Topic: respiratory distress syndrome, broncho – pneumonias, kernicterus
Question:A year old unimmunized boy weighing 6kg presented with fever, cough and difficult breathing for 5 days. There was a history of fever with maculo papular rash lasting for 3 days around 7 days prior to this episode. The child is febrile, has a pulse rate 116/min, respiratory rate: 72/min, SPO2 88%. There is severe chest in drawing and nasal flaring. Auscultation revealed bronchial breath sounds on left side and bilateral crepitations. ① State the complete diagnosis. ② Enumerate 3 most important complications associated with this condition. ③ How would you assess the severity of ‘illness in this child? ③ Discuss in brief the management of this child.
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A. Diagnosis:
This child presents with signs and symptoms of severe pneumonia with respiratory failure, possibly due to measles infection.
B. Complications:
1. Respiratory failure: As evident in this child with increased respiratory rate, chest in-drawing, hypoxia and bronchial breath sounds. Requires oxygen therapy, CPAP or mechanical ventilation.
2. Secondary bacterial pneumonia: Measles infection damages the respiratory epithelium allowing secondary bacterial infections to develop. This child requires IV antibiotics to cover organisms like Streptococcus pneumoniae and Staphylococcus aureus in addition to measles treatment.
3. Encephalitis: Measles virus can invade the central nervous system leading to encephalitis which may present within a week of the rash. Requires IV immunoglobulin or antiviral therapy. May lead to permanent neurological sequelae or death.
C. Assessing severity: This child has signs of severe complicated measles pneumonia with respiratory failure and requires close monitoring and intensive management:
– Respiratory rate >70/min, hypoxia (SPO2<90%), inability to drink/feed: Require oxygen therapy and IV fluids to prevent dehydration. May need CPAP/mechanical ventilation if condition worsens. A respiratory rate greater than 60 breaths per minute in a child under 2 months of age or greater than 50 breaths per minute in a child over 2 months of age is a sign of severe respiratory distress. SPO2 less than 90% indicates severe hypoxia.
– Chest in-drawing, nasal flaring, bronchial breath sounds: These are signs of increased work of breathing and respiratory distress. indicate severe pneumonia. IV antibiotics are required in addition to oxygen/respiratory support.
– Febrile, reduced urine output, lethargy/irritability: suggest systemic toxicity requiring IV fluids and antipyretics to prevent febrile convulsions.
-Mental status: Lethargy, confusion, and irritability can indicate hypoxia and severe illness.
– Monitoring of pulse rate, BP, oxygen saturations, urine output and neurological status is required to assess progression of disease and guide need for escalation of care. Blood tests like blood gas, LFTs and blood cultures may help determine severity of complications.
D. Management:
– Admit to intensive care for close monitoring given respiratory failure. Oxygen therapy/CPAP to maintain SPO2 >94%. Endotracheal intubation if exhausting or not improving.
– IV Ceftriaxone and Clarithromycin for 7-10 days to treat secondary bacterial pneumonia.
– IV fluids at maintenance rates to correct dehydration and support nutrition as unable to feed orally. Nasogastric tube may be required if not tolerating fluids.
– Antipyretics such as IV Paracetamol to control fever and prevent seizures. Cooling measures may also be needed.
– If encephalitis suspected based on neurological symptoms, IV immunoglobulin can be given within 6 days of rash onset. Acyclovir also forms part of treatment.
-Bronchodilators: Nebulized bronchodilators can help to relieve bronchospasm and improve breathing.
– Respiratory isolation and droplet precautions required to prevent spread to other children.- Measles vaccination should be offered to all contacts to limit community spread.
