LN is a 9-year old girl presenting with a 3 month history of productive cough and recent hemoptysis. She reports fever, intermittent dyspnea, chest pain and significant weight loss. On examination, she appears thin and in respiratory distress. Her lungs show decreased air entry and absent breath sounds on the left lower lobe. She is being evaluated for potential causes such as pulmonary TB, pneumonia, or a lung mass. Further testing is needed to make a diagnosis.

1. NELSON
MANDELA
ACADEMIC
HOSPITALPAEDIATRICS
GROUP C

2. Primary Information:
 Name: LN
 Age: 9 year old
 Gender: Female
 Date of Birth: 29/06/2009
 Location: Payne, Mthatha
 Referral: Self-referral
 Date of arrival: 28/10/18
 Date of clerkship: 29/10/18
 Informant: Mother, Grandmother, Patient

3. Presenting complaints:
 The patient presented with a cough of 3 months
duration and 1 day history of coughing up blood

4. History of presenting complaint:
 The patient was well until 3 months ago when she started
coughing. The cough was productive of non-foul smelling
whitish sputum, and she was unable to quantify the
amount. She did not notice any foul-smelling breath. 2
months later she noticed streaks of blood in her sputum.
She then went to the clinic and sputum and bloods were
taken but she does not know the results.
 1 day prior to presentation to NMAH the sputum
consisted of mostly blood, approximately half a cup full
which was red in colour with small clots. There were no
food particles in the sputum. There is no history of
nausea and vomiting as well as no retching or trauma.

5. HPC CONTINUED
 The coughing was associated with a left-sided chest
pain which was sharp, non-radiating, and not
relieved by anything. She rated it 5/10. The patient
also noticed difficulty in breathing which is
intermittent. There was also associated fever and a
significant loss of weight (noticed 2 months ago).
The grandmother did not notice any abnormal
sounds on breathing. There is no history of choking.
 There is no known TB contact

6. HPC CONTINUED
 The patient exhibited no drenching night sweats,
no loss of appetite, no dizziness, no fainting and
no easy fatigability. There were no palpitations,
no orthopnea, no swelling of lower limbs or
abdomen and no RUQ pain. She did not notice
any easy bruising or bleeding from any other sites
and no rash.
 The grandmother reports no use of herbal
medication. The patient says she has not inserted
any foreign objects in her nose or mouth.

7. PAST MEDICAL HISTORY
 The patient has no chronic illnesses e.g.
asthma. She has never been diagnosed with
TB.
 She is RVD negative last tested in January
2018
 She has no known allergies.
 She has never been hospitalized.
 She is not on any medication.
 She has not had any surgeries or blood
transfusions.

8. PERINATAL HISTORY:
PRENATAL HISTORY:
Her mother was a primigravida at the time of pregnancy.
The mother booked late at 6 months as she did not know when
to start ANC. It was an unplanned pregnancy
The mother was found to be RVD reactive on booking bloods
and was initiated on ART. The rest of the blood results are
unknown as she has lost the clinic book. (Rh, RPR, viral
load,CD4)
She did not have any complications during the course of her
pregnancy.
She did not smoke, drink alcohol or use any recreational drugs
during the course of the pregnancy.

9. BIRTH HISTORY:
 The mother delivered by NVD at term at Nessie
Knight hospital. There were no complications
during and after delivery.
 The birth weight was 3200g
 APGARs are unknown but the child cried
immediately after delivery. The child did not
require any oxygen, was not put in an incubator,
and was of normal colour.
 The baby was then started on AZT and Nevirapine
but she is unsure of the duration. PCR was not
done at birth, 10 weeks and ELISA at 18months.
 The mother and baby were discharged 6 hours
post delivery.

10. FEEDING HISTORY:
 The child was not breastfed (The mother was
advised by the nurses not to breastfeed). The child
was given formula feeds (Nan pelargon) for 6
months.
 From 6 months the patient was started on
complementary feeds in the form of purity,
pumpkin, mashed potatoes.
 She continued this until the child was 11 months
and the child was started on solid foods.
 Currently the patient is on home diet.

11. IMMUNIZATION HISTORY:
 The child is up to date with all of her
immunisations according to the mother (RTHC
is lost). Her last immunisation was at 6 years
(Td). The next one is due at age 12 (Td).

13. Growth and Developmental
history:
 The mother reports that the child has been
growing well.
 She began sitting without support at 5
months. She began crawling at 7 months and
began walking without help at 12 months.
 The fine motor, hearing and speech and social
milestones were achieved at appropriate ages.
 Currently the child is in grade 4, never failed a
grade and she is doing well.

