Dr.Subbulakshmi P.S,Dr.Praveena Bhaskaran, Dr.Preethi ,DrCJayakumar
Department of Paediatrics, AIMS, Kochi
Five year old developmentally normal female child, second of non-consanguineous marriage, presented with high grade intermittent fever (Tmax 102) and on and off dry cough of one day duration. Brother had fever
Pointer symptoms suggestive of other system involvement were negative
Immunised as per IAP Schedule
Clinically she had bilateral crepitations with normal air entry and other systemic examination were within normal limits.
In view of persistent fever spikes ceftriaxone was was changed to Injection Piptas and as fever was continuing to Cefipime, Vancomycin, Azithromycin, Oseltamivir. The child was tachypnoeic and had episodes of desaturation for which she was started on 5L Oxygen via mask and shifted to HDU and chest examination revealed bronchial breathing predominantly over the left.
Differential diagnosis:
● Atypical pneumonia- Mycoplasma, Chlamydia, Legionella
● Viral pneumonia with Secondary bacterial infection
● Pneumonia complicated with Pleural effusion
● Associated TB
Investigations:
TC: 8.8K, N: 63, L: 29.8, E: 0.8, Hb: 11.2, Platelets: 305
OT/PT: 29/10
S.Creatinine: 0.4
S.Sodium: 137, S.K: 4.0
CXR: Initially had right upper lobe pneumonia and later had worsening and had left lower lobe consolidation.
USG Chest : Left lower lobe shows basal and posterior consolidation with air bronchogram. Small area of consolidation in right upper lobe anteriorly – corresponds to area of collapse consolidation seen on the radiograph.
Mycoplasma Pneumoniae IgM CLIA : >27 (Positive)
Urine pneumococcal Antigen : Negative
CXR showing right upper lobe collapse and consolidation
Atypical pneumonia panel sent showed positivity for mycoplasma. Mycoplasma IgM titre level was >27. The child was started on chest physiotherapy and oral levofloxacin was also added. The child was weaned to room air and shifted back to ward and was discharged on oral levofloxacin.
DISCUSSION:
Atypical Pneumonia:
Definition:
Atypical pneumonia, also known as “walking pneumonia,” is a type of pneumonia caused less common pathogens compared to typical bacterial pneumonia. It is characterized a more gradual onset and often less severe symptoms.
Etiology:
● Mycoplasma pneumoniae
● Chlamydophila pneumoniae
● Legionella pneumophila sources.
● Viruses such as respiratory syncytial virus (RSV) and, more recently, SARS-CoV-2.
Clinical Features:
– Gradual onset of symptoms, including a persistent dry cough, low-grade fever, headache, and malaise. Patients may also experience myalgia and fatigue.
– Examination may reveal rales or wheezing, but often physical examination findings are less pronounced.
Diagnosis:
– Clinical History and Symptoms.
– Imaging: Chest X-ray ,CT-Chest.
– Microbiological Testing: Sputum Culture, SerologyTests for antibodies against Mycoplasma pneumoniae, Chlamydophila pneumoniae, or Legionella pneumophila.
– PCR Testing: Detects specific DNA or RNA from pathogens.
– Urinary Antigen Tests: Useful for diagnosing Legionella pneumophila.
Management:
– Antibiotics: Treatment usually includes macrolides (e.g., azithromycin, clarithromycin), tetracyclines (e.g., doxycycline), or fluoroquinolones, depending on the pathogen.
– Supportive Care: Includes rest, hydration, and symptom management.
– Follow-up: Essential to ensure resolution of symptoms and prevent complications.
TAKE HOME MESSAGE: Prognosis is generally good, with most patients recovering fully with appropriate treatment. Complications are rare but can include secondary infections or, in severe cases, respiratory failure. Includes good hygiene practices, vaccination where applicable (e.g., for influenza), and avoiding exposure to known sources of Legionella.