17 year old male, student
3 months he experienced on and off moderate grade fever ( 38 C) temporary relieved by paracetamol and associated cough and occasional chest pains. An X-ray which revealed cardiomegaly. Two (2) months, the condition persisted so the relatives brought the patient to the hospital, admitted with the impression of Rheumatic fever with Mitral Regurgitation. He was discharged after a week with slight improvement. The patient was on regular follow-up at the OPD with maintenance medications of Lanoxin and Kalium durules. Six days (6) prior to admission, he consulted again at Private hospital because of fever and cough. Laboratory examinations requested and revealed increased in ESR and CRP and anti-streptolysin O titer. Blood and urine culture are negative. Chest X-ray showed pneumonic infiltrates greater in the right lung with atelectasis and no change in cardiac size since initial chest X-ray. Patient was given the following medications: Clarithromycin 250/ tab b.i.d for 5days and Zinnat 250 mg/ tab for 5 days. Due to persistence of condition the patient was referred to another private hospital for further management of Bronchopneumonia and work-up for PTB.
PHYSICAL EXAMINATION ON ADMISSION
General Survey: awake, ambulatory, not in cardio-pulmonary distress
Vital signs : PR - 120 /min; RR – 28/min; T – 38.2
HEENT: pink palpebral conjunctivae; anicteric sclerae (-) cervical
Lymphadenopathy; (-) neck vein engorgement
Chest / Lung: equal chest expansion, (-) retraction, decreased vocal fremitus(R);
(-) rales/ wheezes
HEART: distant heart sounds; slightly tachycardic, regular rhythm (-) murmur,
(+) heave. (-) thrill
Abdomen: flat soft, normoactive bowel sound, non-tender
Extremities: full and equal pulses, (-) deformities, pink nailbeds, (-) edema
RHEUMATIC FEVER WITH MITRAL REGURGITATION
BRONCHOPNEUMONIA, COMMUNITY ACQUIRED
COURSE IN THE WARDS
Patient was diagnosed to have Rheumatic Fever with mitral regurgitation. Presented with fever, cough, cardiomegaly and elevated acute phase reactants. Patient was maintained on Lanoxin. Physical examination of the heart revealed dynamic precordium with tachycardia but no murmur appreciated. Chest x-ray revealed cardiomegaly. ECHG showed sinus rhythm with poor R wave progression and 2-D Echo revealed pericardial effusion on the anterior and posterior compartment. Assessment then was Pericardial Effusion probably bacterial. Patient was referred to TCVS for possible tube pericardiotomy but was not done because there was no evidence of RV/LV collapse and EF = 67%
Patient presented with fever, cough and colds. Chest X-ray show patchy infiltrates and CBC showed increased WBC (8) with predominance of segmenters (74). Patient was started on Pen G and Netilmycin
TRANSFER PHYSICAL EXAMINATION
- HR : 110/min RR 30/min T 38.0
- pink palpebral conjunctivae; anicteric sclerae (-) cervical
Lymphadenopathy; (-) neck vein engorgement
- equal chest expansion, (-) retraction, decreased breath sounds (R lung fields);
(-) rales/ wheezes
- distant heart sounds; dynamic precordium, tachycardic, regular rhythm
- flat soft, normoactive bowel sound, non-tender, (-) mass/organomegaly
- full and equal pulses, (-) deformities, pink nailbeds, (-) edema
ASSESSMENT: Pericardial Effusion, probably bacterial r/o PTB
Bronchopneumonia, community acquired
COURSE IN THE WARD:
Patient previously maintained on D5 0.3NaCl with Na+, K and Ca+2 incorporation, but on the 16th hospital, feeding was started until eventually intravenous fluid discontinued because feeding was well tolerated,. On the 30th day, he had poor pulses, cold clammy extremities with BP of 80mm Hg palpatory and heart rate ranging from 140-160 and CRT >35. Patient was hydrated and given inotropic support. Dobutamine was given which improved pulses and blood pressure. The electrolytes however persisted to be decreased despite correction
Patient was intubated with FiO2 of 100% and respiratory rate of 20/ continuous ambubagging. Initial arterial blood gases showed pH 7.195 , pCO2 = 18.2; pO2 = 45.7, HCO3 = 6.8, BE = -20. Patient was given 50 meqs NaHCO3 and 30cc/kg plain lactated Ringer’s soln. On repeat ABG , ph – 7.418, pCO2 21.6, pO2 – 178.7, HCO3 13.8, BE 8.7 & O2 sat 99.4%. Chest X-ray showed pleural effusion and patient was referred to pulmonary service for thoracentesis, however on ultrasound, the effusion was loculated with minimal fluid. On repeat chest X-ray, showed no significant changes in size of pleural effusion, thoracentesis was deferred.
He was started initially with Pen G and Netilmycin but later shifted to Oxacillin since Staph was surmised to be the causative agent for pericardial effusion. Completed 17 doses. Patient’s PPD was positive (mother positive for PTB) Patient was started with anti-Koch’s therapy on the 14th day while Netilmycin was shifted to Amikacin. Repeat chest X-ray (16th HD) showed increased infiltrates, Piper-Tazo (200mg/kg/day) started for 7 days. All culture done on the patient were negative, except for culture for fungal ( + Candida spp; 17th HD) Repeat blood culture showed negative results. Repeat Chest X-ray showed decreased pulmonary infiltrates. Patient was started with Vancomycin and Imipinem. On the 24th HD, an abscess formed on the right hand due to an infected IV site. Wound CS showed no growth. Patient (30th day) had completed 16 doses of PTB medication.
CBC on 8/28 showed hemoglobin of 83 and hematocrit of 0.25. Patient was transfused with 1 unit pRBC with increase of Hgb to 121 and Hct of 0.37
Patient has been diagnosed to have pericardial effusion, large, organized. Referred to TCVS for biopsy with CS was deferred because of fever and uncontrolled infection
CIRCUMSTANCES SURROUNDING DEMISE
The patient was at decreased cardiac output state and had 3 episodes of cardiopulmonary arrest resulting to persistent hypoxemia and metabolic acidosis.
He was at the OR for tube pericardiostomy but had 2 episodes of arrest. During the arrest at the OR (needle) pericardiocentesis was done and revealed bloody fluid (from the Right ventricle ?). Needle paracentesis (globular and tense abdomen) was also done but was a dry tap. Pericardiostomy done but the patient expired.