RARE PRESENTATION OF AEP IN A 6 YEAR OLD

1. Case Presentation
Moderated by Unit-1
Dr.Aheed Khan
DNB resident
Department of Pediatrics

2. particulars
• AM
• 6 year old boy
• born out of non-consangious marriage
• resident of shahdra Delhi

3. Chief complaints
• Fever for 8 days
• cough for 5 days

4. fever
• for 8 days
• high grade, intermittent, max being 104 F
• response to medication is poor
• a/w chills, rigors initially

5. cough
• for 5 days
• dry
• non-paroxysmal

6. Type to enter a caption.
other history
• referred to Max hosp
• admitted for 3 days in
private hospital
• raised Neutrophilic TLC
• CXR- B/L opacities
• given IV antibiotics

7. • no vomiting, hematemesis, loose stools
• no hemoptesis
• no jaundice or pain abdomen
• no rash
• no dysuria, hematuria
• no joint pains
• no loss of weight

8. past history
• no h/o frequent nebulisation, TB contact, allergy, major
surgery or similar episode in the past

9. • Personal history: school going first grade student
• birth and developmental history unremarkable
• immunised upto age from private practitioner

10. Anthropometry
• weight- 27 kg
(90-97th percentile)
• height- 122cm(90-97th
• centiles)

11. general physical examination
• conscious, well oriented to time, place and person
• respiratory rate- tachypnoic RR-60/min, SpO2- 90% on room air; on
oxygen-99%
• pulse= 100/min, normal rhythm, good volume, all peripheral pulses
palpable.
• BP= 90/60 mm of mercury in left brachial artery in supine position
• temp= 102 F, in right axilla
No pallor, Icterus, Cyanosis, Lymphadenopathy, pedal edema, clubbing

12. on head to toe exam
• head is normal in shape, no dysmorphic facies
• hair and skin appears normal
• oral cavity normal
• eyes normal
• neck normal
• BCG Scar + on left arm
• extremities normal

13. Respiratory System :
• Inspection- shape normal, RR-60/min, moving B/L symmetrically
• Palpation: trachea central, no heave or thrill,
• Percussion: resonant node+
• Auscultation: air entry B/L decreased; B/L crepitations present.

14. • P/A: shape normal; non-tender, no distension; no
organomegaly, bowel sounds normal
• CVS- precordium normal, apex beat in left 5th ICS, no
thrill or heave palpated, S1-S2 heard normally, no
murmur heard.
• CNS- conscious and Oriented, No signs of Meningeal
irritation, reflexes-normal, tone/power normal in both
upper and lower extremities, cranial nerves and
sensory system intact.

15. • 6 year old boy was admitted with high grade fever for 8
days and mild cough for 5 days
• had received IV antibiotics on IPD basis in last hospital
• On examination there was decreased oxygen saturation,
decreased bilateral air entry in lungs and bilateral
crepitations.
SUMMARY

16. course in hospital

17. day-1 - 11 NOV
• Venous Blood gas-pH-7.421/pCO2-32.9/pO2-81.1/lac-1.3/HCO3-21
• Hb:10.9; TLC- 15.3(N84L10M6E0; Platelets-465; CRP-177
• Radiological- Chest X-ray- b/l Miliary Shadow in both Lung fields

18. D/d
• Miliary Kochs
• Atypical Pneumonitis
• Hypersensitivity Pneumonitis
• Vasculitis Syndromes

19. day-1 X-ray Day-2 X-Ray
Type to enter a caption.

20. Fever and Oxygen Requirement Persisted
• Day-2:12-Nov- Continued on NIV; ECHO- Normal
• Day-3 -13-Nov: Vasculitis and Respiratory Panel:
Normal

21. DAY 4- 14 nov
• Fever Persisted
• Vesicular Rash-on trunk
• Echo-Normal
• CECT Chest: b/L Interstitial infiltrates; interlobular septal
thickening, more in mid and basal zones, hilar Lymph nodes
present with no necrosis
• Blood Culture- Sterile
• Mantoux- non-reactive

