DEPARTMENT OF PAEDIATRICS

KULIYYAH OF MEDICINE
INTERNATIONAL ISLAMIC
UNIVERSITY OF MALAYSIA (IIUM)
CASE SUMMARY 2
NUR HIDAYAH BINTI ABDULL JABBAR
MATRIC NO : 0910032
Year 5 (BATCH 13; 2013/14)
Group B (1)
SUPERVISOR: ASST.PROF DR. MAI NURUL
ASHIKIN
DATE : 21ST FEBRUARY 2014

IDENTIFICATION OF DATA
Name
Age
Gender
Race
Address
Date of Admission
Date of Clerking
Source
of
Information
Diagnosis

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Lowshini A/P S.S. Anand

13 months old (D.O.B 24th December 2012)
Female
Indian
From Berserah, Kuantan, Pahang.
10th February 2014
15th February 2014
From the Mother.

: Acute Exacerbation of Bronchopulmonary Dysplasia

Secondary to Atypical Pneumonia with underlying failure to
thrive and acyanotic congenital heart disease (patent ductus
arteriosus).

CASE SUMMARY
A 13 months old ex-premature Indian baby girl (Corrected Gestational Age of 10 month) with
a medical history of prolonged NICU admission up to 7 months of life, with resolved grade 2
retinopathy of prematurity and intraventricular hemorrhage, bronchopulmonary dysplasia and
acyanotic congenital heart disease, presented with non-resolving high grade continuous fever with
chills and progressively worsening productive cough with yellowish mucopurulent sputum for the
past 10 days in duration and noisy breathing with poor oral intake for 3 days prior to admissions
which doesnt responds to a full course of antibiotic therapy prescribed by the general practitioner.
Otherwise, it was not associated with rhinorrhea, night sweats, history of contact of those with
tuberculosis or URTI at home. The noisy breathing was also associated with rapid breathing and
retractions of the accessory muscle of respiration as noted by the mother one day PTA.
This was her first hospitalization (at 13 months of age) after been discharge at 7 months of
age with a chronic history of NICU admissions with multiple complications. She was delivered at 27
weeks of gestational age via an elective LSCS for 3 previous scars due to PPROM (preterm premature
ruptures of membrane) with a birth weight of 955 gram (A very low birth weight baby). Postnatally:
she was admitted to Neonatal ICU for 7 months in duration with history of being ventilated for the
first 28 days, then was weaned off and been on oxygen dependent for the next 4 months. In the NICU,
she was diagnosed to have grade 2 intraventricular hemorrhage and acyanotic congenital heart disease
since birth, which is patent ductus arteriosus. Ophthalmology assessment revealed that she had a
grade 2 retinopathy of prematurity, and laser surgery was done to halt the disease progression.
Postnatally, on week 2 after birth, she also develop moderate to severe jaundice, where she was put on
phototherapy for 2 weeks and exchange transfusion was done for once. However, there were no
complications as kernicterus seen. Audiology assessment revealed normal ear with no hearing
abnormalities. Otherwise there were no other complications such as necrotizing entorocolitis, anemia
or any other underlying problems.

Post NICU admission, she was discharge with the birth weight of 3.5 kg, with complete
resolution of bilateral stage II intraventricular hemorrhage and retinopathy of prematurity. She was
diagnosed to have bronchopulmonary dysplasia and was put on MDI Salbutamol 400 mcg PRN and
MDI seretide (fluticasone + salmeterol) twice daily (12 hours apart). At home, she doesnt need for
any supplemental oxygen therapy, and there is a presence of continuous baseline low pitch noisy
breathing (wheezing) all the time.
Immunizations history was up to date corresponding to her chronological age with no
postponed vaccinations. Last vaccination was MMR at 12 months old. For nutritional history,
weaning was started at 9 months old (CGA: 6 month). Now shes on nestum/porridge/blended rice
three times per day with 3 ounz of formula milk 4 hourly (Similac).
For her developmental history, it corresponds to her corrected gestational age which is 10
months old where for gross motor, shes able to sit unsupported and able to cruise, for fine motor,
theres presence of palmar grasp and inferior pincer grasp, able to babbling in a combined syllable
mama and waves bye2. Shes the youngest among her 4 siblings. Both her first and second sisters
were healthy, schooling without any known medical problems. Her third sister suffers from moderate
mental retardation and shes schooling in a special school for handicap children. Her father was a 40
years old technician with a monthly salary of RM2000, and her mother was a 38 years old housewife
with no consanguinity. Both are healthy with no known medical illness. They live in a single storey
house at Berserah, Kuantan with complete basic amenities. There was no allergic history.
On examinations (was done on day 5 of hospitalization): she was alert, conscious, and
actively playing on the bed. Hydrational status was good with no signs of dehydrations (with good
skin turgor and moist mucosal membranes). She had a relatively small body built and small head
(microcephaly) with poor nutritional status. She was on respiratory distress evidence by nasal flaring
and the use of accessory muscles of respirations. There was no facial dysmorphism. An IV Drip was
inserted at the left dorsum hand not continuous to any drip (for IV antibiotics) with a nasal prong
attached at the nostrils continuous to an oxygen infusion 2L/minute.
Anthropometric Measurements:
Patient had a small body built with a weight of 5.6 kg, below the 3 rd centile, height was 67 cm, below
the 3rd centile and a head circumference of 43 cm (below the 3 rd centile), which is persistently low
(both body weight and height) with only mild increment in weight which is about 0.5kg per month
since discharge from NICU ( in 5 months time, only gain 2.1 kg).
General examinations revealed normal peripheral findings with no pallor, clubbing, cyanosis or leg
oedema. Vital signs were stable with normal readings except for respiratory rate:
Blood Pressure
Pulse Rate
Respiratory Rate
Temperature
CRT
SpO2

