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Page 1 / September 07


PRESENTATION FELLOW

David Zeilinski
respiratory resident,
Montreal Children's hospital

THE CASE

A 9½ year old previously healthy girl was admitted to hospital following 2 weeks of fevers and multiple symptoms. She subsequently developed respiratory failure on day 8 of her admission.

There will be a brief overview of her history prior to day 8 with focus on the subsequent progression.

History

Prior to her admission she had a 2 week history of fevers of 39-40ºC, a maculopapular rash which began on her extremities, a non-purulent conjunctivitis, and desquamation of hands and feet.

At the time of admission she had desquamation of her palms, fingers and toes, a maculopapular rash predominantly on her extremities, fever of 40ÂșC, thrush, and hepatomegaly.

During the first week in hospital, her symptoms progressed and she developed a persistent fever of 40ºC, splenomegaly, ulcerations on tongue generalized, lymphadenopathy and pancytopenia.

With the exception of rising Mycoplasma cold agglutinins (doubled to 1:256) all investigations were negative or non-contributory at this time.

On day 8 she began to complain of dyspnea after waking up. Her cough worsened and was described as "semi-productive" in nursing notes. Her respiratory rate increased to 50 breathes per minute and she developed retractions and accessory muscle use. She was transferred to the PICU and started on CPAP secondary to increased respiratory effort.

In the evening she had an acute deterioration with an oxygen desaturation to 69% and a loss of consciousness which was interpreted as a possible seizure. She was intubated and started on IV Vancomycin and IV Piperacillin/Tazobactam (IV Azithromycin had been previously started due to rising mycoplasma cold agglutinins). Blood cultures from day 6 were reported as positive for S. aureus on 1 of 2 bottles on this day.

Respiratory Consult on Day 9

HIV ELISA was returned as positive on this day.

A consultation to respiratory medicine due to acute respiratory failure was requested.

The history was noted as above and in addition:

There were no respiratory symptoms at time of admission. A cough began on day 2 of the admission. It was initially described as dry and progressed in intensity and frequency. The patient was tachypneic on admission with an initial baseline respiratory rate of 24-30 breaths per minute. The respiratory rate would increase to 40 breaths per minute with fevers of over 40ºC. By Day 5 her baseline respiratory rate had increased to 40-45/min. This was also associated with worsening fevers. Her initial chest xrays were interpreted as normal and the tachypnea was thought to be related to her fevers. During the first 7 days there were no retractions or accessory muscle use and all chest auscultations were recorded as normal.

The past medical history was non-contributory with no respiratory or infectious problems. She was born of a normal pregnancy. The family history was also non-contributory. Both parents were healthy and there were no siblings. She was born in Montreal, although her parents had immigrated from the Ivory Coast 12yrs earlier. There was no travel, and no known or suspected tuberculosis contacts.

On examination she was ventilated with pressure regulated volume control with a tidal volume of 200 mL (~6ml/kg) and a PEEP of 10 cm H2O. She was requiring peak inspiratory pressures of ~ 26 cm H20. She was ventilated with a rate of 30 and a FiO2 of 0.5.

Her respiratory examination revealed no clubbing, appropriate chest movement and decreased breath sounds to the left base. The cardiovascular examination was normal with a normal blood pressure. Her abdominal exam revealed a liver edge palpable 4 cm below the right costal margin and a spleen tip palpable 2 cm below the left costal margin. Coffee ground aspirates from the naso-gastric tube were reported. Her head and neck exam revealed mild conjunctivitis, several white lesions on the hard palate with tongue and ulcerations on the tongue borders. Her skin examination showed desquamation on her hands and mild desquamation on her feet. There were also multiple firm ~1 cm mobile cervical and inguinal lymph nodes.

An arterial gas showed: pH 7.38; pAO2 91.7; pCO2 37.5; A-a gradient 229
CBC: WBC 5.89 (neutrophils - 5.3; Lymphocytes - 0.3); Hemoglobin 98; Platelets 80,000.

All cultures were negative except 1 of 2 bottles positive for Staph aureus from Day 5.

A Chest xray was ordered.

figure 1

Please interpret the chest xray


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