Case

Presentation
PRESENTER: C2 郭嘉舜 許海寧
SUPERVISOR: R 方泓翔 醫師
VS 周雅玲 醫師
Outline

Case Revie
Report w

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Case report

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Brief Introduction
• Name ：洪 x
• Sex ： Female
• Age ： 4 months old
• Chart number ： 3158290
• Admission ： 2019/11/19 - 2019/11/23

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Chief Complaint

Intermittent fever up to 39.5C with
barking cough and shortness of
breath for 3 days.

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Present Illness
2019/11/1 Her dad had fever and cold since last Friday(11/15).
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2019/11/1 Suffered from cough, fever up to 39.5C, shortness of breath.
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2019/11/1 Went to local clinic on 11/18, where Influenza A infection
8 was noted.
◦ TAMIFLU CAP 75 MG 0.3 CAP were administered.
2019/11/1 Started barking cough severely since early morning with
9 poor appetite, poor activity and intermittent fever.
◦ Went toADRENALIN
ER in 汐止國泰 INJ.1Lab data1showed
MG/ML ML 5mg leukocytosis
INHL
(20.07*10^3/uL),
METHASONE elevated CRP(2.5 mg/dL).
(Dexamethasone) INJ 5 MG/ML 1 ML 2 MG IVA
◦ Due to born at TSGH,
BESMATE she was
Inhalation transferred to TSGH
Solution(Ipratropium) ER (AAD).
0.5 INHL
◦ Persistent stridor and cough, shortness of breath was still noted
after adrenalin inhalation.
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Past History

History of systemic disease: Denied

History of operation or hospitalization: Denied

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Personal History

Nationality: Taiwan

Full term via normal spontaneous delivery

Blood type: O, Rh(+)

Traveling history: No travelling history in recent three months

Occupation: Student( 小班 )

Allergy history: No Known Allergies

Vaccination as scheduled

Development and growth history: Within normal range, no
delay.

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Vaccination
■ HBV1 (1d) ■ HBV2 (1m)
■ DaTP +Hib+IPV1 (2m) ■ DaTP +Hib+IPV2 (4m)
□ BCG (5m) □ DaTP +Hib+IPV3 (6m) □ HBV3 (6m)
□ Chickenpox (12-15m □ MMR1 (12-15m)
□ JE1 (1y3m) □ JE2 (1y3m, 2 weeks later)
□ JE3 (2y3m)
□ DaTP +Hib+IPV4 (2y3m)
□ MMR2 (7y)
□ Tdap booster (5-7y) □ HBV booster (7y)
□ JE booster (7y) □ Rotarix/Rotateq 1 (2m, 4m, 6m)
□ PCV-13/10 (2m, 4m, 1y)
□ Influenza (each year)

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Family History
DM, Asthma DM, HTN HTN

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Review of systems
1.General:
□Body weight change, ■ Fatigue, ■Fever, □ Chills, □ Anxiety, ■ Dyspnea
2.HEENT:
□Headache, □Trauma, □Diplopia, □Photophobia, □Lacrimation, □Pain, □Tinnitus, □Vertigo,
□Earache, □Obstruction, □ Rhinorrhea, □Sore throat, □Hoarseness, □Dry mouth, □Mucosa
defect, □Neck stiffness

3.Cardio-Respiratory system:
■ Cough, □Sputum, □Hemoptysis, □Chest pain, □Palpitation, □Dyspnea, □Orthopnea,
□Edema, □Cyanosis

4.Gastrointestinal system:
■ Change in appetite, □Nausea, □Vomiting, □Diarrhea, □Constipation, □Jaundice,
□Abdominal pain, □Bleeding

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Review of systems
5.Genito-urinary system:
□Frequency, □Dysuria, □Hematuria, □Urethral discharge, □Nocturia, □Acute urinary retention, □Flank
pain

6.Neuro- Psychiatric system:

□Convulsion, □Paresthesia, □Ataxia, □Resting tremor, □Memory defect, □Gait disturbance,
□Dizziness, □Metal status change, □Insomnia, □Suicide attempt, □Hallucination, □Delusion, □Drug
abuse