14. Family History:
 There is nobody else in the family complaining of
similar symptoms (coughing)
 She does not have a family history of any
chronic illnesses. i.e. cardiac conditions,
bleeding disorders, respiratory diseases, or
cancer

15. Social History:
 She is an only child who was raised by the grandmother
from the age of 1 month. She lives in a 3 bedroom
house with 4 other relatives. They have access to water
and electricity. The house is well ventilated. They do not
use firewood and no one smokes in the house.
 The mother works at a private school as a temporary
teacher(income unknown). The grandfather receives
R1700 from an old age grant;2 child support grants
R400 each. Total income is R2500 Income per capita is
R500 (excluding mother’s income) The father is not
involved in the child's life. Thus they have a poor socio-
economic status.
 The household has pets such as dogs (5) and livestock
(goats,cows,pigs).
 The patient has a balanced diet which consists of pap,
rice, vegetables, fruit and all kinds of meat, which is
prepared by the grandmother and with help from the
patient’s cousin.

16. Systems Review:
 GIT SYSTEM: the patient does not have any vomiting,
diarrhoea, abdominal pains, constipation, or bloody
stools,no skin or eye discolouration
 CNS: She reports no headache, photophobia, blurring of
vision, neck stiffness, collapse or any seizures.
 MUSCULOSKELETAL: the patient does not experience
any muscle, joint or bone pain.
 URINARY SYSTEM: the patient does not report burning
urination, frequency, darkened urine or any problems
voiding.

17. History Summary:
 We are presenting LN a 9 year old girl
with a 3 month history of productive
cough, now with haemoptysis of 1 day
duration associated with fever,
intermittent dyspnoea, chest pain and loss
of weight. She is RVD negative with no
known TB contact.

18. Hypotheses:
 Pulmonary TB
Support- chronic cough, haemoptysis, significant loss of weight,
dyspnoea, chest pain
Against- no drenching night sweats, no known TB contact
 Pulmonary Hydatid Cyst
Support- cough, chest pain, haemoptysis, fever, loss of weight, dogs
and livestock
 Pneumonia
Support- productive cough, pleuritic chest pain, dyspnoea, fever
 Lung Abscess
Support- productive cough, haemoptysis, loss of weight, fever
Against– not copious, not foul smelling, no halitosis

19.  Bronchiectasis
Support- Chronic cough, haemoptysis, dyspnoea, loss of weight
Against- No history of recurrent chest infections, no halitosis, no foul
smelling sputum
 Neoplasm (Primary, Secondary)
Support- chronic cough, haemoptysis, significant weight loss,
dyspnoea, fever
Against- No bone pain, no fatigue, no FH of cancers, primary lung
tumours are rare in paediatrics
Foreign body aspiration
Support- cough, dyspnoea, haemoptysis
Against– chronicity, no history of choking, or insertion of foreign body

20. PHYSICAL EXAMINATION
GENERAL APEARRANCE
 The patient appears to be a thin girl evidenced by prominent ribs,
and she in respiratory distress; She was lying in bed with a short
line in-situ and not on oxygen.
 Vital signs
 BP: 105/65 mmHg (97 to 115/ 57-76)- normal
 Heart rate: 128 bpm (75 to 120)- Tachycardia
 Respiratory rate: at 38 b/m (18 to 26) - Tachypnoea
 Temperature: 37.8 degrees Celsius (elevated)
 02 saturation: 96% in room air

21. PHYSICAL EXAMINATION:
General examination:
 No dysmorphic features
 The patient was febrile to touch and had mild pallor;
She had submandibular and cervical palpable lymph
nodes (They were mobile, discrete, non-tender, 0.5 x
0.5 cm)
 There was no jaundice, clubbing, cyanosis, or oedema
and patient was well hydrated.
 The patient had no halitosis or dental carries
 Skin- There was a BCG scar on the right arm. There
were no rashes, no skin lesions, no petechiae, no
ecchymosis

22. Anthropometric Measurements:
 WEIGHT 24KG
 HEIGHT 129CM
 MUAC 15.5CM NORMAL (5-9 YEARS >14,5CM)
 Weight for age: on -1 z-score (normal)
 Height for age: between 0 and -1 z-score (normal)
 Weight for height: between -1 and 0 z-score (normal)
Conclusion: The patient is well nourished

23. Respiratory system
Inspection:
 The child was in respiratory distress evidenced by
tachypnoea of 38 b/m, flaring of alae nasae and
subcostal recessions.
 The chest was asymmetrical, the left side was
slightly elevated, it was moving with respiration and
there was no scars or chest deformities.
Palpation
 There was no tenderness on the chest, the trachea
was slightly deviated to the right.
 Chest expansion reduced on the left globally and on
the right upper zone. Tactile fremitus was decreased
on the left mid-lower lung zones.

