CLINICOPATHOLOGIC

CASE PRESENTATION

Manuel,R., Manzano, Mascarenas,

Medestomas, Meman, Nueva, Ng
PRETERM
Male
 CHIEF COMPLAINT
Swelling on the right scalp
 SALIENT FEATURES

History NICU Course

Physical Exam
• Born from a preeclamptic mother, G1P0
• Preterm male
• Appropriate for gestational age
• Assistive vaginal delivery forceps extraction
• Swelling on the right scalp

HISTORY
 SALIENT FEATURES

History NICU Course

Physical Exam
Head Heart
Adynamic precordium
(+) caput occipitoparietal, R distinct heart sounds
(+) abrasion mid occiput normal regular rhythm
anterior fontanelle soft and flat (-) murmur
Abdomen
Chest and Lungs Soft
Symmetrical chest expansion (-) organomegaly
(-) retractions Vascular
Full and equal pulses
clear breath sounds Musculoskeletal
(-) wheezes (-) fractures
(-) other deformities
Anthropometrics and Vital Signs are normal

PHYSICAL EXAM
 SALIENT FEATURES

History NICU Course

Physical Exam
PHYSICAL EXAMINATION DIAGNOSTICS INTERVENTIONS

NICU COURSE
 DAY 1 DAY 2-5 DAY 6 End of week I

Pale, jaundice, Apnea, cyanosis,

PHYSICAL bradycardia, reflux of milk
asleep but arousable
EXAMINATION Persistence of jaundice
Normal Vital signs per orem and OGT,
Scalp swelling R clear breath sounds
Clear breath sounds
No retractions
Bilirubin 15.02
Bilirubin: 392.63 (increased) Bilirubin 11am:270.04 Blood culture: no growth
DIAGNOSTICS
Bilirubin: 402.7 (increased) Bilirubin 2pm:235.34 after 2 days, no growth after
5 days

O2 support via nasal cannula Meropenem, Amikacin, Phototherapy

RBC transfused (15cc/kg Pentoxifylline Blood transfusion repeated
Fresh frozen plasma Inotrophic support: Umbilical catheter (stayed
INTERVENTIONS
Vit.K Dopamine and dobutamine for 14 days)

Aspiration Pneumonia to rule out nosocomial sepsis NICU Course: Week I

NICU Course: Week I
 DAY 8 DAY 10 DAY 11 End of week II
Grade 3 holosystolic murmur
HR: 168
PHYSICAL RR:60
EXAMINATION Temp:37.8

Bilirubin 11am: 270.04 Table Candida sp. 1.52 hrs Table

DIAGNOSTICS Bilirubin 2pm:235.34 incubation

Vancomycin
INTERVENTIONS Fluconamide
Amphotericin B

Hemic murmur, persisted despite blood transfusion NICU Course: Week II

NICU Course: Week II
 DAY 19 End of week III

PHYSICAL Murmur
EXAMINATION Stable vital signs

Repeated blood culture 8 days ago:

DIAGNOSTICS persistence of Candida sp Candida albicans

INTERVENTIONS Antifungal meds continuation

On inotropic support

NICU Course: Week III

 Day 22 DAY 23-25
Radiograph
Chest APL: hyperaerated lungs,
reticulonodular opacities in perihilar areas
bilaterally, cardiothymic shadow not
enlarged, trachea midline, GT is seen in
place with its distal tip not clearly
visualized
Plain abdominal APL: gas and feces-filled
non-distended bowel loops seen, intact
DIAGNOSTICS Table renal and psoas shadows and flank
stripes, no intraabdominal calcifications,
GT is seen in place with its distal tip not
clearly visualized
24th-25th day
Bilirubin:448.15
(+) Candida albicans
NICU Course: Week IV
End of week IV
Blood culture
(+) Candida sp after 1.16 hours of incubatiom
CRP 12 (N,6)
-Urinalysis : Dark yellow, hazy, SG 1.005, pH 7.5, CHO
(-), CHON trace
-RBC 50-60/hpf, WBC 2-7/hpf, Yeast cells rare,
hyphal elemrnts rare, epithelials negative
-Bacteria few, mucus thread (-), cast (-), crystals (-)
-Bilirubin 3+, leukocyte 1+, urobilinogen normal,
ketone (-), nitrite (-), hgb 1+
-Hepatobiliary tree utz (40th HD)-minimal ascites
Table
NICU Course: Week IV
 DAY 33-34 DAY 35