7.Musculoskeletal system:
□Back pain, □Bone infections, □Joint pain or swelling, □Varicose vein

8.Skin:
□Rashes, □Eruption, □Ulceration, □Pruritus, □Skin Pigmentation

9.Endocrine :
□Heat cold intolerance, □Thyroid problems, □Thirsty, □Polyuria, □Hirsutism, □Delayed puberty

No other remarkable finding

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Physical examination
Height: 68cm, Weight: 7.6kg

Vital signs: BT: 36.2℃(ER 耳温 ), PR: 140/min, RR: 32/min, BP: 108/64 ㎜ Hg
Consciousness: alert

SKIN : skin rash, no petechiae

HEAD : congestion of throat, normal eardrum, bil
NECK : no neck stiffness, , no lymphadenopathy

CHEST : coarse breathing sound, rhonchi, no crackles, no suprasternum

HEART : regular heart beat.no murmur.no thrills

ABDOMEN : soft.no tenderness.no palpable mass

GENITALIA : No examination this time

MUSCULOSKELETAL : no deformity or joint swelling.no pitting edema

NEUROLOGICAL : normal deep tendon reflexes.no babinski sign

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Imaging Finding

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Laboratory Data
6.0 – 14.0

2.89 – 4.83

10.5 – 14.0
11.5 – 13.5 0.03 – 0.5
32 – 42
22 – 63
34 – 40
72 – 88 12 – 45
24 – 30 134 – 143
32 – 36 3.5 – 5.6

3–7

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Impression
1. Influenza A infection
2. Croup

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Plan to do

Diagnosis plan
◦ Follow up blood culture

Therapeutic plan
◦ Adrenalin inhalation if shortness of breath with barking cough.
◦O2 tent
◦Tamiflu for influenza A infection
◦ Supportive treatment with fluid supplement and symptomatic
agents

Educational plan
◦ Explain current condition, possible complications, and
therapeutic plan to the patient's family well

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 Hospital Course
2019/11/1 Hospital admission ADRENALIN INJ 1 MG/ML 1 ML 3mg INHL
◦ Barking cough, METHASONE INJ 5 MG/ML 1 ML 2.5 MG IM
9 resting stridor, O2 tent
dyspnea and
subcostal retraction still noted >> transferred to PICU
2019/11/20 Fever subsided ADRENALINDuring
INJ 1 MG/ML 1 ML 3mg INHL
the admission
◦ No other discomfort, activity and appetite well

2019/11/2 Transfer to general ward

1 ◦ TAMIFLU CAP 75 MG 0.3 CAP (11/22)
2019/11/2 Cough still persisted, but much improved.
2
2019/11/2 No fever, no subcostal reaction or stridor, no dyspnea
3 The patient was discharged and OPD follow up
TPR
Admission
Transfer to ICU Transfer to general ward

MBD

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Culture Report

Blood culture: No growth

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Final diagnosis
1. Influenza A infection
2. Croup with impending respiratory failure.

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Review
CROUP
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 INTRODUCTION

Inspiratory Barking
Hoarseness
stridor cough

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DEFINITION
Viral croup

Viral symptoms(eg, nasal congestion, fever)

A self-limited illness

Spasmodic croup

Symptoms subsiding by the time of presentation for medical
attention

Fever is typically absent

Abrupt onset and cessation, short duration

Frequently recurrent croup

Familial predisposition: allergic croup

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ETIOLOGY
Virus

Parainfluenza virus

Respiratory syncytial virus and adenoviruses

Influenza virus

Human coronavirus NL63 (HCoV-NL63)

Measles

Rhinoviruses, enteroviruses, and herpes simplex virus

Bacteria

Staphylococcus aureus

Streptococcus pyogenes, and Streptococcus pneumoniae

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EPIDEMIOLOGY
Age Sex
six months to
three years of age 1.4:1

Risk factor Season

family history of fall or early
croup winter

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CLINICAL
PRESENTATION
Fever
Nasal discharge
Stridor
Congestion
Barking cough
Coryza
Hoarseness

