1 / 68

Clinical Pathologic Conference

R1 曾敏華 / 洪志興主治醫師. Clinical Pathologic Conference. Chief complaint. A 5 year-old boy was admitted because of fever off and on with chillness, cough with whitish sputum and chest pain for 3 days. Present illness.

hume
Télécharger la présentation

Clinical Pathologic Conference

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. R1曾敏華 / 洪志興主治醫師 Clinical Pathologic Conference

  2. Chief complaint • A 5 year-old boy was admitted because of fever off and on with chillness, cough with whitish sputum and chest pain for 3 days.

  3. Present illness • About 1 week before this episode (10 days before arrival), he suffered from several times of watery diarrhea. • He had chest wall injury while he was playing with his friend. • 3 days before admission, fever off and on with chillness, cough with whitish sputum and chest pain were noted.

  4. Present illness • The pattern of chest pain: -No relieve or aggressive factor -No radiating pain. -Did not improved despite of medication. • 1 day before admission, dyspnea after climbing upstairs and palpitation was also noted. • He was brought to ER on the day of admission, and short of breath, pale lips, pale conjuntivae were found and vomiting for 3 times at ER.

  5. Present illness • Throughout the whole course of present illness, he had no skin rash, headache, abdominal discomfort and urinary change. • His appetite and activity were good.

  6. Past,Personal and Family History • Past history -Allergic rhinitis -Hydronephrosis, left. -Asthmatic bronchitis -Urethritis -Acute gastritis

  7. Past,Personal and Family History • Birth history: -GA: 38 weeks via C/S, Birth weight: 3700 gm • Developmental History: normal • No travel history. • Family history: Grandfather: had been working at mine, (礦物局) driver. : No any family member has the same symptoms like him.

  8. Physical examination • Vital sign: PR: ↑ 132 /min (65-110), RR: ↑ 36 /min(20-25), BT: 37 ºC • HEENT: Pale conjunctiva/ lip , grade 1/4 of tonsils, : congested throat • Chest wall: A tender mass 2 × 3-cm in size at his fore- chest wall. : Coarse breathing sound

  9. Lab. data 0905(admission) B/R: -WBC:14,620 (5,5-15,5 x10 3) -RBC: 4.72 x10 6(3.9-5.3 x10 6 ) , Hct:33.4% -Hgb: 11.3 ( 6mo-6 yr: 10.5 - 14) Nelson 17 ed Table 439-1 -MCV: 70.9 (6 mo-6 yr: 70-74) Nelson 17 ed Table 439-1 -MCH:24 (24-30) -MCHC:33.8(31-37) -PLT: 244 x10 3(150-450 x10 3 ) -Neut. ↑ 77.1% (54-62%); LYM.:25% (25-33%); Mon.:4.9 %(3-7%); Eos.:0.5 %(1-3%)

  10. Lab. data 0907(hospitalization) B/R: -WBC:10,380 (5,5-15,5 x10 3) -RBC: 4.65 x10 6(3.9-5.3 x10 6 ), Hct:33.4% -Hgb: 11.0 ( 6mo-6 yr: 10.5 - 14) Nelson 17 ed Table 439-1 -MCV: 69.7 (6 mo-6 yr: 70-74) Nelson 17 ed Table 439-1 -MCH:23.7 (24-30) -MCHC:34(31-37) -PLT: 234 x10 3(150-450 x10 3 ) -Neut. ↑65 % (54-62%); LYM.:25% (25-33%); Mon.:8 %(3-7%); Eos.:2 %(1-3%)

  11. Lab. data • Mycoplasma AB: < 40 (-) • CRP: ↑2.93 (0.17-1.07) • BUN / Cr: 10 / 0.4 • CPK: 50 U/L(5-110); CK-MB: 1 U/L: 2 %(1.7-7.9 %) • Glucose: 158 mg/dL • Na/ K/ Cl: 136/↓3.4/ 100 • Total Ca: 9.3

  12. Lab. data • Urine routine: - pH: 6.0 -Protein: +/- -RBC: 0-1/ HPF -WBC: ↑5-10/ HPF (Children 0–5/ hpf ) -Spgr: 1.017

  13. Hospital course : • After admission, CxR was taken, and draws blood samples. • He was discharged to home after a series of studies and treatment.

  14. Problem list Major problems: • Chest pain • Short of breath/ dyspnea • Chest wall mass • Fever, cough • Vomiting • Diarrhea Minor problem • Pale conjuntivae/ lip • Hyperglycemia • Pyuria (U/R) ?

  15. Questions? • Correlation between chest injury and chest pain/ chest mass? • Chest mass location ? Rib, costochondritic joint, intercostal muscle or sternum? • Chest wall mass: Mobile or immobile? Warm/ heat? fluctuant ? • Chest pain: sudden onset or progressive? • Needle aspiration (culture)? Mass biopsy ? • Viral culture (throat)? • CxR ? Patchy infiltration? Hilar lymphoadenopathy? • Body weight loss? Night sweating? FHx of TB? Medication Hx? • EKG ? • Sputum culture?

