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Nick Duncan, MD PGY2 1/29/14

9 yo male with h/o allergy induced asthma, frequent RSV

infections presents to the ED with cough, congestion, hives and hypoxia. Had been staying with his father the week prior, was picked up by his mother mid-day. Poor communication between parents at sign-out. Mom initially concerned about cough and congestion due to past hx; reportedly x 1 wk Early afternoon developed hive-like rash in the face, spread to trunk and extremities
Used benadryl cream, hives began to migrate

Subjective fever? Taken to Urgent Care

Urgent Care
Wheezing, increased work of breathing, desaturations

to mid 80s
Albuterol treatment x 2 Rapid strep

History of food allergy-> Anaphylaxis? IM epinephrine 0.2ml of 1:1000 concentration Benadryl Sent to PCH ER

Continued intermittent desaturations Duoneb Zantac Admit to floor

PMH Allergy induced asthma Frequent RSV infections Autism spectrum Sensory integration dysfunction PSH: none
Fam Hx Maternal side: Asthma, latex allergy, sinus polyps, severe seasonal allergies Paternal side: ? Soc Hx Parents divorced, 60:40 custody (F:M) Father h/o tobacco use Immunizations No flu vaccine this yr, otherwise UTD

Meds: None regularly

Allergies: Red dye, Latex

T 35.3 HR 124 BP 115/77 RR 28 SaO2 98% 1.5L NC Weight: 23.6kg (5%ile) Height 130 cm (18%ile) Gen: NAD, appears tired, non-toxic appearing HEENT: EOMI, PERRL, Right TM nml appearing, unable to visualize Left TM due to cerumen, no significant nasal discharge, MMM, oropharynx without erythema or exudates Neck: supple without LAD, no tenderness CV: Tachycrdic, nml rhythm, nml S1 S2, no murmurs or gallops, cap refill < 2 s, nml pulses Pulm: Bilat intermittent expiratory wheezes, coarse breath sounds with decreased airflow Left lung, no retractions Abd: + BS, soft, NTTP, no rebound, no masses Extrem: warm, well perfused. No cyanosis or edema Neuro: tired though interacting appropriately (3 am), normal tone, grossly normal strength Skin: faint areas of resolving erythema on trunk and legs, pictures from moms phone showed confluent areas of erythema c/w urticaria

9 y.o. M with wheezing, hypoxia, cough x 1 wk., urticarial rash

Differential Diagnosis
Derm Infectious urticaria IgE-mediated rxn (meds, food, latex, insects) Immun Anaphylaxis Resp Asthma exacerbation Aspiration PNA Foreign body ID Viral PNA Bacterial PNA Strep Pneumoniae M. Pneumoniae C. Pneumoniae Bronchitis

Rapid strep: Negative
VRP: Mycoplasma pneumoniae +

Among the smallest self replicating life forms
Bacterial class: Mollicutes (sans cell wall) Most clinically relevant: M. pneumoniae M. hominis M. genitalium Ureaplasma urealyticum

Mycoplasma pneumoniae
1960s: discovered as distinct cause of atypical

pneumonia, associated with cold agglutinins

Binds host cells using tip organelles Affinity for respiratory epithelium Cause cilia dysfunction and epithelial cell damage Hydrogen peroxide and superoxide radicals
Can take up residence inside cells Host defense activation Autoimmune response?

Ex: Adhesins w/ AA sequence similar to host CD4, MHC II lymphocyte proteins

Person to person via

Worldwide CAP: approx 12% Hospitalized ped pts w/

respiratory droplets Long incubation period

Approx 3 weeks

CAP: 14%5 Italian study of hospitalized pediatric pts w/ LRTI: 35.8%6

Often asymptomatic
Headache, malaise, fever, chills Cough Wheezing Sore throat Ear pain Visit UptoDate for a chronology of untreated

Mycoplasma pneumoniae pneumonia

Extrapulmonary presentation
Skin Rash: mild erythematous, vesicular Stevens-Johnson syndrome

Worse with Abx?

Hemolysis Cold agglutinin response (IgM to I Ag on RBCs) Can be severe, though rare CNS (uncommon, but associated w/ significant M&M) Asceptic meningitis Miningoencephalitis Peripheral neuropathy Cerebellar ataxia Transverse myelitis

Extrapulmonary presentation
From typical symptoms to pancreatitis

Rheum Myalgias Arthralgia, arthritis Renal Glomerulonephritis: due to immune complex deposition?

XR findings
Atelectasis (typically lower lobes) Nodular infiltration Hilar adenopathy Effusion Empyema (rare)

Can be clinically difficult to distinguish from other causes

of pneumonia
Typically more gradual onset of symptoms May have normal WBC, elevated Retic & ESR, elevated cold


Labs Serology

Ig titers (active disease vs carrier?) EIA

Cx: takes weeks Cold agglutinin test: nonspecific

Macrolide Azithromycin 10mg/kg day 1, 5mg/kg days 2-5 Clarithromycin 15mg/kg div BID x 10 days Erythromycin 30-40mg/kg div 4 doses daily x 10 days Tetracyclines (only in age > 8 yrs) Doxycycline 2-4mg/kg/day (can div BID) x 10 days Tetracycline 20-50mg/kg div 4 doses daily x 10 days Resistant or severe disease Fluoroquinolones (weigh benefit vs risks)

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Arnold FW et al. A Worldwide Perspective of Atypical Pathogens in Communityacquired Pneumonia. American Journal of Respiratory and Critical Care Medicine, Vol. 175, No. 10 (2007), pp. 1086-1093. Baseman JB and Tully JG. Mycoplasmas: sophisticated, reemerging, and burdened by their notoriety. Emerg Infect Dis. 1997 Jan-Mar; 3(1): 2132 Baseman JB, Reddy SP & Dallo SF. Interplay between Mycoplasma Surface Proteins Airway Cells, and the Protean Manifestations of Mycoplasma-mediated Human Infections. AM J RE5PIR CRIT CARE MED 1996; 154:5137 -5144 Dyamed. Pneumonia in Children. Dec. 2013 Michelow IP et al. Epidemiology and Clinical Characteristics of CommunityAcquired Pneumonia in Hospitalized Children. PEDIATRICS Vol. 113 No. 4 April 1, 2004 pp. 701 -707 Nicola P et al. Role of Mycoplasma pneumoniae and Chlamydia pneumoniae in Children with Community-Acquired Lower Respiratory Tract Infections. Clin Infect Dis. (2001) 32 (9): 1281-1289. Zaleznik DF, Vallejo JG. Mycoplasma pneumoniae infection in children. Dec. 2013