24. Respiratory continued:
Percussion
 There was dullness noted on the apices bilaterally, and
the left middle zone. stony dullness was elicited on the
left lower lung zone( from the 6th intercostal space). The
rest of the right lung was resonant.
Auscultation
 There was decreased air entry bilaterally, more severe
on the left, with absent breath sounds on the left lower
lung zone. The breath sounds were vesicular, with no
added sounds such as wheezing or crackles.

25. Cardiovascular System
 Pulse: 128bpm, BP 105/65 mmHg, regular, full volume , no
radio-radial delay, no radio-femoral delay , pulses were not
collapsing
 Hands: felt warm , no cyanosis, no clubbing. Capillary refill was
normal at <2seconds
 Inspection: No distended neck veins, no chest deformities
noted, pulsation was present on the left lower sternal border
 Palpation: apex beat on the 5th intercostal space, midclavicular
line
 no left parasternal heave
 no palpable thrill
 no palpable p2
 Auscultation: S1 & S2 were normal, No loud p2, and no
murmurs heard

26. Abdominal Examination
Inspection
 The abdomen was not distended ,moves with respiration,
umbilicus inverted, no scars or rashes, no distended
superficial veins, no visible masses, and no pulsations.
Palpation
 The abdomen was soft and non-tender on all 4 quadrants, no
masses felt. Liver span was 10cm in the mid-clavicular line
(upper border in the 6th intercostal space); The spleen was
not palpable; there was no renal angle tenderness
Percussion
 Tympanic to percussion, No dullness elicited
Auscultation
 No bruits over the renal and aortic areas; normal bowel
sounds were heard

27. CNS Examination:
Patient was alert and fully conscious. GCS: 15/15.
 Meningeal Signs: No neck stiffness. Negative Kernig’s sign.
Negative Brudzinski neck and leg sign.
 Cranial Nerve Examination: All cranial nerves were intact.
 Motor System: (Upper and Lower limbs bilaterally)
Inspection: No fasciculations; No involuntary movements
Muscle bulk normal, no atrophy
Palpation: Tone- normal globally; Power- proximal and distal 5/5
Reflexes: All deep tendon reflexes were normal
*Babinski sign not present

28. CNS Examination:
 Superficial reflexes
Abdominal reflex were present; Planter reflexes were present
 Sensory Examination
There was normal sensation to light touch, pain and temperature in
both the upper and lower limb bilaterally
 Cerebellar function:
gait was normal; patient had normal speech, no nystagmus, and normal
finger to nose test.
 Developmental Assessment:
 Gross motor: Appropriate for age
 Fine Motor: Appropriate for age
 Speech & communication: Appropriate for age
 Social: Appropriate for age

29. Summary:
 9 year old girl in respiratory distress with signs of
consolidation bilaterally, and signs of a left-sided pleural
effusion. She also has mild pallor, fever, tachycardia and
is well nourished. The rest of the physical examination
was normal.

30. Hypotheses:
 Pulmonary TB with left pleural effusion
 Pulmonary Hydatid Cyst with left pleural effusion
 Pneumonia with left pleural effusion
 Lung Abscess
 Neoplasm (lymphomas, leukaemia-metastasis)

31. 1.Pulmonary TB with left pleural
effusion
 Support:
Respiratory distress
Fever
Decreased chest expansion
Dullness to percussion bilaterally
Stony dullness over the left lower lung zones with absent
breath sounds
Decreased air entry bilaterally
 Against:
No added sounds (crackles)
No bronchial breathing

32. 2. Pulmonary Hydatid Cyst with left
pleural effusion
 Support:
Fever
Respiratory distress
Decreased chest expansion
Dullness to percussion
Stony dullness and absent breath sounds on the left lower zone
Decreased air entry bilaterally

33. 3. Pneumonia with left pleural
effusion
 Support:
Fever
Respiratory distress
Decreased chest expansion
Dullness to percussion
Decreased air entry bilaterally
Stony dullness and absent breath sounds on the left lower zone
Against:
No bronchial breathing
No crackles

34. 4. Lung Abscess
 Support:
Dullness to percussion
Decreased chest expansion
Fever
Decreased breath sounds
 Against:
No clubbing
No halitosis
No added sounds (crackles)

