CASE REPORTCASE REPORT

洪嘉蔚 醫師 洪嘉蔚 醫師 / / 吳維峰 主任吳維峰 主任

台北市立仁愛醫院 小兒科台北市立仁愛醫院 小兒科

General DataGeneral Data

Name: Name: 李 小弟李 小弟 Birth day: 85/04/24Birth day: 85/04/24 Age: 6 y/oAge: 6 y/o Chart number: 15213493Chart number: 15213493 Admission day: 91/05/03Admission day: 91/05/03 Discharge day: 91/05/20Discharge day: 91/05/20 BW: 22 KgBW: 22 Kg

Chief ComplaintChief Complaint

Fever off and on for 8 daysFever off and on for 8 days

Present IllnessPresent Illness

A 6 year-old boy suffered from fever off A 6 year-old boy suffered from fever off and on for 8 days. He also complained of and on for 8 days. He also complained of cough, rhinorrhea and difficult to cough, rhinorrhea and difficult to expectorate sputum. He was taken to expectorate sputum. He was taken to LMD twice and our OPD on 91/04/30, but LMD twice and our OPD on 91/04/30, but the symptoms persisted in spite of drugs the symptoms persisted in spite of drugs use. So he was taken to our OPD again use. So he was taken to our OPD again on 91/05/03. Physical examination on 91/05/03. Physical examination revealed decreased breathing sound on revealed decreased breathing sound on right chest. CXR showed lobar right chest. CXR showed lobar pneumonia. pneumonia.

Brief historyBrief history

Birth Hx: GA: 39 Wks, BBW:3050 gm, NSDBirth Hx: GA: 39 Wks, BBW:3050 gm, NSD Previous admission: DeniedPrevious admission: Denied Vaccination: As scheduleVaccination: As schedule Allergy Hx: DeniedAllergy Hx: Denied Food exposure: DeniedFood exposure: Denied Drug exposure: DeniedDrug exposure: Denied Recent travel: DeniedRecent travel: Denied Family Hx: Non-contributoryFamily Hx: Non-contributory

Physical Examination:Physical Examination:

Vital sign: BT 39.9, PR:120 bpm, RR 32/minVital sign: BT 39.9, PR:120 bpm, RR 32/min General appearance: Acute-ill lookingGeneral appearance: Acute-ill looking HEENT: No gross anomalyHEENT: No gross anomaly Conjunctiva: not injectedConjunctiva: not injected Throat: mild injectionThroat: mild injection Chest: Symmetric expansion Chest: Symmetric expansion Retraction: no Retraction: no decreased breathing sound: right lung,decreased breathing sound: right lung, fine moist rales(+)fine moist rales(+) percussion: dullness of right chest percussion: dullness of right chest

CBC/DC CBC/DC

5/35/3 5/75/7

WBCWBC 91009100 1011010110

HgbHgb 11.911.9 10.610.6

HctHct 32.932.9 29.729.7

MCVMCV 72.672.6 75.275.2

PLTPLT 190000190000 206000206000

NeutNeut 92.392.3 89.589.5

LymLym 3.3%3.3% 5.5%5.5%

MonoMono 2.3%2.3% 1.6%1.6%

EosEos 0.3%0.3% 0.5%0.5%

Urinalysis Urinalysis 5/35/3 5/45/4

AppearancAppearancee

Y-CLEARY-CLEAR Y-CLEARY-CLEAR

SP. Gr.SP. Gr. 1.0101.010 1.0151.015

PHPH 6.06.0 6.06.0

ProteinProtein 1+1+ 1+1+

GlucoseGlucose -- --

OBOB -- --

BilirubinBilirubin -- --

NitrateNitrate -- --

RBCRBC 0-20-2 8-108-10

WBCWBC 4-64-6 40-5040-50

BacteriaBacteria ++ ++

Biochemistry Biochemistry

GluGlu BUNBUN CrCr ASTAST ALTALT NaNa KK

5/35/3 9494 6.06.0 0.50.5 117117 3939 125125 4.54.5

5/45/4 129129

5/75/7 9393 3.03.0 0.50.5 8585 179179 137137 4.04.0

Blood culture Blood culture

5/3 NO GROWTH5/3 NO GROWTH 5/7 NO GROWTH5/7 NO GROWTH

Urine culture Urine culture

5/5 NO GROWTH 5/5 NO GROWTH

Serology Serology

CRP CRP 5/4 163 mg/l5/4 163 mg/l 5/7 126 mg/l 5/7 126 mg/l

Mycoplasma Pneumoniae AntibodyMycoplasma Pneumoniae Antibody 5/4 NEGATIVE5/4 NEGATIVE

