CASE REPORT

3-year-old female, is admitted in the hospital on the 20 th of September of 2022,

presenting with paroxysmal and unproductive cough and rhinorrhea, since the 18th.
The cough started abruptly during the night, from the 18th to the 19th, having a
duration of 3 hours, not allowing the girl to sleep. The cough was like a barking
sound, and, after that, the cough became productive, and the child began to breath
shallowly. The girl took Ventolin syrup 2mg/5ml, a salbutamol, providing short acting
bronchodilation in obstructive airways. On the 19 th an X-ray was done, showing an
emerging infiltration in the right basal segment. That night, the mother gave her
Klacid (clarithromycin). It’s referred that the child was at the pool 2 days before the
symptoms started, and that the very next day she had a cold.

On admission, blood work was done, showing leukocytosis with formula deviation
to the left and a CRP of 14mg/l.

As background, 3 weeks ago she had a strong cough, fever up to 38.5ºC and
rales could be heard. She also had tonsilitis once and she’s vaccinated according to
the plan. Denies allergies and family members are currently healthy.

On the physical exam her condition is moderate. Breathes easily through her nose.
Wheezes can be heard when she takes deeper breaths. On auscultation moist rales
of various calibers can be heard throughout all lungs. Breathing rate is 34 times per
minute. Ear drums are pink, reflexes (+). Saturation of O2 93%. Temperature is
38.4ºC. Heart rate is 138bpm.

Analyses are repeated, showing GBC: leuk 12,6x109/l; Ery 4,54x10*12/l; Hb 112 g/l;
tromb 403x109/l; mon 1%; linf 25 %; gran 67 %. CRP – 22,6 mg/l.

The girl presents herself with 2 days of rhinorrhea and unproductive cough, and,
at the time of admission, she’s showing signs of a lower respiratory tract infection,
with the start of productive cough and high fever. Besides that, the x ray shows an
emerging infiltration in the right basal segment. There’s also, at admission,
leukocytosis with formula deviation to the left and CRP of 14mg/l indicating an
infection in progress. 3 weeks ago, she had a possible superior respiratory tract
infection, with high fever, dry cough and rales.

Lower respiratory tract infections (LRTI) include bronchitis, bronchiolitis and

pneumonia, or any combination of the three. Based on the symptoms, such as fever,
respiratory symptoms at the physical exam, such as wheezes, and rales, and
parenchymal involvement, with the presence of infiltrates in the right basal segment
of the lung, the more probable diagnosis is pneumonia. Pneumonia is also more
common in children younger than 5 years of age, and the patient is 3 years old. In
children of this age (<5 years old), viruses are the most common cause. However,
bacterial pathogens, such as Streptococcus pneumoniae, Staphylococcus aureus,
and Streptococcus pyogenes, are also to be taken in consideration. In fact, in viral
pneumonia, fever is usually present, but temperatures are generally lower so,
CASE REPORT SARA GOMES ALVES
despite not being able to fully classify if this pneumonia is viral or bacterial without
further tests, the high temperatures presented by the child and the lobar
consolidation seen in the x ray, are suggestive of bacterial etiology. However,
wheezing is more common in pneumonia caused by atypical bacteria and viruses,
than bacteria. It is also a characteristic feature of bronchiolitis and asthma. Bacterial
pneumonia can be difficult to distinguish from bronchiolitis in young children because
the symptoms and signs of both conditions are nonspecific; children with bacterial
pneumonia may be more ill appearing (higher fever), but clinical features cannot
reliably differentiate bacterial from viral lower respiratory tract infection.

This pneumonia is probably also a community acquired pneumonia (CAP), as the girl
acquired the infection in the community, maybe from the pool she attended 2 days
prior to starting these symptoms, and not from the hospital, as she wasn’t admitted
until the 20th.

The child also presented with nightly cough, not being able to sleep, and that cough
had a very specific barking sound. Croup is a respiratory illness characterized by
inspiratory stridor, barking cough, and hoarseness. These symptoms result from
inflammation in the larynx and subglottic airway. There are two types of croup, the
classical croup (viral croup) and spasmodic croup.

Viral croup occurs commonly in children from six months to three years of age, and it
is caused by respiratory viruses, having typical viral symptoms as nasal congestion
and fever. Viral croup is usually a self-limited illness and the cough typically resolves
within three day.

Spasmodic croup also occurs in children six months to three years of age and
always occurs at night. The onset and cessation of symptoms are abrupt, and the
duration of symptoms is short. Fever is usually absent. Seeing as the girl had a
strong barking cough during the night, with abrupt onset and cessation, for 3 hours,
she probably had an acute laryngitis with spasmodic croup, although more episodes
are needed to diagnose this condition.

With all these clinical signs and symptoms presented by the 3-year-old girl, the most
probable diagnosis is an acute laryngotracheobronchitis with secondary bacterial
infection: Laryngotracheobronchitis occurs when inflammation extends into the
bronchi, resulting in lower airway signs (wheezing and crackles presented by the girl)
and, sometimes, more severe illness than laryngotracheitis alone. Extension of
inflammation further into the lower airways results in
laryngotracheobronchopneumonitis, which can be complicated by bacterial
superinfection, such as pneumonia.

