Miral is a 2.5 year old girl who has had intermittent fever and respiratory symptoms for 1 month. She has lost 1.2 kg and has decreased activity levels. Examinations suggest she has a pleural effusion that was drained, revealing 1000ml of pus. She underwent VATS surgery and is being treated with vancomycin, albumin, dexamethasone, and intubation. VATS procedures can be used to drain effusions, perform biopsies, and remove parts of the lung or tumors. Preschool aged children with pneumonia are usually treated with amoxicillin, while older children receive macrolides.

1. Case presentation
Habiba Al Harthi
R3 FAMCO residents

2. • Miral 2.5 year old term toddler previously healthy with 1 month
history of intermittent fever after onset of sore throat
• ho tachypnea , increased work of breathing over the month
• Decreased level of activity
• Weight loss of 1.2 kg
• She has been to a number of private clinics where she received more
than one course of antimicrobials .

6. Pneumonia
• The diagnosis can be based on the history and physical examination
results in children with fever plus respiratory signs and symptoms.
• Chest radiography and rapid viral testing may be helpful when the
diagnosis is unclear.
• The most likely etiology depends on the age of the child.
• Viral and Streptococcus pneumonia infections are most common in
preschool-aged children,

7. • Mycoplasma pneumoniaeis common in older children. The decision
to treat with antibiotics is challenging, especially with the increasing
prevalence of viral and bacterial coinfections.
• Preschool-aged children with uncomplicated bacterial pneumonia
should be treated with amoxicillin.
• Macrolides are first-line agents in older children.
• Immunization with the 13-valent pneumococcal conjugate vaccine is
important in reducing the severity of childhood pneumococcal
infections.

11. • First impressions are important in the clinical diagnosis of CAP in
children.
• Common physical findings include fever, tachypnea, increasingly
labored breathing, rhonchi, crackles, and wheezing.
• Hydration status, activity level, and oxygen saturation are important
and may indicate the need for hospitalization.
• Tachypnea seems to be the most significant clinical sign.

12. • Chest imaging is most useful when the diagnosis is uncertain or when
the findings from the history and physical examination are
inconsistent.

16. • No randomized controlled trials have established the optimal duration
of therapy for children with uncomplicated CAP.
• In most cases, seven to 10 days of empiric outpatient therapy is
sufficient.
• Azithromycin (Zithromax) should be continued for five days. Patients
should be reevaluated 24 to 48 hours after the initiation of empiric
therapy

20. Chest US ,CT both suggest a pleural effusion (proteinacious) with
minimal septae

21. • Was taken for VAST , drained 1000ml of pus

22. Management
• VATS (video-assisted thoracic surgery )
• vancomycin
• Albumin
• Dexamethasone
• Intubation

24. Indications of VATS
• Septal lung biopsy
• Lobectomy or pneumonectomy
• Rescetion of peripheral pulmonary nodule
• Evaluation of mediastinal tumors of adenopathy
• Pleural biopsy

27. • Reference , www.AAFP.org