Hospital Course (I) Hospital Course (I)

Initially (5/3), empiric antibiotics with Initially (5/3), empiric antibiotics with Cefuroxime 500mg IV q6h and Cefuroxime 500mg IV q6h and Erythromycin 250mg PO q6h were Erythromycin 250mg PO q6h were used, but intermittent high fever up used, but intermittent high fever up to 39C was still noted.to 39C was still noted.

Gentamicin was added on 5/4 due to Gentamicin was added on 5/4 due to pyuria of urinalysis and suspected pyuria of urinalysis and suspected UTIUTI

WHAT’S YOUR WHAT’S YOUR INITIAL INITIAL

IMPRESSION ?IMPRESSION ?

Hospital Course (II) Hospital Course (II)

On 5/5, multiple fine, discrete, On 5/5, multiple fine, discrete, rubella-like skin rashes developed on rubella-like skin rashes developed on the face, trunk and extremities with the face, trunk and extremities with itchy sensation. Vena infusion and itchy sensation. Vena infusion and Sinbaby lotion were used for Sinbaby lotion were used for symptom relief. symptom relief.

Serology Serology

5/7 IgA 126 (70-400) 5/7 IgA 126 (70-400)

IgM 105 (40-230)IgM 105 (40-230)

IgG 778 (700-1600)IgG 778 (700-1600)

5/8 Measles IgM (-)5/8 Measles IgM (-)

Rubella IgM (-) Rubella IgM (-)

Hospital Course (III)Hospital Course (III)

On 5/7, followed CXR showed On 5/7, followed CXR showed massive amount of pleural effusion, massive amount of pleural effusion, right lung. So we do chest CT, and right lung. So we do chest CT, and erythromycin was changed to 220mg erythromycin was changed to 220mg IV q6hIV q6h

On 5/8, thoracocentasis was done On 5/8, thoracocentasis was done and showed exudate effusion. So we and showed exudate effusion. So we do chest tube insertion. About 200ml do chest tube insertion. About 200ml of yellow-reddish fluid was drained. of yellow-reddish fluid was drained.

Chest CTChest CT

Date 91/05/07Date 91/05/07 Impression:Impression:

Consolidation of right lower Consolidation of right lower lobe and medial segment of lobe and medial segment of middle lobe, pneumonia is likely. middle lobe, pneumonia is likely. Moderate amount of right pleural Moderate amount of right pleural effusion and scanty amount of effusion and scanty amount of left pleural effusion.left pleural effusion.

Abdominal echoAbdominal echo

Date 91/05/07Date 91/05/07 Ultrasonic Impression:Ultrasonic Impression:

Negative finding of abdominal Negative finding of abdominal ultrasonography ultrasonography

Pleural Effusion Study (I)Pleural Effusion Study (I)

5/8 Pleural fluid 5/8 Pleural fluid Appearance cloudyAppearance cloudy Color reddish-yellowColor reddish-yellow Bloody (+)Bloody (+) Chylous (-)Chylous (-) Coagulation (+)Coagulation (+) Sp. Gr. 1.025Sp. Gr. 1.025

Pleural Effusion Study (II)Pleural Effusion Study (II)

WBC 630 cummWBC 630 cumm

Polynuclear cells 55.0%Polynuclear cells 55.0%

Mononuclear cells 45.0%Mononuclear cells 45.0%

Abnormal cells (-)Abnormal cells (-) Pleural, Acid-Fast Stain: Not FoundPleural, Acid-Fast Stain: Not Found Pleural, Gram’s Stain: Not Found Pleural, Gram’s Stain: Not Found

