Neonatal Pneumonia

General Data

• 3 day old male• Wt: 2360 g

• CC: “nanginigtim ang binti”

History of Present Illness

• 3 days PTC:• Patient was born pre-term via SVD, breech

presentation, to a then 20 y/0 primigravid mother, delivered at home c/o a midwife. On regular prenatal check-up (2x) at the local health center, with no exposure to teratogenic substances or radiation

• At birth, patient was noted to have bluish discoloration of the left upper and lower extremities and back area.

• Patient’s family was advised to seek consult at tertiary hospital for further evaluation and management, hence this consult.

• In transit, patient was noted to have increased breathing rate and retractions.

Review of Systems

• (-) fever• (-) change in sensorium• (-) cough• (-) colds• (-) cyanosis• (-) hematuria• (-) seizures

Family Medical History

• (+) DM – Maternal side of the family• (-) HPN, BA, CA, Congenital Anomalies

• Paternal side unknown

Birth and Maternal History

• Pre-term, 34 weeks by PA, 38 weeks by LMP, delivered via SVD, breech presentation, BW 2390 g, AS = ?, NID

• Born to a then 20 y/o primigravid, (+) regular PNCU (2x)

Developmental History

• (+) Moro Reflex• (+) Rooting Reflex• (+) Grip Reflex

Course at the ER

• Patient was received awake, with spontaneous movement, and good cry

• HR 172 RR 88 T 36.7 fair pulses• PC, AS• SCE, Harsh Breath Sounds, (+) occasional

grunting, (+) subcostal retractions, (+) crackles• AB @ 4th ICS, MCL, (-) murmurs• Globular Abdomen, soft, (-) masses

Course at the ER

• Grossly male genitalia, (+) bilateral descended testis

• Fair Pulses, CRT < 3 secs• (+) bluish discoloration of Left Upper

Extremity, and Bilateral Lower extremities• Started on Ampicillin (75) and Amikacin (40),

O2 support done -> Ward Admission

Differential Diagnoses

Hyaline Membrane Disease• Rule In: Patient was born preterm (34 weeks)

with persistent cyanosis of extremities, presented with occasional grunting, subcostal retractions, crackles, and tachypnea of 88 breaths per minute on the first hours of life. The patient might also had perinatal asphyxia due to difficult delivery secondary to breech presentation.

• Rule Out: The incidence of HMD decreases significantly after 30-32 weeks of gestation. The patient improved with administration of antibiotics and oxygen.

Hyaline Membrane Disease• Evaluation: CXR is diagnostic and shows diffuse

atelectasis with an increased density in both lungs and a fine, granular, ground-glass appearance of the lungs. The small airways are filled with air and are clearly surrounded by the increased density of the pulmonary field, creating air bronchograms.

Transient Tachypnea of the Newborn

• Rule In: Patient presented with tachypnea of 88 breaths per minute during the first 24 hours of life, associated with grunting, subcostal retractions, and persistent cyanosis of extremities. Note of minimal improvement with administration of oxygen support.

• Rule Out: Physical examination revealed the presence of crackles. Tachypnea did not resolve within 24-48 hours of life.

• Evaluation: CXR reveals prominent pulmonary vascular markings, fluid in the intralobar fissures, overaeration, and flat diaphragms.

Persistent Pulmonary Hypertension of the Newborn

• Rule In: Patient presented with persistent cyanosis of extremities, associated with occasional grunting, subcostal retractions, and tachypnea of 88 breaths per minute. The patient might also had perinatal asphyxia due to difficult delivery secondary to breech presentation.

• Rule Out: The presence of crackles does not support the diagnosis of PPHN.

• Evaluation: CXR reveals decreased pulmonary vascular markings.

Neonatal Pneumonia

• Rule In: Patient presented with signs of respiratory distress such as tachypnea, subcostal retractions, crackles, and cyanosis of extremities.

• Rule Out: Cannot be ruled out.

Diagnostics• Chest X-ray to evaluate the condition of the lungs. Pulmonary

infiltrates suggests pneumonia, diffuse atelectasis supports HMD, fluids in intralobar fissures points out to a probable TTN, and decreased lung markings suggests PPHN.

• CBC to evaluate if there is an increase in WBC count that supports the presence of probable infection. It would also show probable derangement in RBC and hemoglobin that decrease the oxygen-carrying capacity.

• ABG to assess the peripheral oxygen saturation of arterial blood and probable acidosis/alkalosis of the patient.

• Bloo CS to document the presence of infection, know the culprit organism and test its sensitivity t particular antibiotics.

• Hyperoxia test to differentiate if the disease is secondary to a pulmonary condition or due to a presence of AV shunt.

• Serum electrolytes

Laboratory Results

CBC

WBC 7.67

HGB 159

HCT 0.464

PC 222

Neut 0.53

Lymph 0.31

Electrolytes

Calcium 1.94 2.07

Sodium 140 139

Potassium 3.8 4.8

Chloride 111 107

Physical Examination

• HR 150 RR 40 T 36.8oC GP• PC, AS• ECE, CBS, (-) retractions• DHS, NRRR, (-) m2• Globular, soft, (-) masses• FEP, PNB, CRTs < 2s• (+) bluish discoloration of bilateral plantar

area

Neonatal Pneumonia

Definition:

• Inflammation of the parenchyma of the lungs • Onset may be within hours of birth or after 7

days & confined to the lungs• caused by microorganisms,

noninfectious causes aspiration of food or gastric acid, foreign bodies hypersensitivity reactions

• Early onsetpart of generalized sepsis that presents at or within hours of birth

• Late onsetoccurs after 7 days of age

Etioloic agents according to time of acquisition

I. Transplacental- CMV, HSV, M. tb, Rubella virus, T. pallidum, VZV

II. Perinatal- anaerobic bacteria, Chlamydia, CMV, Enteric

bacteria, GBS, H. influenza, HSV, L. monocytogenes, Mycoplasma

III. Postnatal- Adenovirus, Candida sp., Coagulase-negative staph, CMV, Echo virus, Enterics, Influenza viruses A,B, Parainfluenza, Pseudomonas, RSV, S. aureus

Group B Streptoccocci- most common cause of fulminant infections

Signs and Symptoms:

• Early- nonspecific such as poor feeding, lethargy, irritability, cyanosis, temp instability, overall impression that the infant is not well

• Respiratory symptoms: grunting, tachypnea, retractions, alar flaring, apnea, cyanosis, progressive respiratory failure

• Signs of pneumonia on PE such as dullness to percussion, change in breath sounds and presence of rales/ rhonchi are very difficult to appreciate in neonate.

Prenatal Features Increasing Risk for Neonatal Pneumonia:

• Unexplained preterm labor• PROM• Maternal fever• uterine tenderness• foul-smelling amniotic fluid• infection of maternal GUT• Fetal tachycardia• meconium in the AF• Recurrent maternal UTI

Diagnostics:

• The diagnosis of pneumonia in neonates is usually presumptive

• Blood culture - done to isolate etiologic agent but is usually negative

• CXR- presence of pulmonary infiltrates• - Difficult to differentiate from RDS

especially in preterm infents

Treatment

• Early Onset infections (1st 7 days of life): Ampicillin + Aminoglycosides (Gentamicin)/ Cefotaxime

• GBS- Penicillin G• MRSA- Vancomycin• Pseudominas – Aminoglycosides + Ceftazidime/

Piperacillin/ Ticarcillin/ Cabernicillin • C. trachomatis- Erythromycin/ TMP-SX