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MORBILI, BRONCHOPNEUMONIA, ACUTE

DIARRHEA IN A CHILD

By

Mira Febriani Hontong

Supervisor

dr. Audrey Wahani, SpA(K)

1

June 2014

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INTRODUCTION

2

Morbili (measles,

rubeola)

An acute

contagious

disease caused

by an infection of

morbilivirus

Incidence in Indonesia from1990 to 2002 is appr. 3.000-

4.000 cases a year

Most common complications :

Bronchopneumonia and

gastroenteritis

Self-limittinguncomplicated: supportive

tx; complicated: antibiotics

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INTRODUCTION

3

Bronchopneumonia

Aninflammation

on lungparenchyma

Mostly caused by

microorganism

n morbili: caused by morbilivirusorby superimposed infection causedby other agents.

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INTRODUCTION

4

Acute Diarrhea

In infant orchildren

defecation of>3x/day with achange in stool

consistency, inwhich the stool

may become softor even liquid

In morbilli, diarrhea may result fromthe replication of morbilli virus

inside the gastrointestinal tract.

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CASE REPORT

5

RS, , 6months

old

Gorontalese

admitted :May 29th,

2014

chiefcomplaints

shortness ofbreath since

1 day priorto

admissionpreceded bycough andfever since

1 weekprior to

admission

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Fever andcough (1

week priorto

admission)

Shortnessof breath(1 dayprior to

admission)

Shortnessof breath,

fever,cough

Red rashes(1 dayafter

admission)

ADMISSION:

May 29th

,2014

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History of prenatal care and birthANC : regular , tetanus toxoid : twiceThis patient was born spontaneously

aterm, birth weight was 3300 grams

History of experienced illnessHe had history of diarrhea andseveral bouts of cough before

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Family Tree

8

7/24/2014

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Developmental milestonesSocial smile : 4 monthsTurning in prone position: 5 months

Sitting : -

Crawling : -

Standing : -

Calling mama/papa : 6 months

Walking :-Normal according to thedevelopment age

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History of feedingBreast feeding : birth6 months

Formula milk : birth - 6 months

Milk porridge : 5 months - present

Soft rice porridge : -Rice : -

Immunization

he received basic immunization completely as

recommended

7/24/2014

It is normal to his age

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Social, economic and environmentfather 46 years old , a farmer, junior high

graduate

mother 34 years old, a housewife, junior high

graduate

They live in a permanent house 3 bedrooms,

with 5 adults and 4 children

In-house bathroom and lavatoryElectricity from government company

Water from artesian well

Wastes are collected and thrown away

This patient is usingJAMKESMAS

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Vital sign : Pulse rate : 130 times/minutes, regularly

Respiratory rate : 40 times/minutesTemperature : 37.4 C

Head : mesochepaly, thick black hair, not easily pulled

out

Eyes : conjungtiva was not anemic, sclera was not icteric,

palpebral edema (-/-), facial edema (-), both pupil were round,

same diameter with size of 3-3 mm, eyes reflexes were normal

Ears : clear external ear canal, normal ear drumsNose : there was no secretes nor flares

Mouth : there was no cyanosis, no signs of hyperemic

pharynx nor both tonsils

Neck : no lymph nodes enlargement

Within normal limit

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Chest : symmetrical respiratory movement, no

retractions

Heart : normal rate, regular rhythm, no murmur, no

thrill

Lungs : bronchovesicular breathe sound, no cracklesnor wheezing, rales +/+

Abdomen : round, soft, normal bowel sound, liver and

spleen were not palpable

Extremities : warm, not cyanotic, capillary refill time lessthan 2 seconds, normal muscle tone, normal physiological

reflexes and no pathological reflexes was found

Genitalia :male, no abnormality

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Laboratory and Diagnostic Workups

(May 29th, 2014)

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Malaria : -Haemoglobin : 10.3 g/dL