35. 4. Neoplasm with left sided
pleural effusion
 Support:
Pallor
Decreased chest expansion
Dullness to percussion
Decreased air entry
Stony dullness and absent breath sounds on the left lower zone
 Against:
No clubbing
No bronchial breathing
She is not cachexic
Rare in paediatrics

36. Hypothesis-triggered
Investigations
1. Pulmonary TB and Pneumonia
 Sputum (geneXpert with Rifampicin sensitivity; MCS):Pending
 Chest X-Ray: *refer to image*
 Mantoux skin test: Negative
 FBC: Hb- 10.1 g/dl (low);Hct 0.316 L/L (low);MCV 70.9 fL (low); MCH 32.6 pg
(low); RCC 4.46 x10^12/L (N)
WCC with differential: 22.5 x10^9/L (high) Diff not done
Platelet: 668 x 10^9/L (high)
 CRP not done and ESR Specimen was insufficient
 Urea and electrolytes: Urea 2.8 mmol/L (N); Creat 42 umol/L (N); Na 137
mmol/L (N); K 4.2 mmol/L (N); Cl 100 mmol/L (N); Bicarbonate 15 mmol/L
(low); anion gap 26 (high)
 ABGs: not done
 Total protein: 97 g/L (high); Albumin: 36 g/L (N)
 HIV ELISA: Negative
 Blood culture: not done

37. 2. Pulmonary Hydatid Cyst
 CXR: *refer to image*
 Ultrasound abdomen and the chest
 CT chest: booked for Friday (02/11/2018)
 Ecchinochosis ELISA: pending
 FBC: Hb- 10.1 g/dl (low);Hct 0.316 L/L (low);MCV 70.9
fL (low); MCH 32.6 pg (low); RCC 4.46 x10^12/L (N)
WCC with differential: 22.5 x10^9/L (high) Diff not done
Platelet: 668 x 10^9/L (high)
 CRP not done and ESR Specimen was insufficient

38. 3. Lung Abscess
 CXR: *refer to image*
 CT Chest: booked for Friday
 FBC: Hb- 10.1 g/dl (low);Hct 0.316 L/L (low);MCV 70.9
fL (low); MCH 32.6 pg (low); RCC 4.46 x10^12/L (N)
WCC with differential: 22.5 x10^9/L (high) Diff not done
Platelet: 668 x 10^9/L (high)
 Blood culture: not done
 CRP not done and ESR Specimen was insufficient

39. 4. Neoplasm
 CXR: *refer to image*
 CT Chest: booked for Friday
 FBC: Hb- 10.1 g/dl (low);Hct 0.316 L/L (low);MCV 70.9
fL (low); MCH 32.6 pg (low); RCC 4.46 x10^12/L (N)
WCC with differential: 22.5 x10^9/L (high) Diff not done
Platelet: 668 x 10^9/L (high)
 CRP not done and ESR Specimen was insufficient
 Bronchoscopy with biopsy after CT scan: not done
 Tumour markers: LDH and uric acid - not done

41. Ultrasound findings:
 Ultrasound abdomen and the chest: showed clear well
defined cystic masses noted in the left and right upper
zones and one on the left lower zone, few septations
noted on one outer left lower zone measuring 80,6mm.
There were no intra abdominal masses and no free fluid
Conclusion : Multiple cystic masses in the lungs in keeping
with hydatid cyst

42. Working diagnosis:
 Bilateral pulmonary hydatid cyst
(unruptured) to rule out TB

43. Management:
 Non- Pharmacological:
- Educate the patient about how the disease is
contracted, how it may complicate and how it shall be
managed.
- Education on hand washing and hygiene practices
- Dietary regulation of pets (dogs)
- Avoid stray dogs
- De-worm dogs
- De-worm children according to the national guidelines

44.  Pharmacological:
- Albendazole 15mg/kg/day OR 200mg p.o. b.d. for 2
weeks before surgery. Post-surgery continue for 28 days
- This patient is being managed with:
 Albendazole 200mg p.o. b.d
 Augmentin 375mg p.o. 8 hourly
 MVT 10ml p.o. daily
 Surgical management:
- The patient should be discussed with paediatric
pulmonology department at Albert Luthuli Hospital for
surgical management
- Preferably lung conservation therapy.

45. Prognosis:
 The prognosis is guarded as the patient has multiple
large cysts.
The risk of recurrence low. In cases of rupture, there is a
higher chance of recurrence, as well as complications such
as empyema and bronchiectasis developing in the future.