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95 / 50 mm Hg (normotensive)
160 beat per minute with good volume and regular rhythm
55 breaths per minute ---shes tachypneic
37 C - afebrile
< 2 second
99% under nasal prong oxygen 2L/min

Systemic Examination:
Respiratory Examinations: There is presence of chest deformity, which is pectus excavatum, the

chest moves with respiration, with thoracoabdominal breathing and suprasternal, subcostal and
intercostals recessions with no prominent veins or surgical scars seen and there was a BCG scar seen
at the left deltoid region. On palpation, the trachea was centrally located. Chest expansion was
reduce bilaterally especially at the lower zone of the lung. Percussion revealed dullness at the
lower zone of the left lung and liver dullness was noted at 5th right intercostals space. Auscultations
revealed reduced air entry bilaterally on lower zone of the lung with generalized coarse
crepitations, with bronchial breath sound. Unable to perform vocal fremitus in a 13 months old
child. Palpation for lymph nodes revealed no cervical lymphadenopathy.
Cardiovascular Examinations : There were no surgical scars, no chest wall deformities or pericardial
bulge, and no prominent pulsations or visible apex beat. On palpation, all peripheral pulses were
palpable. Apex best is located at the 4th intercostal space on the mid clavicular line and of normal
character. There were no thrills and no parasternal heave. On auscultation, normal S1 and S2 heart
sound were heard. An ejection systolic murmur grade 3/6 was heard loudest at the aortic region,
and radiate along the left sternal edge.
Other systemic examinations were unremarkable.

MANAGEMENT AND PROGRESSION

She was admitted for further evaluation and management of her unresolving continuous high grade
fever with moderate to severe respiratory distress and poor oral intake.
In the ward, on the first day of hospitalization, patient was nebulized with combination of
normal saline and salbutamol for 3 hourly, and with nebulizer combivent 6 hourly. Intravenous
Hydrocortisone was given with administration of Intravenous broad spectrum antibiotic, IV
cefuroxime and oral erythromycin. She was continued with her MDI seretide twice daily, put on nasal
prong oxygen 2L/minute, ryles tube for feeding due to severe respiratory distress with poor oral intake
and was rehydrated with normal saline together with continuous monitoring of vital signs. FBC,
Blood for Culture and Sensitivity, Renal Profile and Serology test for Mycoplasma and Legionella
was done. Chest physio with daily suctioning was perform to clear the airway. The result was as
followed:

COMPONENTS

HEMOGLOBIN (Hg)
MCV
TWBC
Neutrophil Count
Lymphocytes Count
PLATELETS
UREA
SODIUM
POTTASIUM
CHLORIDE
CREATININE

INVESTIGATIONS RESULT:
11 February
NORMAL
2014
RESULT
At the ward
th

10.8
76.0
16.37
81%
26%
300
7.8
136
4.7
104
20

COMMENT

FULL BLOOD COUNT

11.5 15.5
Slight reduction in hemoglobin level and MCV level
77.0 95.0
which is not significant.
6.0 14.0
Elevated total white blood cells; leukocytosis with
13 33
neutrophilia and lymphopenia indicating bacterial
46 76
infections.
150 400
Normal Range
RENAL PROFILE
2.0 19.0
Normal Range
136 145
Normal Range
3.5 -5.8
Normal range
97 106
Normal range
23 68
Slight reduction not significant

In ward, patient was continued given his daily doses of IV broad spectrum antibiotic course
up until day 5 and IV hydracortisone for 3 days before changed to oral prednisolone 2.5 mg bd on day
4 of hospitalizations before tapering the steroid dose. Serology result was positive for Mycoplasma
pneumoniae and oral erythromycin was continued up for two weeks course until resolution of
symptoms and chest radiograph clearance seen. Follow up appointment was schedule monthly for
respiratory clinic and 6 monthly for cardiology clinic. Corrective surgery for her patent ductus
arteriosus has not been schedule yet by the cardiology specialist. Parents were educated regarding
their childs health conditions together with ways to increase her weight and height by increasing
normal daily calorie requirement with proper hygienic care and infections preventions.