  16. Chest pain: possible differential diagnosis • Infectious costochondritis: Tietze syndrome • Pleurodynia • Pneumonia: Pyogenic Empyema Necessitatis • Musculoskeletal chest wall pain: Osteomyelitis

  17. Dyspnea: possible mechanism Pediatric Respiratory Medicine P370 • ↓Pulmonary compliance: Inflammation • ↑Airway Resistance: Airway inflammation & hyperreactivity • ↑Sensory Stimuli: Chest wall • ↑Chemical Stimuli: Hypoxemia, CO2, Acidosis

  18. Chest wall lesions in childhood • A wide range of pathologies. I. Benign lesions: include a. Lipoma /Lipoblastoma: usually painless, occur in the first 2 years b. Neurofibroma: Painless, associated with neurofibrosis type I c. Lymphangioma: Painless,associated with a variety of other syndromes such as asplenia,Noonan’s syndrome, and tuberculosis.

  19. Chest wall lesions in childhood d. Haemangioma and AVM : congenital lesions. e. Mesenchymal hamartoma : benign lesion of infancy with most lesions presenting before 2 years of age.

  20. Chest wall lesions in childhood II. Malignant lesions: include a. Neuroblastoma: occur before 5 years of age, abdominal mass b. Rhabdomyosarcoma:common found in head/ neck or extremities c. Ewing’s sarcoma, Askin tumour, Primitive neuroectodermal tumours: : all belong to the group of small round blue cell tumor of childhood. : Usually presenting in the second decade of life.

  21. Chest wall lesions in childhood II. Manifestations of systemic diseases: e. Leukaemia/ Lymphoma : always be excluded in a child : presenting with multiple bone lesions or bone pain, hematologic finding. f. Langerhans cell histocytosis

  22. Chest wall lesions in childhood III. Infections a. Tuberculosis: -TB on the chest wall can occur as an isolated primary infection with no evidence of pulmonary disease - Spread to the chest wall from pulmonary infection may also occur althrough symptoms may be minor - Presentation may be similar to pyogenic abscess or simply an enlarging mass.

  23. Chest wall lesions in childhood b. Actinomycosis : rare, may mimic TB with pulmonary infiltration and spread to the chest wall c. Aspergilosis: in immunocompromised patients, usually by local invasion from the lung. d. Progenic abscess : Staphylococcus, Klebsiella infection e. Other infection illness: Strongyloidiasis (Strongyloides stercoralis)糞小桿線蟲

  24. Chest wall lesions in childhood IV. Other lesions: a. Pseudo-lesions: found in cildren of early teenage years presenting with a hard lump in costochondral cartilage. : Usually no specific symptoms. b. Thoracic cage anomalies,osteochondroma, hemangiopericytoma

  25. Chest wall mass: possibile DDx • Tuberculosis • Actinomycosis • Pyogenic abscess • Strongyloidiasis (Strongyloides stercoralis)

  26. Differential diagnosis Chest pain • Infectious costochondritis: Tietz syndrome • Pleurodynia • Pneumonia- Pyogenic Empyema Necessitatis • Osteomyelitis Chest mass • Tuberculosis • Actinomycosis • Pyogenic abscess • Strongyloidiasis • Dyspnea • ↑Airway Resistance: Airway inflammation & hyperreactivity • ↓Pulmonary compliance: Inflammation • ↑Sensory Stimuli: Chest wall • ↑Chemical Stimuli: Hypoxemia, CO2, Acidosis

  27. 1. Tietze syndrome: infectious costochondritis • Inflammation of the costal cartilages (Costochondritis) with a large, tender, fusiform (spindle-shaped), nonsuppurative swelling at the costochondral or chondrosternal junction. Principles and Practice of Pediatric Infectious Diseases, 2nd ed • Etiology: -Exact cause unclear -Most often idiopathic -Associated with excessive exercise, chest injury or a preceding viral respiratory illness (postinfectious)

  28. 1. Tietze syndrome • Epidemiology -Generally occurs in late teens to early twenties, but has been described in young children. • S/s: sharp pain in anterior chest wall, may radiate to back or upper abdomen. : varies in intensity and quality. • PE: Tender by palpation at local site or movements of the arm or shoulder. :May show evidence of tachypnea, tachycardia or systolic HTN. : Distortion of local soft tissue.

  29. 1. Tietze syndrome • Diagnostic workup -Made with historical and physical clues. -Biopsy: increased cartilage and lack of inflammatory fibrosis. • Management: NSAIDs, Injections into the painful area with triamcinolone are sometimes curative. Question: Fever ? preceding viral respiratory illness?

