PICTURE OF THE MONTH Dr. Hagit Levine Schneider Children’s Med Cr of Israel Israel Pediatric Pulmonology Society 02/2015 Case I • 2 yo, healthy boy • fever + cough • Wbc: 15K, NEU: 80% CRP: 35.5(mg/dl) • Chest x-ray - Pleuropneumonia • IV Ceftriaxone • Pig tail chest drain: empyema – pH= 6.8, WBC=150,000, – glucose =0, LDH=50 • • • • • – culture - S. pneumoniae Still febrile Clindamycin added US - loculated fluid Urokinase After 5d drain out (no drainage) 16/11/2014 • 2 yo, healthy boy • fever + cough • Wbc: 15K, NEU: 80% CRP: 35.5(mg/dl) • Chest x-ray - Pleuropneumonia • IV Ceftriaxone • Pig tail chest drain: empyema – pH= 6.8, WBC=150,000, – glucose =0, LDH=50 • • • • • – culture - S. pneumoniae Still febrile Clindamycin added US - loculated fluid Urokinase After 5d drain out (no drainage) 18/11/2014 Chest CT at 11d: Necrotizing Pneumonia 27.11.2014 • CT - loculated pleural fluid and pockets of air, atelectatic left lung • Still febrile -> Tazocin + Clindamycin • 2nd large chest drain at 11d + Urokinase (27/11/14) • VATS with debridement at 14d (30/11/2014). • Improved clinically, drain removed after 4d • Boy was discharged at 24d with Augmentin PO (10/12/2014). 29.11.2014 Larger bore tube Readmitted at 24d Readmitted: • Fever • Sero-sanguinous discharge from the wound. • CXR: infiltrate, pneumothorax & effusion • Transferred to Schneider’s 10/12/2014 Chest CT at 36d: Bronchopleurocutaneus Fistula 22.12.2014 • • • • • • Broncho-pleural-skin fistula: discharging sero-sanguinous fluid + air Organizing pleural fluid + air in pleural space. IV Tazocin and Vancomycin 5d -> IV Ceftriaxone 4w Afebrile, air entry improved WBC: 11K, CRP 0.4 Pneumococcal Ab: 1.2 (low) What Would You Do…!? Chest X-Ray at 52d 30.01.2015 Primum non nocere Case II Case II • 3 wk old girl. • Prenatal US LUL SOL, suspected to be bronchogenic cyst What Would You Do…!? US Venous Aneurism US DOPPLER MRI/MRA MRI/MRA What Would You Do…!? Chest x-ray after embolization Onyx® is a non-adhesive liquid embolic agent used for the embolization. Injected directly into the aneurysm through a small, thin micro-catheter Case III Case III • 7 yo girl • Fever 2 days, cough, vomiting, weakness for a week • WBC: 20K • CRP: 11 -> 25 1st US CT CT Cystic lung lesion (HC) with dependent wavy contour consistent with Germinative membranes - the camalote or the water lily sign 2nd US 2nd US Scolices Diagnosis? Diagnosis? What Would You Do…!? CASE IV CASE IV • 18 yo boy • VACTER • S/P EA+TEF Surgery repair • Rec. Aspiration pneumonia UPP GI What Would You Do…!? • Stopped eating & drinking 2 hours before sleeping • Bed was sloped with head raised THANKS!