Pleural Effusion Study (III)Pleural Effusion Study (III)

Pleural EffusionPleural Effusion Glucose 71 mg/dl Glucose 71 mg/dl LDH 3149 IU/L (H) LDH 3149 IU/L (H) Protein 3.30 g/dl (L) Protein 3.30 g/dl (L)

Pleural Effusion Study (IV)Pleural Effusion Study (IV)

Pleural effusion culturePleural effusion culture

on 5/8 no growthon 5/8 no growth

on 5/13 no growth on 5/13 no growth

Pleural Effusion Study (V)Pleural Effusion Study (V)

5/8 Pleural effusion cytology:5/8 Pleural effusion cytology:

No evidence of malignancy No evidence of malignancy 5/14 Pleural PCR assay for 5/14 Pleural PCR assay for

mycobacteriamycobacteria

result: Negativeresult: Negative

Hospital Course (IV)Hospital Course (IV)

On 5/10, followed CBC/DC showed On 5/10, followed CBC/DC showed leukocytosis with left shift (WBC leukocytosis with left shift (WBC 19570, Neu 92.9%). Persistent high 19570, Neu 92.9%). Persistent high fever was noted. So Cefuroxime was fever was noted. So Cefuroxime was changed to Ceftriaxone 1g IV q12hchanged to Ceftriaxone 1g IV q12h

High fever up to 40C persisted in High fever up to 40C persisted in spite of Ceftriaxone + Gentamicin + spite of Ceftriaxone + Gentamicin + Erythromycin combined use Erythromycin combined use

CBC/DC CBC/DC

5/35/3 5/75/7 5/105/10 5/135/13 5/155/15

WBCWBC 91009100 1011101100

1957195700

2645264500

1227122700

HgbHgb 11.911.9 10.610.6 8.88.8 8.48.4 8.98.9

HctHct 32.932.9 29.729.7 25.225.2 24.224.2 25.125.1

MCVMCV 72.672.6 75.275.2 85.785.7 76.276.2 74.174.1

PLTPLT 190001900000

206002060000

378003780000

551005510000

707007070000

NeutNeut 92.392.3 89.589.5 92.992.9 92.892.8 87.187.1

LymLym 3.3%3.3% 5.5%5.5% 4.2%4.2% 3.5%3.5% 6.9%6.9%

MonoMono 2.3%2.3% 1.6%1.6% 2.2%2.2% 1.9%1.9% 2.6%2.6%

EosEos 0.3%0.3% 0.5%0.5% 0.4%0.4% 0.8%0.8% 1.8%1.8%

Urinalysis Urinalysis 5/35/3 5/45/4 5/115/11 5/145/14

AppearancAppearancee

Y-CLEARY-CLEAR Y-CLEARY-CLEAR Y-CLEARY-CLEAR Y-CLEARY-CLEAR

SP. Gr.SP. Gr. 1.0101.010 1.0151.015 1.0101.010 1.0201.020

PHPH 6.06.0 6.06.0 5.05.0 6.56.5

ProteinProtein 1+1+ 1+1+ -- --

GlucoseGlucose -- -- -- --

OBOB -- -- -- --

BilirubinBilirubin -- -- -- --

NitrateNitrate -- -- -- --

RBCRBC 0-20-2 8-108-10 0-20-2 0-10-1

WBCWBC 4-64-6 40-5040-50 0-20-2 8-108-10

BacteriaBacteria ++ ++ ---- ----

Biochemistry Biochemistry

GluGlu BUNBUN CrCr ASTAST ALTALT NaNa KK AlbAlb

5/35/3 9494 6.06.0 0.50.5 117117 3939 125125 4.54.5

5/45/4 129129

5/75/7 9393 3.03.0 0.50.5 8585 179179 137137 4.04.0

5/95/9 5.05.0 0.40.4 4646 9999 131131 5.25.2

5/115/11 136136 3.03.0

5/145/14 11.211.2 0.40.4 8585 175175

5/165/16 7171 146146 3.53.5

Blood cultureBlood culture

5/3 NO GROWTH5/3 NO GROWTH 5/7 NO GROWTH5/7 NO GROWTH 5/11 NO GROWTH5/11 NO GROWTH

Urine cultureUrine culture

5/5 NO GROWTH5/5 NO GROWTH 5/10 NO GROWTH5/10 NO GROWTH 5/12 NO GROWTH5/12 NO GROWTH

Serology (I)Serology (I)