  30. 2. Pleurodynia Nelson 17ed p1045, Principles and Practice of Pediatric Infectious Diseases, 2nd ed P1183 • Etiologic agents are most frequently coxsackieviruses B3 and B5, as well as coxsackieviruses B1 and B2 and echoviruses 1 and 6. Nelson 17ed p1045 • Sex:Males are affected more than females. Half of these patients are younger than 5 years, and 30% are younger than 1 year. • Coxsackievirus B usually causes an asymptomatic or brief upper respiratory tract or gastroenteric infection. Nelson 17ed p1045 • The virus has an incubation time of 1 week in the GI tract and subsequently involves the target organs through hematogenous dissemination.

  31. 2. Pleurodynia Nelson 17ed p1045, Principles and Practice of Pediatric Infectious Diseases, 2nd ed P1183 • Prodromal symptoms such as malaise, myalgias, headache and diarrhea are followed by sudden onset of fever and pain. Principles and Practice of Pediatric Infectious Diseases, 2nd ed P1183 • Involvement of the intercostal and other muscles of respiration results in enhanced pain with deep breathing and a sensation of “pleuritic” pain that can result in splinting of the chest and rapid, shallow breathing. Principles and Practice of Pediatric Infectious Diseases, 2nd ed P1183 • Pain, typically located in the chest or upper abdomen, and is spasmodic and can be excruciatingly severe. Nelson 17ed p1045 • During spasms, respirations are usually rapid, shallow, and grunting, pale, sweaty, and shock-like appearance.Nelson 17ed p1045

  32. 2. Pleurodynia Nelson 17ed p1045, Principles and Practice of Pediatric Infectious Diseases, 2nd ed P1183 • Causes necrosis of the striated intercostal muscles in patients with pleurodynia. • Muscle tenderness can be detected by direct palpation; less commonly, localized swelling is observed ( Sylvest, 1934 ) • Associated symptoms related to the viral infection may include the following: -Upper respiratory tract symptoms, including sore throat, rhinitis, and cough. -Constitutional symptoms, including headaches (50%), fever, and malaise

  33. 2. Pleurodynia Nelson 17ed p1045, Principles and Practice of Pediatric Infectious Diseases, 2nd ed P1183 -GI symptoms, including nausea, vomiting, diarrhea (50%), and in children, abdominal pain (usually in the epigastric area) • Diagnosis: -Viral cultures(throat) isolation of coxsackievirus B in cell cultures . -RT-PCR(throat) -Histologic Findings: Necrosis of the striated intercostal muscles is visible . -Serum creatine kinase is usually elevated because of muscle necrosis. -CxR: reveals clear lung fields; less than 10% of patients have a pleural friction rub or pleural fluid evident on chest radiographs.

  34. 2. Pleurodynia Nelson 17ed p1045, Principles and Practice of Pediatric Infectious Diseases, 2nd ed P1183 • Illness usually lasts 3–6 days, but can last up to a couple of weeks. • Illness may occasionally be associated with meningitis, orchitis, myocarditis, or pericarditis. • Management: -Analgesics and limitation of physical activity are helpful in reducing pain, which is generally most severe on presentation and then progressively diminishes during the course of illness (which is typically 4 to 6 days but which may last as long as 3 weeks) ( Warin et al., 1953) • Question: Serum creatine kinase within normal range

  35. 3. TuberculosisPrinciples and Practice of Pediatric Infectious Diseases, 2nd ed I. Bony tuberculosis • Osteomyelitis is otherwise most frequently found in the metaphysis of long bones, although theribs, pelvis and skull may be infected. • In children in countries in which TB is prevalent, osteomyelitis is a significant cause of crippling deformity. • Trauma does not predispose to tuberculous osteomyelitis

  36. 3. Tuberculosis Principles and Practice of Pediatric Infectious Diseases, 2nd ed • Bony TB may be accompanied by sinus tracts or soft tissue masses. • Diagnosis: -May be difficult because lesions can appear osteolytic or sclerotic on radiography. -Biopsy : acid-fast bacilli (AFB) stains, culture or PCR

  37. 3. Tuberculosis Principles and Practice of Pediatric Infectious Diseases, 2nd ed II. Tuberculous abscesses: • May form in most soft tissues, including muscle . • This is usually secondary to contiguous spread of infection but may follow hematogenous dissemination. • The classic abscess site is in the psoas muscle, and such an abscess can occur with or without localizing signs • Cough, diarrhea and vomiting can be happened, but rare and chronic when the pulmonary and gastointestinal were involved. • Question: Contact history? insidious enlarging mass? Chronic steroid usage? Body weight loss? Night weating?

