Pediatrics

Case write-up 2
Bronchiolitis

Aisha Abubakr Alyassi

U18105466

2022/2023
 Section A
The Demographics
● Name: Z.N
● MRN: 162554
● Ward: Pediatrics ward 1 in al qassimi
● Age: 2 months old / Gender: male
● Nationality: Filipino
● Blood group: A positive
● Date of admission: 26-3-2023
● Source of history: from the patient’s mother

Chief complaint
Increased work of breathing, with coughing and vomiting,

History of presenting illness

M.A, a 2 months old baby boy, was brought to the emergency department by his mother with
increased work of breathing that started yesterday evening suddenly and is getting worse
progressively. Both parents noticed that he was breathing faster, with more effort, and was
wheezing; they described the breathing as shallow. His symptoms started 4 days ago with coughing
and a runny nose.

The cough started suddenly and is progressing since it started. It was productive, it had a clear
sputum, thin in consistency and no blood was found in it. He also had vomiting; which contained
milk and mucus but no blood noted. The vomit was also described as being of large amount.
According to the mother; the child coughs and vomits after every feed and he keeps crying until he
gets tired and sleeps again. He couldn’t sleep at night because of the coughing and the shortness of
breath.

He also had a congested nose which made him uncomfortable the whole time and the parents
believe this is the reason that his oral intake decreased significantly. The mother reported that he
used to take 90 ml of formula mild every 2-3 hours, but since his symptoms appeared he’s
tolerating only 60 ml and ends up throwing it up. His urine output has also decreased, he passed
urine only twice per day. And he did not pass stool since yesterday. The mother also noticed that he
is more sleepy since yesterday and rarely consumes milk as he’s tired all the time.

2 days ago he was taken to a private clinic amd was sent home in the first visit with nasal sprays and
drops. He was also given antibiotics but the mother did not give him. She denied noticing rash,
fever, cyanosis and diarrhea.

This is the first time he experiences such symptoms since he was born. In addition; he has 2 siblings
at home and both of them have upper respiratory tract infection symptoms.
Associated symptoms
The patient had shortness , associated with coughing, vomiting containing milk
He also had a congested, runny nose.
He experienced loss of appetite and decreased urine output and not passed stool since
yesterday.
He’s tired, fatigued and deprived of energy.

Review of systems of the patient:

● He’s not sweating and there’s no fever.
● The patient’s hearing is well, there’s no discharge. No visual issues.
● He has a productive cough with clear sputum. He also had a runny nose, but no sore
throat.
● His breathing was shallow and rapid and he had palpitations.
● No loss of consciousness episodes.
● No tenderness, abdominal dissension or scars.
● He had so many episodes of vomiting, nearly after every feed; containing milk.
● He had a decreased urine output.
● No episodes of diarrhoea.
● He is fatigued, tired, and deprived of energy.
● No swelling in the lower limb or redness.
● No cyanosis was noted.
● No bruises or rashes were noted.

Birth history
Ante Natal: The mother’s pregnancy was uneventful, it was a healthy pregnancy with no complication, she
did not get sick during it. She did not take any medication except for the vitamins and folic acid. She went to
all her prenatal appointments and did all the ultrasound but no abnormalities were noted.

Natal: The baby is preterm; He was born in 33 weeks of gestation with lower segment C-section. The reason
for the c-section was because of the previous 2 c-sections, and the first one was because of failure to progress.
He weighed 2.3 kgs.

Post-Natal: He was admitted in the NICU for 18 days with breathing difficulties. And he was intubated for
1 week.
Developmental history
Gross motor:

- Lifts head briefly when placed on tummy

Fine motor:

- Brings hands to mouth.

- Holds a rattle when placed on his hands.

Language:

- Makes sounds other than crying

- Cries to communicate needs.
- Turn head toward sounds.

Social:

- He smiles back when someone talks to him.

- Calms down when spoken to or picked up.
To conclude; his developmental milestones are appropriate for his age.

Immunization history
He received the birth vaccine, but still did not receive the 2 months vaccine.

The patient’s medical and surgical history

The only significant thing in his past medical history is that he had difficulty
breathing because he was preterm and had to get intubated for 1 week and gets
admitted for 18 days.
Medications and allergies
He is not taking any medications at home.

No reported allergy towards any food or medications.

Family history
The parents are not consanguineous. He has 2 older siblings who are healthy with no illnesses.

His father had a history of childhood asthma and was receiving medications until high school.
The older brother is allergic to fish and peanuts, no family history of eczema. No other chronic
diseases or long term illnesses in the family that is worth mentioning.

The mother is the primary caregiver.