Tachypnea
Signs of lower
Respiratory
airway
distress

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EVALUATION
Rapid assessment and initial management

General appearance, vital signs, pulse oximetry, airway stability,
mental status, and hydration status

Pharmacologic treatment and respiratory support

History

Onset, duration, and progression of symptoms

Examination

Severity assessment

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Severity assessment—Westley score

Mild croup(≤2), Moderate croup(3 to 7), Severe croup(≥8),Impending respiratory failure(≥12)

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EVALUATION
Rapid assessment and initial management

General appearance, vital signs, pulse oximetry, airway stability,
mental status, and hydration status

Pharmacologic treatment and respiratory support

History

Onset, duration, and progression of symptoms

Examination

Severity assessment
Laboratory studies Imaging

Blood tests 
Steeple sign

Microbiology

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Steeple sign

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DIAGNOSIS
Clinical diagnosis

Stridor, barking cough and hoarseness

PE: normal to moderately inflamed pharynx, and a slightly
increased respiratory rate

CXR: Steeple sign (excluding)

Etiologic diagnosis

Viral culture of secretions

Rapid test of viral antigen

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 DIFFERENTIAL
DIAGNOSIS
Acute epiglottitis Abscesses
Х Barking cough Х Barking cough
√ Drooling √ Stiffness, lymphadenopathy
Allergic reaction or acute
Foreign body angioneurotic edema
√ History of sudden Х cold symptoms or fever
onset of choking √ Dysphagia without
hoarseness
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TREATMENT

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¥ Discharge criteria include all of the following: no stridor at rest, normal pulse oximetry, good air exchange, normal color,
tolerating fluids by mouth, and caregivers understand instructions and are able to return for care if needed.

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TREATMENT
Glucocorticoids

Dexamethasone: orally→IV→IM

Prednisolone: more palatable than the oral liquid preparation of
dexamethasone, but increased risk of symptom recurrence

Nebulized epineprine

Racemic epinephrine(which is a 1:1 mixture of the D- and L-
isomers) and L-epinephrine appear to have similar efficacy and a
similar side effect

Mist therapy

Limited efficacy

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TAKE HOME
MESSAGE

Clinical presentation: Inspiratory stridor, barking cough,
hoarseness

Etiology: Parainfluenza virus, RSV, influenza virus

Image: Steeple sign

Severity assessment: Westly score

Treatment: Methasone(Dexamethasone) 0.6 mg/kg

Adrenalin(nebulized epinephrine) 5 mg

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 國考題
A 1. 一個 3 歲男童，發燒、咳嗽三天，並有喉嚨痛與聲音沙啞。血液檢查白血球 11000/uL ， 其中 segment 佔 45% ，
lymphocyte 占 50% ， monocyte 占 3% ， eosinophil 占 2% 。身體診察肺部呼吸音較粗（ coarse
breathing sound ），沒有囉音（ rales ）或喘鳴聲（ wheezing ）。請依此回答下列 3 題。 X 檢查如下，臨床診斷
最有可能為下列何者？
(A). 哮吼（ croup ）
(B). 喉頭軟化（ laryngomalacia ）
(C). 扁桃腺炎（ tonsillitis ）
(D). 細菌性氣管炎（ bacterial tracheitis ）

2. 承上題，想要確定致病原因，應執行何種檢查？
C (A). 支氣管鏡檢查
(B). 咽喉細菌培養
(C). 咽喉病毒培養
(D). 抽血做黴漿菌抗體檢測

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 國考題
B 3. 三歲病童有發燒 (39.5℃) 、呼吸困難、哭聲沙啞、吸氣時尖銳喘鳴聲。頸部 X 光可見氣管成尖塔形 。則下列何者是
最可能的致病微生物？
(A). 嗜血桿菌 (H. influenza)
(B). 副流行性感冒病毒 (Parainfluenza virus)
(C). 金黃葡萄球菌 (S. aureus)
(D). 腸病毒 (enterovirus)

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REFERENCE

Nelson 21e chapter 412 p6725-6727

Uptodate
Croup: Clinical features, evaluation, and diagnosis
Management of croup

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