Dr.Shobika,Dr.VinithaPrasad ,Dr.Steffy,Dr.Shela
DrC Jayakumar
Nine year old male child presented with complaints of wet cough of 10 days duration associated with high grade intermittent fever and chills of 7 days duration with at least 2-3 spikes everyday, initially,he was managed with oral antibiotics (azithromycin).
Due to persistent fever spikes,child was admitted in local hospital,where labs CRP-65 and CXR was abnormal and started on multiple antibiotics (inj.ceftriaxone,amikacin,clarithromycin,oseltamivir,cefoperazone sulbactam). Inspite of all antibiotics,as the child continued to have fever spikes brought to AIMS for further management.No h/o breathing difficulty, chest retractions, abdominal pain, altered sensorium, rashes.
BIRTH HISTORY :3rd child of NCM. ANTENATAL HISTORY :Uneventful normal HISTORY :Term/AGA/Birth wt-3.6 kg/LSCS no asphyxia
POSTNATAL HISTORY :Unevent
No previous hospital admissions.
Developmentally normal and immunized upto age
At admission,Child was febrile, tacypneic,tired looking. No PICCLE
Growth parameters were normal.
Systemic examination revealed air entry decreased on left Infraaxillary inframammary and interscapular areas,Bronchial breathing was also heard.
Labs done at the time of admission-CRP-150,TLC-8,N/L-80/14
Chest x ray -left lobe consolidation
The child was started with inj.piptaz,vancomycin,nebulised bronchodilators and other supportives.
On day 2 of admission, i/v/o persistent fever spikes,repeat counts showed CRP-190
Repeat Cxr was worsening
USG chest was done showed left upper lobe collapse with cardiac shift to left.Left lower lobe posterior basal segmental consolidation with air bronchogram.Thin rim of basal pleural fluid so Inj.Meropenam was also added.
Again, repeated counts on day 4 of admission, CRP-184
CT chest was done showed left upper lobe and lingual collapse,left lower lobe consolidation,relatively sparing the superior segment.Patchy right lower lobe consolidation,proximal left upper lobe,lingual bronchi visualised,distally not seen,with no definite intraluminal filling defects or extrinsic lesions causing compression.
Rapid respiratory panel – detected mycoplasma pneumonia and influenza B virus IgM mycoplasma was positive
Antibodies were changed to Ceftriaxone,levofloxacin,azithromycin and oseltamivir. No further fever spikes. Levofloxacin continued for 10 days.
X ray repeated at the time of discharge
Drug resistant mycoplasma pneumoniae:Macrolides are the treatment of choice for atypical pneumonia because of their low minimum inhibitory concentration (MIC) and high safety profile in children.
However, macrolide antibiotics should be used only in confirmed Mycoplasma infections. MRMP may be considered in patients with proven Mycoplasma pneumoniae who show no response to macrolide treatment for 72 hours. Levofloxacin and doxycycline are alternative second-line antibiotics for MRMP.
Doxycycline 2 to 4 mg/kg orally or IV per day in one or two divided doses (maximum daily dose 200 mg) for 10 days; it can be administered for ≤21 days to children of all ages.
Levofloxacin -≥6 months and <5 years – 8 to 10 mg/kg per dose every 12 hours (maximum daily dose 750 mg/day) for 7 to 10 days•≥5 years – 10 mg/kg per dose once per day (maximum daily dose 750 mg/day) for 7 to 10 days.