22. Type to enter a caption.

23. DAY 5-15 nov
• persisting fever, mild cough, tachypnoea
• on oxygen with nasal prongs
• Antibiotics added- Meropenem+Doxycycline- i/v/o broad spectrum
coverage and ?Rickettsial
• antifungals added- on suspicion of Histoplasmosis & Cryptococcus d/t
contact with Pigeons
• BRONCHO-ALVEOLAR LAVAGE DONE:
• BAL-TLC-5-7/HPF;N-78%;L-4%;E-18%
• BAL Fluid- Gram Stain, AFB, fungal elements not found

24. Day-6-7
• fever persisted;
• oxygen by nasal prongs+ IV antibiotics
• CXR- b/l infiltrates
Type to enter a caption.

25. Day-8-19 Nov
• fever persisting, tachypnoea present but not worsening
• BAL- Gene Xpert- negative
• BAL Culture- Pseudomonas aeruginosa, sensitive to Colistin
• CT guided Lung Biopsy planned
• Pneumothorax-ICD was put;
• Steroid Added to the T/t
• CBC- Leukocytosis[16k]; Thrombocytosis[654]; raised
CRP[142]

26. Day-9: 20 Nov
• oxygen by nasal prongs+ IV antibiotics
• response to Steroids
• Fever and Respiratory Distress Settled
Type to enter a caption.

27. Day-10-21 Nov
• Started taking Orally
• ICD removed; Pneumothorax Resolved
• Lung Biopsy report:
• Multiple Granulomatous Lesions composed of langerhans
Background with no e/o Vasculitis
• Tissue culture and Fungal- Negative
• Tissue Gene Xpert- Negative
• ACE levels [?sarcoidosis] - not elevated

28. Multiple well formed Granulomas without caseous Necrosis with
Langherhan cells and mononuclear infiltrate

29. Type to enter a caption.
Day-12-23 Nov
• steroid continued
• antibiotics stopped
• weaned off O2 support
• CXR-Clearing of opacities
• afebrile with no resp distress
• Discharged on Oral Steroids

30. Possible Diagnosis
• Hypersensitivity Pneumonitis
• Acute Eosinophilic Pneumonia
• Sarcoidosis
• Interstitial Lung Disease

31. Hypersensitivity Pneumonitis
• extrinsic allergic alveolitis -inciting agent is inhaled from the environment, is a complex immunologic-
mediated syndrome
• primary source in children-birds
• Criteria:
• identifying antigen exposure
• Clinical Symptoms
•BAL-Usually with low CD4:CD8 ratio (i.e., CD8 is higher than normal)
•Histopathology showing compatible changes with hypersensitivity pneumonitis by 1 of these findings:
• Poorly formed, non-caseating granulomas (most often found closer to the respiratory epithelium
where deposition of the offending antigen occurs)
• Mononuclear cell infiltrate in the pulmonary interstitium
1.
•

32. • mid zone and upper zone opacities with ground- glass appe

33. Eosiniphilic Lung Disease
• Eosinophilic lung disease, regardless of the stage of disease or etiology, shows m
• BAL- diagnostic- >25% Eosinophils
• Dyspnoea - most common Symptom
• CXR- Fluffy Alveolar Infiltrates

34. ACUTE EOSINOPHILIC PNEUMONIA
• rapid onset, marked Hypoxemia, teenagers
• absence of circulating Eosinophils
• Pleural Effusion
• Criteria: Acute Onset; B/L infiltrates; PaO2<60mmhg;
BAL>25%; Absence of Determined Cause of
Eosinophilia
• <25% eosinophils- advise Lung Biopsy

35. Sarcoidosis
• Sarcoidosis is an idiopathic inflammatory disease involving multiple organ
systems, with characteristic histology of non-caseating granulomas
• C/F- Dyspnoea, Cough
• Children- Skin Rash, Arthritis,Iridocyclitis
• Lab- Hypergammaglobinemia; hypercalciuria, Hypercalcemia;
• Elevated ACE Levels-75% patients
• BAL- Lymphocyte>16%; CD4:CD8 Ratio>4;
• Bx- Non-caseating Granulomas in bronchial Walls, Alveolar Septa
• CXR- Hilar Lymphadenopathy with Reticular Opacities

36. Aadi on Discharge