Bronchiolitis is also a diagnosis to have in consideration and is broadly defined as

a clinical syndrome of respiratory distress that occurs in children <2 years of age,
characterized by upper respiratory symptoms (rhinorrhea) followed by lower
respiratory infection with inflammation, which results in wheezing and/or crackles.
Bronchiolitis typically is caused by a viral infection, being respiratory syncytial virus
(RSV) the most common cause. Bronchiolitis generally presents with fever (usually
≤38.3°C), cough and respiratory distress (wheezing, crackles). It often is preceded
by a one- to three-day history of upper respiratory tract symptoms (nasal
congestion). Typical illness with bronchiolitis begins with upper respiratory tract
CASE REPORT SARA GOMES ALVES
symptoms, followed by lower respiratory tract signs and symptoms on days 2 to 3,
which peak on days 3 to 5 and then gradually resolve. Despite being a valid
differential diagnosis, the type of cough, with the barking sound, doesn’t go with the
type of cough presented in Bronchiolitis, so this diagnosis is less probable.

Foreign body aspiration is to also be taken in consideration, and there often is a

history of the sudden onset of choking and symptoms of upper airway obstruction in
a previously healthy child. If an inhaled foreign body lodges in the larynx, it will
produce hoarseness and stridor. If a large foreign body is swallowed, it may lodge in
the upper esophagus, resulting in distortion of the adjacent soft extrathoracic trachea
and producing a barking cough and inspiratory stridor. However, if the child had
swallowed a foreign body, her symptoms would have a much more acute onset and
she would have more trouble breathing. Also, foreign body aspiration doesn’t explain
the findings of infiltration in the right basal segment in the x-ray.

Asthma is also a differential diagnosis to have in consideration as the child

presented wheezing. However, she didn’t have any previous episodes of
bronchiolitis, doesn’t have allergies and/or family history, therefore, this diagnose is
improbable.

Treatment:

Supportive respiratory care: For children not requiring immediate intubation,

supportive respiratory care consists of providing supplemental oxygen and a trial of
inhaled bronchodilator therapy (nebulized epinephrine if stridor is noted; albuterol if
wheezing is noted)
Supplemental oxygen: For patients with hypoxia and respiratory distress,
supplemental oxygen should be provided to maintain oxygen saturation ( SpO2
≥94%);
Fever control and treatment with antipyretics (oral paracetamol 10-20 mg/kg/toma) or
suppository matched to the weight of the child.

Nebulized epinephrine – For most children presenting with acute respiratory distress
and stridor:
Racemic epinephrine is administered as 0.05 mL/kg per dose (maximum of
0.5 mL) of a 2.25% solution diluted to 3 mL total volume with normal saline. It is
given via nebulizer over 15 minutes.
L-epinephrine (parenteral product) is administered as 0.5 mL/kg per dose
(maximum of 5 mL) using the 1 mg/mL strength (may also be referred to as a 1:1000
dilution). It is given via nebulizer over 15 minutes.

Intubation: Close respiratory monitoring is critical to all children admitted for

management of bacterial tracheitis given the risk for acute airway compromise from
the tracheal exudate and pseudomembranes. However, as the girl isn’t in distress
and is able to breath without any help, this would only be applicable if her situation
worsens.

CASE REPORT SARA GOMES ALVES

For the bacterial infection:

For appropriately immunized, healthy children younger than five years who are
thought to have bacterial CAP based upon clinical presentation, examination
findings, and supportive radiographic or laboratory data if obtained (lobar
consolidation on radiograph, white blood cell count >15,000/microL, C-reactive
protein >35 to 60 mg/L) but do not require inpatient therapy, amoxicillin is usually
considered the drug of choice. A high-dose amoxicillin, 90 to 100 mg/kg per day,
divided into two or three doses with a maximum dose of 4 g/day.

Sara Gomes Alves

Group 3
Erasmus +

CASE REPORT SARA GOMES ALVES

REFERENCES

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Barson, W.J. (2022) Community-acquired pneumonia in children: Outpatient

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Isaacson, G.C. (2020) Congenital anomalies of the larynx, UpToDate. Available at:

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Woods, C.R. (2021) Bacterial tracheitis in children: Clinical features and

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Woods, C.R. (2021) Bacterial tracheitis in children: Treatment and prevention, UpToDate.

Available at: https://www.uptodate.com/contents/bacterial-tracheitis-in-children-
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Woods, C.R. (2022) Croup: Clinical features, evaluation, and diagnosis, UpToDate.

Available at: https://www.uptodate.com/contents/croup-clinical-features-evaluation-
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Zyngman, B. (ed.) (no date) Whooping cough (pertussis) in children, Whooping Cough

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CASE REPORT SARA GOMES ALVES