Diagnostic Dilemma

Pneumonia in a 4 month old

A 4-month-old boy presented with fever, cough, cold for 5 days and breathlessness for 1 day with decreased appetite. He was a full term normal delivery without antenatal or postnatal complications on bottle feeds with cow’s milk. He was immunized for his age. On examination, he had respiratory rate of 58/min with intercostals, substernal retractions and was febrile. There were bronchial breath sounds on right infrascapular region. Other systems were normal. Investigations showed:
• Hemoglobin = 10.2 gm/dl
• WBC count = 30,800/cumm [58% polymorphs, 42% lymphocytes]
• Platelet count = 6,75,000/cumm
• Arterial blood gas = pH = 7.39, PCO2 = 35, mm PO2 = 61, mm of Hg, bicarbonate = 21 mEq/L and oxygen saturation of 91%.
• ESR = 115 mm at end of 1 hour
• Chest X-Ray = Bilateral lower zone pneumonia with minimal pleural effusion and inter fissural effusion on right side.

Which is the organism causing the pneumonia?
Expert Opinion :
The common organisms causing pneumonia in this age group are:
• Streptococcus pneumoniae
• Hemophilus influenza b (Hib)
• Staphylococcus aureus
• Atypical organisms such as Chlamydia pneumoniae
• Viral pneumonia.

This child has high counts and has bronchopneumonia with effusion. Hence viral pneumonia seems unlikely. The atypical organisms usually cause cough and breathlessness and have crepitations. Also in infants, chlamydia pneumonia is usually seen following neonatal conjunctivitis due to Chlamydia infection. Mycoplasma and ureaplasma are usually seen in school going children. Thus, atypical pneumonias cause more signs of interstitial lung disease rather than lobar pneumonia and also seem unlikely in this child. Among the bacterial infections, Hib is the commonest organisms in this age group and can lead to effusions. Streptococcus pneumoniae leads commonly to lobar pneumonia whereas staphylococcus aureus leads to a rapidly progressive necrotizing pneumonia with deterioration in a matter of hours. Thus most likely cause of pneumonia in this child is a Hib infection. This child’s respiratory PCR panel grew H influenza b and he responded to ceftriaxone.
Answer Discussion :
lobna Mohammad
Strep. Pneumoniae
3 years ago
saeed attom
3 years ago

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