CRP CRP 5/4 163 mg/l5/4 163 mg/l 5/7 126 mg/l5/7 126 mg/l 5/14 113 mg/l 5/14 113 mg/l

Serology (II) Serology (II)

5/13 Direct Coombs’ test: positive5/13 Direct Coombs’ test: positive

Indirect Coombs’ test: positiveIndirect Coombs’ test: positive

5/14 RA< 10.2 IU/ML (<40.0)5/14 RA< 10.2 IU/ML (<40.0)

C3 166.0 mg/dl (90.0-180.0)C3 166.0 mg/dl (90.0-180.0)

C4 21.4 mg/dl (10.0- 40.0) C4 21.4 mg/dl (10.0- 40.0)

Serology (III)Serology (III)

5/14 Heterophil Ab: Negative 5/14 Heterophil Ab: Negative

ANA NegativeANA Negative 5/14 Legionella Ab: Negative5/14 Legionella Ab: Negative

Chlamydia Ab: NegativeChlamydia Ab: Negative

Ga-67 Inflammation SurveyGa-67 Inflammation Survey

Date 91/05/15Date 91/05/15 A patch of abnormal tracer A patch of abnormal tracer

uptake at the right lower lung uptake at the right lower lung field, may be inflammatory field, may be inflammatory focus.focus.

Diffusely increase uptake of liver. Diffusely increase uptake of liver. This phenomenon can be found This phenomenon can be found in iron deficiency anemiain iron deficiency anemia

WHAT’S YOUR WHAT’S YOUR DIAGNOSIS ?DIAGNOSIS ?

Serology (I)Serology (I)

Mycoplasma Pneumoniae Mycoplasma Pneumoniae AntibodyAntibody

5/4 5/4 NegativeNegative 5/7 160X5/7 160X 5/14 320X5/14 320X

Pleural Effusion Study (II)Pleural Effusion Study (II)

5/8 5/8 Pleural fluid for MycoplasmalPleural fluid for Mycoplasmal

pneumonia antibody: 80X pneumonia antibody: 80X

Serology (III)Serology (III)

5/16 Cold hemaglutination: 512 X 5/16 Cold hemaglutination: 512 X (<32X) (<32X)

Hospital Course (V)Hospital Course (V)

Chest tube was removed on 5/13Chest tube was removed on 5/13 We used prednisolone (2mg/kg/day We used prednisolone (2mg/kg/day

in 4 divided doses) on 5/14. Fever in 4 divided doses) on 5/14. Fever subsided on the night of 5/14.subsided on the night of 5/14.

Steroid was tapered graduallySteroid was tapered gradually On 5/20, patient was discharged On 5/20, patient was discharged

under stable condition. under stable condition.