Total Bilirubin:838.8 Blood Culture: (+) for Candida albicans after 2

DIAGNOSTICS Direct Bilirubin: 489.4 days and 1 hr of incubation
Indirect Bilirubin: 349.4

NICU Course: Week V

 DAY 36-37 DAY 40-41
36th HD
Follow up study to one done 13 days prior
no longer show previously noted bilateral perihilar
opacities. However, reticulonodular opacities are now
seen in the posterior basal segment of the R lower
lobe. Hepatobiliary Tree Ultrasound:
36th minimal ascites
DIAGNOSTICS Follow up study one done earlier in the
day shows development of reticulonodular opacities Table Table 40th day
in R inferior lung zone. There is increase in the Table 41st day
previously noted pneumonia in the posterior basal
segment of the R lower lobe. ETT with distal tip
0.7cm from the carina

Table

NICU Course: Week VI

NICU Course: Week VI
 PHYSICAL Referred for 0 vital sign
EXAMINATION Fresh blood per OGT and ET tube

Intracardiac blood extraction was performed for

repeat culture:
GS (+) for gram negative bacilli, CS (+) for Klebsiella
DIAGNOSTICS
pneumoniae after 3 hours.
Sensitive to Amikacin, Ertapenam, Meropenem
Intermediate to to Ciproflxacin
Resistant to CoAmoxiclav, Ampicillin-Sulbactam,
Aztreonam, Cefoxitin, Cefepime, Ceftriaxone,
Cefuroxime, Gentamicin, trimethoprim

ACLS
INTERVENTIONS Given a total of 65 cc/kg of plain NSS
2 meqs NaHCO3

PATIENT NOT REVIVED 42nd Day

 DIFFERENTIALS

Immunologic Infectious Hemorrhagic

TTP HAP CMV, Neonatal Cholestasis VKDB

 DIFFERENTIALS
Immunologic
RULE IN RULE OUT
Jaundice (-) More common in adolescent and
Dark colored adults
RULED OUT
Decrease RBC and hemoglobin (-) seizure
Positive RBC in urine Petechiae and purpura
Unconjugated and conjugated bilirubin
increased
Thrombocytopenia presenting in 72 hours
of life

TTP
 DIFFERENTIALS
Infectious
RULE IN RULE OUT
Premature infant Microcephaly
Small size at birth Seizure
Immunocompromised Petechia or purpura
Anemia RULED OUT Hepatomegaly
Jaundice Splenomegaly
Thrombocytopenia

Pediatric CMV
 DIFFERENTIALS
Infectious
RULE IN RULE OUT
Premature (-) hepatomegaly
Small birth size Acholic stools
Presence of infection (-) splenomegaly
Jaundice
RULED OUT
Dark yellow urine
Ascites
Increase conjugated and unconjugated
bilirubin
Decrease RBC and hemoglobin
Decrease platelet-thrombocytopenia

Neonatal Cholestasis
 DIFFERENTIALS
Infectious
RULE IN RULE OUT
Delivered Vaginally Cannot be ruled out this time
Tachypneic
Increase of temperature
CANNOT BE TOTALLY RULED OUT
Jaundice
(+) Klebsiella pneumoniae
Low levels of O2 sat
X-ray: Hyperaerated lungs
reticular opacities at the posterior basal
segment
HAP
 DIFFERENTIALS
Hematologic
RULE IN RULE OUT
Born from a preeclamptic mother Insufficient history of the mother with regards to
Neonate medications and Vitamin K administration during
pregnancy
Traumatic delivery produced scalp swelling
CANNOT BE TOTALLY RULED OUT
Born with good APGAR score
Abrasion on mid occiput
Caput
Pallor
Prolonged PT and
PTT

Classical VKDB
 PATHOPHYSIOLOGY
Disseminated Intravascular Coagulopathy
 RISK FACTORS
Disseminated Intravascular Coagulopathy

Mother Forcep Umbilical IV

Prematurity Male with assisted catheter for
Preecclampsia delivery 2 weeks
Anemia Blood smear:
Mod. Hypochromasia
mod. Anisocytosis
marked poikilocytosis
Decrease platelet
Decrease Hct

Decrease RBC life span

Jaundice Phototherpapy is
Red blood cell hemolysis Total bilirubin ineffective hemolysis
Pallor persist
 RISK FACTORS
Disseminated Intravascular Coagulopathy