DISCUSSION

Patients was a 13 months old ex-premature baby with corrected gestational age of 10 months,
born at 27 weeks of gestation age to a mother with risk of maternal age > 35 years old, a multigravida
lady with early booking, proper antenatal care and with 3 previous scar, which presented at 27 weeks
of pregnancy with PPROM, preterm premature ruptures of membrane and was admitted for elective
lower segment caesarean section for her child, who was born prematurely with a very low birth
weight, which is 955 gram. From the minutes of birth until the first 28 days of her life, she was
ventilated due to prematurity as those borns before 28 weeks of gestational age must be ventilated due
to absence of surfactant production by the lung, which usually is produced after 28 weeks of
gestational age. Surfactant reduces surface tension, so that the alveoli in the lungs able to expand.
Without it, the wet surface of alveoli in the lungs sticks together and prevents the expansion of the
lungs. It also increased the pulmonary compliance, prevents atelectasis at the end of expirations and
facilitated recruitment of collapsed airways. Premature infants have high risk of developing
respiratory distress syndrome due to incomplete productions of lung surfactant.
At the first week of NICU admissions, she was diagnosed to have grade two intraventricular
hemorrhage and acyanotic congenital heart disease. Intraventricular hemorrhage is bleeding into the
fluid-filled areas, or ventricles, which is commonly seen in premature babies. This is because blood
vessels in the brain of premature infants are not yet fully developed and are extremely fragile and
superimposed conditions such as respiratory distress syndrome, pneumothorax, or high blood pressure
can cause rupture of these vessels causing hemorrhage into the ventricles which later can lead to
hydrocephalus, developmental delay or motor disabilities. Patent ductus Arteriosus was among the
commonest cause of left to right shunt acyanotic congenital heart disease, which commonly closes
after delivery due to low pressure of pulmonary circulations and high pressure of systemic
circulations. In premature infant, failure of this circulations and improper functioning of the lungs
leads to persistence of this ductus. During the NICU admissions, intravenous indomethacin was given
to stimulate the closure of this duct, however, failure of ductal closure warrant corrective surgery after
the child were fit physically for a major surgery, usually after one or two years of life with cardiology
follow up to monitor for failure signs and reversal of shunt, pulmonary hypertension and congestive
heart failure, which is the complications of untreated congenital heart disease.
Premature infant are very toxic to high dose of oxygen, and prolong oxygen dependent
causing the development of retinopathy of prematurity and bronchopulmonary dysplasia in this
patient. Ophthalmology assessment and follow ups with immediate treatment are important in order to

prevent complications related to this, where blindness can be the end result of untreated or delayed
treatment of retinopathy of prematurity. In this child, immediate treatment of her ROP with laser was
done during NICU admissions causing her to retain good eyesight with resolved grade 2 of
retinopathy of prematurity. Bronchopulmonary dysplasia, or a chronic lung disease can be established
once a premature child had been ventilated for 28 days. Oxygen requirement for more than 28 days
can be categorized into moderate BPD (<30% oxygen) and severe BPD (>30% oxygen). Due to this
definitions, my patient can be categorized as having a moderate bronchopulmonary dysplasia, or a
chronic lung disease where shes are susceptible for many long term complications such as infection,
pulmonary hypertensions and even cor pulmonale which can leads to congestive heart failure in
future.
This also was the main reasons of her failure to thrive, as both her weights and heights are
persistently below the 3rd centile since been discharge from NICU admissions, together with her
prematurity and long term NICU admissions, among the contributing factors for her Failure to thrive.
She was on meter dose inhaler salbutamol per needed, which is a short acting beta two
agonist, which is used to relieve acute onset of bronchospasm and MDI seretide, which was a
combinations of fluticasone and salmeterol, a long acting beta two agonists and steroids, use mainly
as long term prophylaxis and prevention of inflammation and bronchospasm where infections and
inflammations can be common and recurrent in those with underlying chronic lung disease.
For these current admissions, she presented with acute exacerbations of bronchopulmonary
dysplasia secondary to atypical pneumonia, which was confirmed by laboratory investigations as
bacterial infections (lymphocytosis with neutrophilia and relative lymphopenia) and serology
confirmation of Mycoplasma pneumoniae as the etiology. Atypical pneumonia generally are common
in children more than 5 years old, however due to underlying chronic lung disease and long term
steroid inhalation dose which predisposes this child to an immunocompromised state can lead her to
acquired almost all the atypical microorganisms in the surrounding environment. Such child needs for
hygienic care and clean environment, and prophylaxis immunizations with pneumococcal and
influenza vaccinations are recommended for the long term benefits, which can save her from getting
recurrent lower respiratory tract infections and from frequent hospitalizations.
Thus, educating the mothers regarding the childs health conditions and addressing important
issues especially about the childs nutrition, ways of how to increase her weight and height, hygienic
care and infections preventions are important, and chest physio together with being compliance to
follow up appointment which is important for the long term benefits for her child.
Socially, the childs mother has a strong background and social support from the family and
friends. She was an educated housewife who takes care of her child and concerns about the childs
health.

GLOSSARY:
PTA

Prior to admission

FTT

Failure to thrive

ROP

Retinopathy of prematurity

NICU

Neonatal Intensive Care Unit

MDI

Meter Dose Inhaler

REFERENCE:
1. Paediatric Protocols 3rd Edition, 2013.
2. Nelson Textbook of Paediatrics, 16th Edition.
3. www.medscape.com
4. www.uptodate.com