Social and Nutritional history

The mother decided not to breastfeed her baby since he got admitted to the NICU. So he has
been formula fed since he was born. He is taking Aptamil brand.
The child is not loud, he sleeps well at night and had suffered from gases in the first period
but responded well to medications.
He has 2 older siblings, they all live in the same house with their parents in Sharjah. The
mother does not work but the father works in the Salon. The family income is adequate but
they’re afraid it won’t cover all the expenses so they’re willing to ask for help.
None of the family drinks or consumes alcohol.
 Section B

Vitals at admission
Temperature: 36.6 ̊C (tympanic)
Pulse: 119 bpm
Respiration rate: 43 br/min
Blood pressure: 103/34 mmHg
SpO2: 97%

Weight: 3.8 kg
Height: 52 cm
Body mass index: 16.7 kg/m2

Clinical examination
The general assessment
The patient is alert and active, fairly hydrated, the capillary refill is less than 2 seconds. He is
coughing and seems sick and tired. He is breathing rapidly as well. He has no abnormal
discoloration in his skin.

Head, ENT, and neck

● He had a normal head shape with no abnormal face features.

● He had no pallor or icterus; normal conjunctiva. He had dry mucous membranes but no
cyanosis under the tongue.
● He had a congested, runny nose.
● His throat and his bilateral tympanic membranes are clear.
● No enlarged lymph nodes.

CVS & Respiratory

● He had a working ala nasi.

● Upon inspection of his chest he had subcostal and intercostal retractions.
● The heart rate and rhythm were of normal character and volume.
● He is tachypneic and breathing mode is abdominothoracic.
● Heart sounds are normal, with normal S1 and S2. No murmurs detected.
● He had equal bilateral air entry, conductive sounds, scattered crepitations on the right side.
Musculoskeletal and Dermatology

● His skin was warm, dry and pink.

● Mongolian spots were on the left shin.
● No cyanosis is noted anywhere in the skin.
● No rashes were there.

GI exam

● The abdomen was soft, there was no tenderness, no dissension was noted, there was
normal bowel sounds, with no organomegaly, and no masses felt.
● His genitalia are normal looking, circumcised with no abnormalities.

Neurological

● He is awake and alert

● There were no signs of meningeal irritation.
● Glasgow coma score is 15/15.
● He’s normotensive.
● Moro and rooting reflex were noted.
Growth chart

Weight - 3.8 kgs falls on the 15th percentile

Height - 52 cm falls on the 25th percentile

Head circumference - 38 cm falls on the 5th percentile

Differential diagnosis
- Bronchiolitis
- Pneumonia
- Asthma

The investigations significants are highlighted

● CBC:
○ WBCs: 13.24
○ Hemoglobin: 10.5 low
○ Hematocrit: 30.9%
○ RBCs: 3.78 low
○ MCV: 81.80
○ MCHC: 34
○ RDW: 14.70
○ Platelets: 752 low
○ Neutrophils: 35
○ Lymphocytes: 51
○ Monocytes: 10
○ Eosinophils: 4
○ Basic metabolic panel:
● Creatinine: 23.40 umol/L
● Na: 136
● K: 5.12
● Cl: 101
● CO2:
● Urea: 3.57
● Uric acid: 180.1
○ LFTs:
● Total protein: 66.70
● Albumin level: 34
● Total bilirubin: 6.3
● ALT: 24
● AST: 19
● Alkaline phosphatase: 191
● CRP: 33 mg/L (Indicating an ongoing inflammation)

PCR for RSV, Influenza A&B, Covid-19: were all negative

Chest X-ray:
Lung fields: Bilateral prominent para hilar lung vascular markings. No consolidative patches.
Parenchymal infiltration or mass lesion.

Pleura: clear with no collection of fluid.

Bony thorax: normal and unremarkable.

Cardiothoracic ratio within normal limits. No mediastinal masses.

CONCLUSION: No significant findings on the AP radiograph

Abdominal X-ray:
No abnormal air-fluid levels. No calcified foci. No free intraabdominal air.
Bowel gas pattern: distended

Provisional diagnosis
● Bronchiolitis
My management plan
First we should admit the patient to the ward to correct the dehydration if any since the mother
reported that his urine output is decreased. We should start intravenous 0.9 normal saline
accordingly.

Then we should monitor the vitals and saturation every 2 to 4 hours. And if the saturations
dropped below 90% we should give oxygen supplementation.

We should encourage oral feeding, but since the patient is vomiting continuously with coughing,
nasogastric tube should be considered. Inhaled racemic epinephrine PRN.

Follow-up
Subjective
The child looks better now, not in distress and his breathing improved. He smiles back and
look well hydrated.
Objective
The patient’s breathing is better and not rapid or shallow, he’s vitally stable. His urine output
has improved, he’s well hydrated. His chest is clear, no crepitations.
Assessment
He responded well to the treatment since his hydration status has improved. He is no longer
vomiting but the cough is still there. The CRP has decreased to 4.1. Lab values all
normalized.
The patient has responded to the treatment adequately, no complications has arised. Her
symptoms are improving, the fever has subsided and she is no longer vomiting but had an
episode of diarrhea this morning. CRP is reduced to 2.3. And all other lab values were within
normal range.
Plan
The mother has been explained about the diagnosis and the management plan along with red
flags signs to look out for. Then he was discharged today.
He was given an appointment in the outpatient clinic after 1 week.
 Section C
Learning points