Mother Forcep Umbilical IV

Prematurity Male with assisted catheter for
Preecclampsia delivery 2 weeks
Anemia Blood smear: Increase risk of bleeding
Mod. Hypochromasia
mod. Anisocytosis
marked poikilocytosis
Decrease platelet
Decrease Hct

Decrease RBC life span

Jaundice Phototherpapy is
Red blood cell hemolysis Total bilirubin ineffective hemolysis
Pallor persist
 RISK FACTORS
Disseminated Intravascular Coagulopathy

Mother Forcep Umbilical IV

Prematurity Male with assisted catheter for
Preecclampsia delivery 2 weeks
Anemia Blood smear: Increase risk of bleeding Metabolic acidosis
Mod. Hypochromasia
mod. Anisocytosis
marked poikilocytosis
Decrease platelet
Decrease Hct Peripheral vasodilation

Decrease RBC life span

competitive inhibition of the
slow calcium current by
hydrogen ions

Jaundice Phototherpapy is
Red blood cell hemolysis Total bilirubin ineffective hemolysis
Pallor persist
 Slow calcium current initiates cardiac
contraction (initial response)

Inability to compensate

reduced contractility

Decreased cardiac output

Decreased tissue perfusion to vital organs

 Multiple organ failure

Fresh blood per OGT and ET tube

Vital sign 0
 RISK FACTORS
Disseminated Intravascular Coagulopathy

Mother Forcep Umbilical IV

Prematurity Male with assisted catheter for
Preecclampsia delivery 2 weeks
 Diffuse extracalvarial soft
Force applied cause shearing tissue swelling w/
effect on the scalp hyperdensities in the right
parietal region

Emissary vein tends to be Subgaleal hematoma

severely damage

Endothelium of the vessel wall directly tear

Systemic activation of hemostasis

 Clot formation accelerated

Red blood cell hemolysis Microvascular thrombotic obstruction Activate fibrinolysis

Tissue ischemia

Anaerobic metabolism

Lactic acid production

Anemia Blood smear: Increase risk of bleeding Metabolic acidosis
Mod. Hypochromasia
mod. Anisocytosis
marked poikilocytosis
Decrease platelet
Decrease Hct Peripheral vasodilation

Decrease RBC life span

competitive inhibition of the
slow calcium current by
hydrogen ions

Jaundice Phototherpapy is
Red blood cell hemolysis Total bilirubin ineffective hemolysis
Pallor persist
 Slow calcium current initiates cardiac
contraction (initial response )

Inability to compensate

reduced contractility

Decreased cardiac output

Decreased tissue perfusion to vital organs

 Multiple organ failure

Fresh blood per OGT and ET tube

Vital sign 0
 Clot formation accelerated

Red blood cell hemolysis Microvascular thrombotic obstruction Activate fibrinolysis

Tissue ischemia Consumption of anticlotting

factor and platelet

Anaerobic metabolism
Depletion of anticlotting
factor and platelet
Lactic acid production

hemorrhage
 Slow calcium current initiates cardiac
contraction (initial response )

Inability to compensate

reduced contractility

Decreased cardiac output

Decreased tissue perfusion to vital organs

 Multiple organ failure

Fresh blood per OGT and ET tube

Vital sign 0
 RISK FACTORS
Disseminated Intravascular Coagulopathy

Mother Forcep Umbilical IV

Prematurity Male with assisted catheter for
Preecclampsia delivery 2 weeks
Surface molecules that permit adherence of the
organism to other structures

Microbial overgrowth

Complement activation

Endothelial activation
 Clot formation accelerated

Red blood cell hemolysis Microvascular thrombotic obstruction Activate fibrinolysis

Tissue ischemia Consumption of anticlotting

factor and platelet

Anaerobic metabolism
Depletion of anticlotting
factor and platelet
Lactic acid production

hemorrhage
Anemia Blood smear: Increase risk of bleeding Metabolic acidosis
Mod. Hypochromasia
mod. Anisocytosis
marked poikilocytosis
Decrease platelet
Decrease Hct Peripheral vasodilation

Decrease RBC life span

competitive inhibition of the
slow calcium current by
hydrogen ions

Jaundice Phototherpapy is
Red blood cell hemolysis Total bilirubin ineffective hemolysis
Pallor persist
 Slow calcium current initiates cardiac
contraction (initial response )