CBC/DCCBC/DC

5/35/3 5/75/7 5/105/10 5/135/13 5/155/15 5/235/23

WBCWBC 91009100 1011101100

1957195700

2645264500

1227122700

97809780

HgbHgb 11.911.9 10.610.6 8.88.8 8.48.4 8.98.9 10.110.1

HctHct 32.932.9 29.729.7 25.225.2 24.224.2 25.125.1 30.230.2

MCVMCV 72.672.6 75.275.2 85.785.7 76.276.2 74.174.1 78.978.9

PLTPLT 190001900000

206002060000

378003780000

551005510000

707007070000

377003770000

NeutNeut 92.392.3 89.589.5 92.992.9 92.892.8 87.187.1 66.166.1

LymLym 3.3%3.3% 5.5%5.5% 4.2%4.2% 3.5%3.5% 6.9%6.9% 22.322.3

MonoMono 2.3%2.3% 1.6%1.6% 2.2%2.2% 1.9%1.9% 2.6%2.6% 10.010.0

EosEos 0.3%0.3% 0.5%0.5% 0.4%0.4% 0.8%0.8% 1.8%1.8% 1.01.0

BiochemistryBiochemistry

GluGlu BUNBUN CrCr ASTAST ALTALT NaNa KK AlbAlb

5/35/3 9494 6.06.0 0.50.5 117117 3939 125125 4.54.5

5/45/4 129129

5/75/7 9393 3.03.0 0.50.5 8585 179179 137137 4.04.0

5/95/9 5.05.0 0.40.4 4646 9999 131131 5.25.2

5/115/11 136136 3.03.0

5/145/14 11.211.2 0.40.4 8585 175175

5/165/16 7171 146146 3.53.5

5/235/23 2121 3030

Serology (I)Serology (I)

CRP CRP 5/4 163 mg/l5/4 163 mg/l 5/7 126 mg/l5/7 126 mg/l 5/14 113 mg/l5/14 113 mg/l 5/30 5.2 mg/l5/30 5.2 mg/l

Final DiagnosisFinal Diagnosis

Mycoplasmal lobar Mycoplasmal lobar pneumonia, complicated pneumonia, complicated with prolonged fever, skin with prolonged fever, skin rashes, right lung pleural rashes, right lung pleural effusion, and hemolytic effusion, and hemolytic anemiaanemia

DISCUSSIONDISCUSSION

Mycoplasma Pneumoniae

In 1944, M. pneumoniae was In 1944, M. pneumoniae was reported by Monroe Eaton, originally reported by Monroe Eaton, originally called the Eaton agent.called the Eaton agent.

Smallest free-living microorganism, Smallest free-living microorganism, belongs to the class Mollicutes.belongs to the class Mollicutes.

Mycoplasmas lack a cell wall, so tend Mycoplasmas lack a cell wall, so tend to be pleomorphicto be pleomorphic..

Clinical ManifestationsClinical Manifestations

M. pneumoniae causes approximately 20% M. pneumoniae causes approximately 20% of all cases of pneumonia.of all cases of pneumonia.

Peak incidence at 6-21 years of age.Peak incidence at 6-21 years of age.

Incubation period of 2-3 weeks.Incubation period of 2-3 weeks.

Transmission by inhalation of infected Transmission by inhalation of infected

droplet aerosols.droplet aerosols.

Pneumonia is the most important clinical Pneumonia is the most important clinical manifestation of M. pneumoniae infection.manifestation of M. pneumoniae infection.

* Bronchopneumonia pattern mostly.* Bronchopneumonia pattern mostly. Lobar pneumonia and large amountLobar pneumonia and large amount pleural fluid are unusual.pleural fluid are unusual. Pediat Radiol 1989;19(8):499-503 Pediat Radiol 1989;19(8):499-503

* Respiratory disease other than * Respiratory disease other than pneumonia: unspecific URI, pharyngitis,pneumonia: unspecific URI, pharyngitis, AOM, croup, sinusitis, bronchitis, AOM, croup, sinusitis, bronchitis, bronchiolitis, asthma.bronchiolitis, asthma.

Cutaneous manifestations : common.Cutaneous manifestations : common. * Exanthem and enanthem of Mycoplasma* Exanthem and enanthem of Mycoplasma pneumoniae infection are observed in 5 to pneumoniae infection are observed in 5 to 24% of cases24% of cases AAP, Report of Committee on Infectious Diseases, 1994:333-5AAP, Report of Committee on Infectious Diseases, 1994:333-5

* Most common with an erythematous * Most common with an erythematous maculopapular rash on the trunk and back; maculopapular rash on the trunk and back; discrete (rubelliform) or confluent discrete (rubelliform) or confluent (morbilliform).(morbilliform).

* Most serious presentation: Erythema * Most serious presentation: Erythema

multiforme and Stevens-Johnson syndromemultiforme and Stevens-Johnson syndrome.. Clini Pediatrics 1991:30(1),42-9Clini Pediatrics 1991:30(1),42-9

Hematologic manifestations:Hematologic manifestations: * Hemolytic anemia: usually mild,* Hemolytic anemia: usually mild, however, it may become severe and however, it may become severe and result in 50% reduction in hemoglobinresult in 50% reduction in hemoglobin concentration.concentration. Pediat Infec Dis J 1998;17(2):173-7Pediat Infec Dis J 1998;17(2):173-7

* Direct Coombs test usually positive.* Direct Coombs test usually positive.

