<NA3 :IAGN<SIS



:;:

• ronchiectasis• )ropical diseases 6dengue, malaria,

enteric fever, 3)I7• Hemolytic anemia• ImmunodeAciency



• ++;'nemia with mildthrombocytopenia

•

H;D., g;*l• E+ ; 1!$99

• ;4=G

•

D;1?G• -;=G

• latelet;&.(,Dakhs/mm!

• eripheral smear !icrocy$ic'y0oc'ro!ic ane!iawi$' !il*

$'ro!ocy$o0enia no

)I+; F4$ mcg/dl#+8;D*E

+8;!$Sr0 erritin; normal#+H+ ;normal

Hbelectrophoresis;normal

eticount ;2G;



• S/)/-D-+)*D<)-S;N*#'D•

*,-1./*-120/ )0ilirubin;

N*#'D

• *r3A(&-435 g/dl . 5D*;!0$. 'D ;!1$

•

+oagulation proAle normal•

3rine /-;normal• lood urine c/s;sterile

• Stool +/S;No enteric growth

• :engue Ig# -lisa negative• 3e0$o Ig#;negative

• 4<RH proAle negative

• #;negative



• '5;respiratoryalkalosis

• Sr0ammonia;normal

• +S analysis ;normal

•

Man$ouxs$rongly0osi$i#e-



4 4'orax-R$ !i**le loe consoli*a$ion an* );3no*ular o0aci$ies 9

>*H 5 t i ' i t



5'#S S)'IN )iddle lobe aspirate

>*H; 5astric 'spirat

D+

G $ i i A%) 6!ti 7



• Gas$ric uice A%) 6!times7 negative

• )reated with ampicillin Kclo"acillin K gentamicin

• No response fever persisted

•

one marrow aspirate normal

• one marrow c/s;normal

3i i t / I-#



• +') II ')) started

• Steroids added

•

Reasons fors$ar$ing A44

• 3i#er io0sy to r/o I-#;normal

• An$iio$ics c'ange* tomeropenam and vancomycin

• %ungal ;S +andida5rowth

• Started on amphotericin ;1F days



-SIS)-N) N-3#*NI'

+ < S ) I +

, I / * S I S

•+ystic Abrosis work up normal•etroviral screening 6parents/child7 -#e•Immunoglobin proAle normal

# tuberculosis ca$alase 0osi$i#e


http://slidepdf.com/reader/full/respiratory-system-final 30/346&

•#0tuberculosis;ca$alase 0osi$i#e organism ; *isor*er of 0'agocy$osis •N)4;showed



HR<NIGRAN"3<MA4<"S

:ISEASE

• low cytometry ; parents notaOordable



:IS"SSI<N G:HR<NI GRAN"3<MA4<"S:ISEASE@G:B

In'eri$e* disorder of phagocyticactivity common in boyssusceptibility to recurren$ infec$ion

since ir$'#utations in NA:PH oxi*ase

subunits



3INIA3MANI%ES4A4I<NS

Onset ; infancy to young adulthood• ecurrent pneumonia•

Hepatic or any other abcess• 'nemia of chronic disease• oor growth• Hepatosplenomegaly• GRAN"3<MA formation

-)I*D*5<;catalase

K8-organisms ;

#0tuberculosis.Serratia,

urkholderia

,



<N%IRMA4I<N• low cytometry

6:H7• N) dye test

4REA4MEN4• HS+)• rophylactic antibiotic Bantifungal

• +orticosteroids

• Interferon P

respiratory system final

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