Inability to compensate

reduced contractility

Decreased cardiac output

Decreased tissue perfusion to vital organs

 Multiple organ failure

Fresh blood per OGT and ET tube

Vital sign 0
Surface molecules that permit adherence of the
organism to other structures

Microbial overgrowth

Complement activation

Endothelial activation

IL6, IL8 reactive oxygen free radicals Activation of IL4 and IL10
 vasodilation

Increase permeability

Shifting of fluid from intravascular to the

interstitial space

Lungs: alveolar edema Klebsiella pneumoniae

 Provokes immune respose

Alveolar edema + exudate

congestion Given more than 2 antibiotic medication

Bilateral hilar opacities,
Reticulonodular opacities R lower lobe

Unable to exchange
gases effectively
Pneumonia
Hyperaerated lungs
Apnea
 Slow calcium current initiates cardiac
contraction (initial response )

Inability to compensate

reduced contractility

Decreased cardiac output

Decreased tissue perfusion to vital organs

 Multiple organ failure

Fresh blood per OGT and ET tube

Vital sign 0
 Provokes immune respose

Alveolar edema + exudate

Meropenem, Amikacin,
congestion Given more than 2 antibiotic medication and Vancomycin

Bilateral hilar opacities,

Reticulonodular opacities R lower lobe

Unable to exchange Promotes fungal growth

gases effectively
Pneumonia
Hyperaerated lungs Unresponsive to medications
Apnea and treatment
 Multiple organ failure

Fresh blood per OGT and ET tube

Vital sign 0
Surface molecules that permit adherence of the
organism to other structures

Microbial overgrowth

Complement activation

Endothelial activation

IL6, IL8 reactive oxygen free radicals Activation of IL4 and IL10
 Inhibits production of proinflammatory
Provokes immune respose
mediators (IL6, TNF alpha)

Alveolar edema + exudate immunocompromised

congestion Given more than 2 antibiotic medication

C. albicans
Meropenem, Amikacin,
and Vancomycin overgrowth and
directly penetrate
Unable to exchange Promotes fungal growth into the
gases effectively bloodstream
Pneumonia
Hyperaerated lungs
Apnea
Unresponsive to medications
Given Amphotericin B
and treatment
and Fluconazole
 Multiple organ failure

Fresh blood per OGT and ET tube

Vital sign 0
 Inhibits production of proinflammatory
Provokes immune respose
mediators (IL6, TNF alpha)

Alveolar edema + exudate immunocompromised

congestion Given more than 2 antibiotic medication

C. albicans
Meropenem, Amikacin,
and Vancomycin overgrowth and
directly penetrate
Unable to exchange Promotes fungal growth into the
gases effectively bloodstream
Pneumonia
Hyperaerated lungs
Apnea
Unresponsive to medications
Given Amphotericin B
and treatment
and Fluconazole
 Grade 3 holosystolic murmur,
Heart manifestation such as right sided endocarditis
hemic murmur

Dobutamine and dopamine

 Inhibits production of proinflammatory
Provokes immune respose
mediators (IL6, TNF alpha)

Alveolar edema + exudate immunocompromised

congestion Given more than 2 antibiotic medication

C. albicans
Meropenem, Amikacin,
Bilateral hilar opacities, overgrowth and
Reticulonodular opacities R lower lobe and Vancomycin
directly penetrate
into the
Unable to exchange Promotes fungal growth bloodstream
gases effectively
Pneumonia Given Amphotericin B
Hyperaerated lungs Unresponsive to medications and Fluconazole
Apnea and treatment
 Multiple organ failure

Fresh blood per OGT and ET tube

Vital sign 0
 DIAGNOSIS
Disseminated Intravascular Coagulopathy
Secondary to Septicemia
Immediate Cause
Multi organ Failure
of Death

Antecedent Cause
DIC
of Death

Underlying Cause Septicemia from Candidiasis

of Death Trauma
 MAIN REFERENCES
Cunningham, et al. 2014. William’s Obstetrics. 24th ed

Book Kasper, et al. 2015. Harrison’s Principle of Medicine. 19th ed

Kliegman, et. al. 2015. Nelson’s Textbook of Pediatrics 20th ed
Kumar, et al.2015. Robbins and Cotran Pathological Basis of Disease 9th ed

Reid, J. Neonatal Subgaleal Hemorrhage. Birth Injuries Series # 2. Neonatal Network. Vol. 26
Journal Soldin, S.J. Pediatric Reference Range

Emedicine.com
Websites Mescape