* Steroid administration may be * Steroid administration may be beneficial.beneficial. South Med J 1990;83(9):1106-8South Med J 1990;83(9):1106-8

Hemolytic anemia is presumably Hemolytic anemia is presumably related to the presence of cold related to the presence of cold agglutinins in serum which at high agglutinins in serum which at high concentration, may agglutinate concentration, may agglutinate erythrocytes at 37℃erythrocytes at 37℃

Rev Pneumol Clin 1990,46(2),83-4Rev Pneumol Clin 1990,46(2),83-4

Gastrointestinal findings are nonspecific with Gastrointestinal findings are nonspecific with nausea, vomiting, abdominal pain, and/or nausea, vomiting, abdominal pain, and/or diarrhea.diarrhea.

Neurologic disease association was reported 2.6-Neurologic disease association was reported 2.6-4.8%.4.8%.

* Encephalitis, meningitis, transverse * Encephalitis, meningitis, transverse myelitis, psychosis, Bell palsy andmyelitis, psychosis, Bell palsy and Guillain-Barre` syndrome.Guillain-Barre` syndrome.

Arthritis in association with M.pneumoniaeArthritis in association with M.pneumoniae infection have not been established.infection have not been established.

Hepatitis was once thought to be Hepatitis was once thought to be unusual, but recent studies unusual, but recent studies suggest that liver dysfunction suggest that liver dysfunction may be present in up to 30% of may be present in up to 30% of M. pneumoniae infection.M. pneumoniae infection.

Pediatr Pulmonol 1990;8:182-7Pediatr Pulmonol 1990;8:182-7

Liver dysfunction was Liver dysfunction was observed more frequently in observed more frequently in patients with pleuropneumonia patients with pleuropneumonia than in simple pneumonia than in simple pneumonia cases.cases.

Pediatr Pulmonol 1990;8:182-7Pediatr Pulmonol 1990;8:182-7

Radiographic Manifestation (I)Radiographic Manifestation (I) Interstitial infiltration was more Interstitial infiltration was more

commonly seen in pediatric than adult commonly seen in pediatric than adult patients (46% vs 20%)patients (46% vs 20%)

Unilateral lesions 80%Unilateral lesions 80% Single lobe lesions 77%Single lobe lesions 77% Lower lobe predominant 69%Lower lobe predominant 69% Pleural effusion 7% Pleural effusion 7%

高雄醫學科學雜誌 高雄醫學科學雜誌 1993;9(4):204-111993;9(4):204-11

Radiographic Manifestation (II)Radiographic Manifestation (II)

Unilateral infiltration 84%Unilateral infiltration 84% Lower lobe predominance 60%Lower lobe predominance 60% Confluent consolidation 56%Confluent consolidation 56% Patchy consolidation 33%Patchy consolidation 33% Pleural effusion 24% Pleural effusion 24%

長庚醫學雜誌 長庚醫學雜誌 1991;14(3):156-621991;14(3):156-62

Diagnosis (I)Diagnosis (I)

WBC, CRP, ESR are non-specific, may be WBC, CRP, ESR are non-specific, may be normal or elevated.normal or elevated.

Growth of the organism takes weeks, Growth of the organism takes weeks, generally only in expertise laboratories.generally only in expertise laboratories.

PCR is sensitive and specific.PCR is sensitive and specific. Serologic testing : Cold agglutinins, titer Serologic testing : Cold agglutinins, titer

of >1:64 is suggestive of infection; Anti-of >1:64 is suggestive of infection; Anti-mycoplasmal Ab detection, fourfold or mycoplasmal Ab detection, fourfold or greater rise are considered diagnostic.greater rise are considered diagnostic.

Diagnosis (II)Diagnosis (II)

Imaging : Interstitial infiltrate or Imaging : Interstitial infiltrate or bronchopneumonia pattern. bronchopneumonia pattern. Lobar consolidation and pleural Lobar consolidation and pleural effusion are uncommon but may effusion are uncommon but may occur.occur.