Hematocrits : 30.8 %

Leukocytes : 4.8 x 103/mm3

Thrombocytes : 558 x 103/ mm3

Sodium :129 mmol/LPotassium :4.6 mmol/L

Chloride :103 mmol/L

CRP : 12

Plain chest X-ray : indicative of bronchopneumonia

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Working diagnosis

Bronchopneumonia

Treatment

Cefixime 2 x 35 mg pulv Paracetamol 3 x tsp

Zinc 1 x 20 mg

Oralyte 70-100 mL

Nebulization with Ventolin R + 2,5 mL NaCL / 8 hours

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Date ComplPhysic

ExamLab Dx

Tx

05/30/13(2nd day)

Fever (+),soft stool(+) onceRed rasheson skin (+)

RR 38x/minPulse146x/minT 38.70C

Chest :symmetrical,no retraction,no heartmurmur,bronchovesicular respiratorysound, no

wheezing,rales +/+

Other aspects ofexaminationswere withinnormal limit

- Bronchopneumonia

Acute

Diarrhea

withoutdehydration

Hyponatremia

Cefixime 2 x 35 mg pulv

Paracetamol 3 x tsp

Zinc 1 x 20 mg

Oralyte 70-100 mL

Nebulization with

Ventolin R + 2,5 mLNaCL / 8 hours

Salycil Talk 3 x app

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Date CompPhysic

examDx Tx

05/31/14to06/01/14(3rd & 4thday)

fever (+),Redrashes(+),shortness

of breath(+)

RR 60x/minPulse 144x/minT 37.90C

Chest :

symmetrical,retraction (+),no heartmurmur,bronchovesicular respiratorysound, nowheezing, rales

+/+

Others: WNL

Bronchopneumonia

Acute Diarrhea

without dehydration

Hyponatremia

Morbilli

Fecal Analysis

(May 31st):

pH: 7

Color: yellowish

Blood: -

Leukocyte : 1-2

Erythrocyte : -

Epithelial cells: 1-2

Cefixime 2 x 35 mg pulv STOP

Paracetamol 3 x tsp

Zinc 1 x 20 mg

Oralyte 70-100 mL

Nebulization with Ventolin R +

2,5 mL NaCL / 8 hours

Salycil Talk 3 x app

Planning:

Stop oral medications

O2 1-2 L/min

IVFD KaEn 1B (NS) 10-11 gtt/min

Ampicillin inj. 4 x 150 mg i.v

Chloramphenicol inj. 4 x 200 mg.i.v

Consult tropical-infection division

Close observation

Move to isolation room

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Date CompPhysic

examDx Tx

06/02/14(5th day)

Fever (+),coughdecreased, redrashes (+)

turningblackish,shortnessof breathdecreased

RR 28x/minPulse 110x/minT 37.50C

Chest :

symmetrical,minimalsuprasternalretraction (+),no heartmurmur,bronchovesicular respiratory

sound, nowheezing, rales+/+

Status Localis:red rashesturning black onall bodysurfaces

Bronchopneumonia

Post-Acute Diarrhea

without dehydration

Morbili

Hyponatremia

O2 1-2 L/min

IVFD KaEn 1B (NS) 10-11 gtt/min

Ampicillin inj. 4 x 150 mg i.v (3)

Chloramphenicol inj. 4 x 200 mg

.i.v (3)

Paracetamol 3 x tsp

Zinc 1 x 20 mg

Tropic feeding with 8 x 10 cc milk

via NGT

Planning

Urinalysis

Complete Fecal Analysis

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Date CompPhysic

examDx Tx

06/03/14(6th day)

Fever (-),coughdecreased, redrashes (+)

turningblackishanddecreasing,shortnessof breathdecreased

, no rapidbreathing,intake (+)

RR 30x/minPulse 108x/minT 36.50C

Chest :symmetrical,minimalsuprasternalretraction, noheart murmur,roughbronchovesicula

r respiratorysound, nowheezing, rales+/+ minimal

Status Localis:red rashesturning black onall bodysurfaces

Bronchopneumonia

Post-Acute Diarrhea

without dehydration

Morbili

Hyponatremia

Urinalysis :Molecular weight:1,005Leukocytes: 1-2Erythrocytes: 0-1Epithelium: 2-3Protein : -Billirubins: -Urobillins:normalBlood/erythrocytes: 0-1

