Case presentation
A 26-month-old boy was admitted to our hospital in September, 2019, with complaint of coughing for two days, fever and wheezing for one day.
Birth History
The patient was born at same hospital at 29 weeks 6 days’ gestation to a 31-year-old primigravid mother by cesarean section. His mother had got preterm premature rupture of membranes (pPROM) for 22 days, and the placental pathology after birth suggested mild stage I chorioamnionitis (CAM). His birth weight was 1230g (50th percentile), and the 1-minute and 5-minute Apgar scores were 8 and 9, respectively. He had spontaneous breathing after birth and was supported by nasal continuous positive airway pressure (nCPAP) and transferred from the operating room to the neonatal intensive care unit (NICU) in a transfer shuttle. He was diagnosed as transient tachypnea syndrome received nCPAP for 24 days with fraction of inspired oxygen (FiO2)<0.35. During the first 72 hours after birth, the nCPAP level was kept within at 6 cmH2O, then it was titrated to 4 to 5 cmH2O to achieve the lowest FiO2 level. The boy was treated with cefoperazone sodium and sulbactam sodium for 10 days due to the suspected amnion infection. He was on nasogastric feeding with own mother’s milk and premature infant formula, supplemented partial parenteral nutrition in the first 25 days during hospitalization. At discharge, he was on 36 weeks corrected gestational age with body weight 2260g (10th percentile).
Follow-up
The boy was followed in the healthcare center in our department. He had moderate speed of catch-up growth (Figure 1). He had eczema since 5 months after birth. And upper respiratory tract infection 3 times during infancy. His body weight was 10.1kg and body length was 73.5cm at corrected 8 months. The breast feeding was stopped at corrected 15 months because the mother was back to work. Only about 200ml formula milk was supplement to the diet except for three meals per day. His body weight was 12.8kg and body length was 89 cm at corrected 17 months. Then, he had suffered from repeated wheezing since 18-month-old and diagnosed as bronchial asthma in other hospital. Since then, he had received intermittent inhalation therapy with budesonide and terbutaline. Four weeks before admission, he had an episode of wheezing and thoracic radiograph showed bronchitis changes without other abnormal findings.
After admission, full clinical examination including general, cardiac, chest and abdominal was performed. On examination, the patient appeared lethargy and slightly uncomfortable. The temperature was 38.6℃, the heart rate was 155 beats per minute, the respiratory rate was 50 breaths per minute, and the transcutaneous oxygen saturation (SpO2) was 92% while he was breathing ambient air. Signs of respiratory distress were observed and presence of inspiratory retractions. Chest auscultation was done by the same physician during the hospital stay. Abnormal auscultatory findings included diminished breath sounds and presence of bronchial breath sounds fine crepitations in the left lung, and presence of wheezing and crackles in the right lung. The remainder of the examination was normal.
Results of laboratory tests are shown in Table 1. The white blood cells count was normal with slightly increased neutrophils proportion. Liver function and kidney function were normal. Arterial blood gas analysis showed hypoxemia. Antibody quantification of mycoplasma pneumoniae was negative.
After the patient was admitted, intravenous injection azithromycin (10mg/kg) and methylprednisolone were administered. Supplemental oxygen was given. The oxygen saturation ranged from 92 to 95 percent while the patient was breathing 100 percent oxygen. Tachypnea persisted, with minimal retractions and paroxysmal acute cough. A chest radiograph revealed air trapping with hyperinflation in the right lung and opacification of the left upper lobe which could represent atelectasis (Figure 2). He received inhaled budesonide 1mg ipratropium bromide 250μg, and terbutaline 2.5mg four times a day.
On the second day, a computed tomographic (CT) scan of the chest confirmed superior lobe of left lung atelectasis, and the bronchial openings of the upper and lower lobes disappeared (Figure 3). We continued his treatment with inhaled budesonide 1mg ipratropium bromide 250μg, and terbutaline 2.5mg four times a day and started nebulized Nacetylcysteine (2.5 mL 20% solution) twice a day. The bronchoscopy was planned on the morning of next day.
During the second night in the hospital, after a severe cough, the patient expelled large casts, sticky whitish secretions, shaping as the tracheobronchial tree (Figure 4). After the cough, inspiratory retractions were disappeared and the respiratory rate slowed down to 30 breaths per minute. Coarse breath sounds were heard in both lungs with fine crepitations and wheezing.
On the third day, chest-X ray reexamined normal permeability in both lungs. Then the bronchoscopy was canceled. Chest auscultation was clear on the fifth day. The patient was discharge home. He is always followed-up in the pediatric pulmonary clinic.