Treatment

• Erythromycin is the drug of choice.

(40-50mg/kg/24hr q6h for 10-14 days).

• Newer macrolides:

Azithromycin (10mg/kg on day 1, and

5mg/kg/24hr on days 2-5) or

Clarithromycin (15mg/kg/24hr given in two

divided doses for 10 days).

Empiric Therapy for Lobar Empiric Therapy for Lobar PneumoniaPneumonia

Clinically moderate to severely toxic, Clinically moderate to severely toxic, treat empirically for S. pneumonia, S. treat empirically for S. pneumonia, S. pyogens ( and H. influenzae type b in pyogens ( and H. influenzae type b in unimmunized children)unimmunized children)

In toxic children, tests for In toxic children, tests for Mycoplasma should be considered Mycoplasma should be considered because focal pneumonia is a rare because focal pneumonia is a rare presentationpresentation

Cefuroxime intravenously, Cefuroxime intravenously, ceftriaxone or cefotaxime ceftriaxone or cefotaxime intravenouslyintravenously

For anti-staphylococcal coverage, For anti-staphylococcal coverage, add to the above, either: nafcillin, add to the above, either: nafcillin, oxacillin, or clindamycinoxacillin, or clindamycin

For Mycoplasma: intravenous For Mycoplasma: intravenous erythromycin or azithromycin; or oral erythromycin or azithromycin; or oral erythromycin, azithromycin, or erythromycin, azithromycin, or clarithromycin.clarithromycin.

Pneumonia, with pleural fluid or Pneumonia, with pleural fluid or empyemaempyema

Treat empirically for S. pneumonia, S. Treat empirically for S. pneumonia, S. pyogenes, and S. aureus ( and H. pyogenes, and S. aureus ( and H. influenzae type b in unimmunized influenzae type b in unimmunized children)children)

Consider aspiration pneumonia with Consider aspiration pneumonia with anaerobic oral flora as pathogens; needle anaerobic oral flora as pathogens; needle or catheter aspiration of pleural fluid, or catheter aspiration of pleural fluid, with drainage, is often required for with drainage, is often required for clinical cure.clinical cure.

Ceftriaxone or cefotaximeCeftriaxone or cefotaxime

For antistaphylococcal covarage, add to the For antistaphylococcal covarage, add to the above either: nafcillin, oxacillin, or above either: nafcillin, oxacillin, or clindamycin (also covers anaerobes found in clindamycin (also covers anaerobes found in aspiration pneumonia as well as most aspiration pneumonia as well as most pneumoncocci)pneumoncocci)

Single agent therapy with meropenem, or Single agent therapy with meropenem, or ticarcillin/clavulanate (Timentin) both of which ticarcillin/clavulanate (Timentin) both of which cover both aerobic and anaerobic pathogenscover both aerobic and anaerobic pathogens

CONCLUSIONCONCLUSION

Presence of pleuropneumonia Presence of pleuropneumonia appears to be associated with appears to be associated with more severe and prolonged more severe and prolonged course of illnesscourse of illness

Pediatr Pulmonol 1990;8:182-7Pediatr Pulmonol 1990;8:182-7

Even in patients with Even in patients with clinically mild pneumonia, clinically mild pneumonia, Mycoplasma pneumoniae Mycoplasma pneumoniae may be the cause of severe may be the cause of severe anemiaanemia

Ann of Hematol Ann of Hematol 2001;80(3):180-22001;80(3):180-2

Association of exanthem and Association of exanthem and pneumonia or of hemolytic pneumonia or of hemolytic anemia and pneumonia are anemia and pneumonia are considered to be strongly considered to be strongly suggestive for the diagnosis suggestive for the diagnosis of M. pneumonia infectionof M. pneumonia infection

Clin Infec Dis 1993;17(Suppl 1):S47-51Clin Infec Dis 1993;17(Suppl 1):S47-51

THANKS FOR YOUR THANKS FOR YOUR ATTENTION !ATTENTION !

THE ENDTHE END