O2 1-2 L/min

IVFD KaEn 1B (NS) 10-11 gtt/min

Ampicillin inj. 4 x 150 mg i.v (4)

Chloramphenicol inj. 4 x 200 mg

.i.v (4)

Paracetamol 3 x tsp

Zinc 1 x 20 mg

Tropic feeding with 8 x 10 cc milk

via NGT gradual rapid increase to

8 x 40-50 mL milk

Try oral feeding today

Attending Physicians Advice:Remove INT and NGTSwitch to oral antibiotic(Cefixime 2 x 40 mg pulv)Discharge tomorrow

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Date CompPhysic

examDx Tx

06/04/14(7thday)

Cough (-),shortnessof breath(-), rapidbreathing(-), fever(-), redrashes (+)turningblackishanddecreasing, intake

(+)

RR 28x/minPulse 110x/minT 36.30C

Others: WNL

BronchopneumoniaMorbiliHyponatremi

a

Cefixime 2 x 40 mg pulv

Paracetamol 3 x tsp

Zinc 1 x 20 mg

Milk on demand

Nebulization with Ventolin

respule + 2.5 mL NS every 12

hours

Planing :

Discharge

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DISSCUSSION

22

Morbili

Infectious disease coused bymorbilivirus

Mainly affects children

Classification Prodromal phase

Eruption phase

Convalescing phase

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DISSCUSSION

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Clinical Sympoms

Prodromal phase:

Cold

Coughs

Enanthema on cheek mucosa

Inflammation on pharynx andconjunctiva

Eruption phase

Occurrences of rash

Starting from the back of the ear, spreadingto face, trunk and extremities

Preceded by increasing body temp

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DISSCUSSION contIn this caseDx base :history, physical examination

24

History : fever and cough since 6 days before admission and thecough later accompanied by shortness of breath since 1 day prior toadmission. This clinical symptom indicative of a bronchopneumoniais also accompanied by cold, coryza and reddish coloration ofconjunctiva especially in the mornings indicative of a prodromalphase of morbilli.rashes then started to darken in color (hyperpigmentation) with milddesquamation starting day 4 of treatment, indicating that the patienthas entered the convalescence phase of morbilli

PE: other than rales on both lungs, other aspects ofpatients physical examination were within normallimit

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DISSCUSSION

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It is known that morbilli maycause certain degree ofimmunosuppression, facilitatingthe occurrences of secondary

infection or complications.

The most common

complications of morbilli isbronchopneumonia (75.2%) andgastroenteritis (7.1%)

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Complication Disscussion cont

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Defecation frequency of morethan 3 times in 24 hours with softstool consistency lasting less thana week.

The invasion of virus into tointestinal mucosa yields in an

inflammation on the mucosallayer which in turn causesdiarrhea and malabsorption.

AcuteDiarrhea

soft stool since 3 days prior

to admission, with 5 times aday frequency

No signs of dehydrationIn this patient

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Complication Disscussion cont

27

inflammation on lungparenchyma.

in morbili might be the result ofan infection by the morbilivirusitself or due to bacterial invasion.

characterized by cough, increasedrespiratory frequency and wetsoft crackles (rales)

Bronchopneumonia

Cough, shortness of breath,rales

X-ray confirms diagnosisIn this patient

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Management Disscussioncont

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Uncomplicated morbili treat asoutpatient, supportive treatment

Complicated morbili treat asinpatients, consider antibioticadministration

Manage

ment

Given antibiotics

Symptomatic treatment for fever and cold symptoms

Treated in isolation room due to the contagiousnature of the disease

Inthispatie

nt

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Prevention Disscussion cont

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The most effective way to prevent anderadicate morbilli is vaccination,

may be given as both active and

passive immunization

Vaccination

Not yet vaccinated (due to age)

Explains the more severe clinical course compared toother cases

Inthispatie

nt

P i

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PrognosisDISSCUSSION cont..

The prognosis is

excellent if giventhe correct and

rapid treatment

This patients

prognosis is

good

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TH NKYOU