● Bronchiolitis is an acute inflammatory injury of the bronchioles, usually caused by a viral

infection, most commonly respiratory syncytial virus. The condition can affect people of all
ages, but severe symptoms usually appear only in young children.
● 2 years of life and the most common cause of hospitalization during the first year.
● This disorder predominantly affects children younger than 2 years of age.
● The male to female ratio is 2:1. Epidemics occur from November to April.
● Risk of infection is increased with day care attendance,multiple siblings, exposure to
tobacco smoke, and lack of breastfeeding.
● More significant disease occurs in patients with chronic lung disease, congenital heart
disease, history of prematurity, immunodeficiency diseases, and genetic abnormalities, as
well as in infants younger than 3 months of age.
● Respiratory syncytial virus (RSV) is the most common cause. Less common causes include
human metapneumovirus, parainfluenza, adenovirus, rhinovirus, influenza, and
coronavirus.
● The onset is gradual,with upper respiratory symptoms, such as rhinorrhea, nasal
congestion, fever, and cough.
● Progression of respiratory symptoms includes tachypnea, fine rales, wheezing, and
increased work of breathing. Hypoxemia may occur. Apnea may occur, especially in young
infants and in children with a history oF apnea of prematurity. CXR may reveal
hyperinflation with air trapping, patchy infiltrates, and atelectasis.
● Improvement is usually noted within 2 weeks. More than 50% develop recurrent wheezing.
● Complications may include apnea, respiratory insufficiency, respiratory failure, and death.
Bacterial superinfection occurs rarely. Immunity is incomplete, although repeat infections
tend to be less severe.
● Diagnosis is made on the basis of clinical features. Virologic testing is available if needed.
● Treatment is primarily supportive with nasal bulb suctioning (infants are obligatory nose
breathers), hydration, and oxygen as needed for SpO2 < 90%.
● Hand decontamination (preferably with alcohol-based rubs) is an essential part of contact
isolation to prevent spread of infection.
● Exposure to environmental tobacco smoke should be avoided.
● Nebulized hypertonic saline may help hospitalized infants, but albuterol, epinephrine, and
corticosteroids are no longer recommended.
● Hospitalisation is indicated for respiratory distress, hypoxemia, apnea, dehydration, or
underlying cardiopulmonary disease.
Literature review:

Title: Development of mRNA vaccines against respiratory syncytial virus

(RSV)

Journal: National library of medicine

Published in 13th of October 2022

RSV, a single-stranded negative-sense RNA virus, is the main culprit responsible for
bronchitis and pneumonia in young children and the elderly. There isn't an RSV infection
prophylactic vaccination available right now. However, new targets for preventive measures
have been made possible by developments in the characterisation and structural resolution
of the RSV surface fusion glycoprotein, revolutionizing the development of the RSV vaccine.

Particle-based vaccinations, vector-based vaccines, live-attenuated or chimeric vaccines,

subunit vaccines, mRNA vaccines, and monoclonal antibodies are the six main techniques
that have generally been used in the development of prophylactic RSV therapies. The
following preventive measures are MVA-BN-RSV, RSVpreF3, RSVpreF, and Ad26. Phase 3
clinical trials are testing RSV.preF, nirsevimab, clesrovimab, and mRNA-1345, with newborn
or elderly populations showing the greatest promise.

The enormous success of mRNA vaccines in COVID-19 has accelerated the development of
mRNA vaccines, and many of them have entered clinical investigations where they have
shown good results and acceptable safety profiles. In fact, the FDA gave Moderna's
investigational single-dose mRNA-1345 vaccine against RSV in adults over 60 years of age
approval, providing fast-track status. Consequently, mRNA vaccinations might signify a
fresh, more fruitful chapter in the ongoing struggle to create RSV prevention methods that
work. The structure, life cycle, and brief history of RSV are discussed in this study along with
the most recent developments in RSV preventatives, with an emphasis on the creation of an
RSV mRNA vaccine. Finally, the field's potential futures are discussed.

References:
1. Qiu X, Xu S, Lu Y, Luo Z, Yan Y, Wang C, Ji J. Development of mRNA vaccines against
respiratory syncytial virus (RSV). Cytokine Growth Factor Rev. 2022 Dec;68:37-53. doi:
10.1016/j.cytogfr.2022.10.001. Epub 2022 Oct 13. PMID: 36280532.
2. Liang B, Matsuoka Y, Le Nouën C, Liu X, Herbert R, Swerczek J, Santos C, Paneru M, Collins
PL, Buchholz UJ, Munir S. A Parainfluenza Virus Vector Expressing the Respiratory Syncytial
Virus (RSV) Prefusion F Protein Is More Effective than RSV for Boosting a Primary
Immunization with RSV. J Virol. 2020 Dec 22;95(2):e01512-20. doi: 10.1128/JVI.01512-20.
PMID: 33115876; PMCID: PMC7944453.
3. Shan J, Britton PN, King CL, Booy R. The immunogenicity and safety of respiratory syncytial
virus vaccines in development: A systematic review. Influenza Other Respir Viruses. 2021
Jul;15(4):539-551. doi: 10.1111/irv.12850. Epub 2021 Mar 25. PMID: 33764693; PMCID:
PMC8189192.