  38. 4. Actinomycosis Nelson Textbook of Pediatrics, 17th • Actinomyces israelii , a slow-growing, gram-positive bacteria that are part of the normal oral flora in humans. • Infection caused by these bacteria is termed actinomycosis, which is a chronic, granulomatous, suppurative disease characterized by peripheral spread with extension to contiguous tissue in the formation of numerous draining sinus tracts. • 7% of the patients <10 yr of age. The youngest patient in this series was 28 days old.

  39. 4. Actinomycosis Nelson Textbook of Pediatrics, 17th • Actinomycosisis usually not an opportunistic infection, disease has been described in patients receiving corticosteroids and those with leukemia, renal failure, congenital immunodeficiency diseases, and HIV infection • three important sites of Actinomyces infection in order of frequency are cervicofacial, abdominal, and thoracic • Pulmonary actinomycosis may present as fever, productive cough, chest pain, and weight loss. • Infection frequently dissects along tissue planes and may extend through the chest wall or diaphragm, producing numerous sinuses.

  40. 4. Actinomycosis Nelson Textbook of Pediatrics, 17th • Diagnosis : confirmed by examining purulent sinus tract drainage for sulfur granules, and by appropriate cultures. • The differential diagnosis of pulmonary actinomycosis includes lung abscess and tuberculosis. • Tx: mainstay of treatment for actinomycosis is prolonged antibiotic therapy (Penicillin) and an appropriate surgical approach to sinus tracts and abscesses.

  41. 4. Actinomycosis Nelson Textbook of Pediatrics, 17th Question: Chronic process, underlying immunocompromise status; diarrhea? Vomiting?

  42. 5. Pneumonia- Pyogenic Empyema Necessitatis • Pyogenic Empyema Necessitatis: A rare complication of empyema; is a collection of inflammatory tissue that usually extends directly from the pleural cavity into the thoracic wall forming a mass in the extrapleural soft tissues. • The hallmark of empyema necessitatis is a mass • The most common etiologies are tuberculosis and actinomycosis.

  43. 5. Pneumonia- Pyogenic Empyema Necessitatis • 1-year-old boy with Streptococcus pneumoniaeempyemanecessitatis and review previously reported . Pediatr Infect Dis J - 01-FEB-2004; 23(2): 177-9 • Symptoms: as the underlying disease, fever, chest pain, chest wall mass,cough and short of breath may be occur. Pediatr Infect Dis J - 01-FEB-2004; 23(2): 177-9 • The mass might be painful and fluctuant.

  44. 5. Pneumonia- Pyogenic Empyema Necessitatis • Diagnosis: -Chest radiograph: Pleural effusion, with thickening of the pleura at the involved site, may be an enlargement of the overlying ribs with a thick, calcified pleural rind. -CT scan: may show a thick-walled, possibly well-encapsulated, pleural mass that protrudes through the chest wall.(Virtually diagnostic of empyema necessitatis)

  45. 5. Pneumonia- Pyogenic Empyema Necessitatis Questions: Rare chronic complication of pneumonia, decreased breath sounds, dull percussion on physical examination, vomiting, diarrhea?

  46. 6. Pyogenic abscess • Pyogenic abscesses involving Staphylococcus or Klebsiella infection of the chest wall may also occur and may be due to central line or catheter-related sepsis in immunocompromise. • Large multifocal lesions may develop . • Question: diarrhea, vomiting? Cough? No predisposing factor? Not multifocal mass?

  47. 7. Osteomyelitis: Rib or sternum Nelson 17ed P2297 • Most cmmon in young children, more common in boy than girl(2:1) • The majority of infection in otherwise healthy children are hematogeneous origin. • Long bone is principlly involved in osteomyelitis (2.9% in chest bones) • Blunt trauma, bacteremia, illness, malnutrition, immune system deficiency have been described as predisposing conditions.

  48. 7. Osteomyelitis • Etiology: S. aureus is the most frequently isolated pathogen excluding patients with hemoglobinopathies, such as SCD, where Salmonella sp. is more likely . • Primary viral infections of bone are exceedingly rare, but accompanied viral syndrome, suggesting immune-mediated pathogenesis. Nelson 17ed P2298 - Extremely rarely, the viruses which cause chickenpox and smallpox have been found to cause a viral osteomyelitis.

  49. 7. Osteomyelitis • Clinical features may including chills, fever,chest pain,tenderness,swelling and erythema over the involved bone. Scand J Infect Dis 1999 ;31: 98–100. • Insidious onset of nonspecific symptoms associated with gradual painful swelling over the bone area. • Pediatr Infect Dis J 2001; 20: 547–50

  50. 7. Osteomyelitis • Diagosis: -CBC: leukocytosis with left shift, and a thrombocytosis may be present.Pediatric Clinics of North America 43: 933-947, 1996 -ESR and CRP are the nonspecific sign of inflammation. -Culture taken from the bone, either surgically or by needle aspiation. -CT or Three phases bone scan • Question: More insidious process? Chickenpox? Smallpox?

More Related