13 F with fever, sob, left lower limb swelling

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13 year old female with complaints of sudden onset left lower limb edema: non pitting type with fever since 5 days high grade and cough since 2 days .

Patient was initially admitted in ortho in view of osteomyletis but xrays normal esr (112) and crp elevated.

Usg left lower limb showed subacute thrombosis external iliac vein to femoral vein.

Patient had sudden onset sob yesterday night. 

General Medicine consultation was taken 

Patient found lying on bed concious coherent cooperative and tachypnoeic with rr : 44 cpm 

Bp : 110/80 mm hg

Pr 154 bpm regular 

Cvs s1 s2 normal 

Rs decreased air entry on left side and b/l basal crepitations 

                                        chest xray shows B/L lower zone consolidation

HRCT suggestive of ?Viral pneumonia

Temp 101.4 F

Ecg sinus tachycardia

Differentials : Type 1 respi failure secondary to pneumonia viral with DVT (sepsis induced hypercoagulability)

? PE

Patient was then refered to Corporate teritiary branch in near by city to admit under cardiology under government scheme.

course in the hospital : 

After arriving to teritiary center patient triage was done and admitted in peadiatrics department in view of respiratory distress. 

Cardiology cross consultation was taken in view of DVT and Mild PE where 2D echo was done - Normal LV/RV function, Normal sized chambers, no RWMA. Fondaparinux was started.

Treatment given : 

1. VANCOMYCIN

2. CEFTRIAXONE

3. AZITHROMYCIN

4. CLINDAMYCIN

5. FONDAPARINUX

Screening ANA - Negative

Sickling test - Negative

DAY 2 : patient was kept on CPAP 

In view of drop in saturations patient was intubated and kept on mechanical ventilation.

Added MEROPENEM.

I/V/O retractions and tachypnea and CT Pulmonary angiogram showing Pulmonary nodules and consolidation, serial ABG showing uncompensated Respiratory alkalosis on HHHFNC.On day 2 of admission i/v/o severe respiratory distress,child was intubated and started on mechanical ventilation VCV-AC mode. I/v/o persistent fever spikes and leucocytosis her antibiotics were upgraded after sending blood and ET cultures.Plan was made to do MRI left lower limb and pelvis i/v/o persistent fever spikes. Serial chest xray and ABG are suggestive of ARDS picture. 

inj. meropenem 1gm iv tid
inj. linezolid 350mg iv bd
inj. clindamycin 240mg iv tid
inj. azithromycin 350mg iv od
inj. atracurium 4ml/hr
inj. morphine 3ml/hr
inj. fondaflu 5mg od
neb. mucomix 3cc 6th hourly
inj. pan 35 mg od
inj. pcm 350mg qid
syp. sucralfate 15ml.

DAY 3:

Haemogram showed showed fall in Hb from 7.7 on admission to 5.4 on day 3 ,hence 1 unit PRBC transfusion was done .RTPCR for Covid 19 was negative.on day 3 of ventilation, in view of peristent desaturations and decreased air entry on left side , chest x ray was done suggestive left sided pneumothorax and clinical signs and symptoms suggestive of tension pneumothorax,surgery cross consultation was done and ICD tube was inserted.     

  Chest xray shows left pnemothorax

resolution of pneumothorax post ICD     

There was continous fresh bleed in ICD and child was landed into hypotensive shock with cool peripheries, iv fluid bolus and prbc transfusions started and injection vitamin.k was given.

ET tube culture senstivity was sent which revealed  - MSSA

GRAM STAIN : PLENTY OF INFLAMMATORY CELLS. GRAM POSITIVE COCCI IN PAIRS SEEN. SIGNIFICANT GROWTH OF METHICILLIN SUSCEPTIBLE STAPHYLOCOCCUS AURESU > 1 LAKH CFU/ML.VANCOMYCIN HAS POOR EFFICACY AGAINST MSSA.

ORGANISM STAPHYLOCOCCUS AUREUS ANTIBIOTICS INTERPRETATION

DRUG                           PATTERN          MIC

Benzylpenicillin           RESISTANT   > = 0.5 Oxacillin                       SENSITIVE   < = 0.25 Gentamicin                  RESISTANT   > = 16 Ciprofloxacin              RESISTANT    > = 8 

Levofloxacin               RESISTANT         4 

Erythromycin              RESISTANT    > = 8 

Clindamycin                SENSITIVE    0.25 

Linezolid                     SENSITIVE        2 

Teicoplanin                SENSITIVE     <= 0.5 

Vancomycin               SENSITIVE        1 

Tetracycline                SENSITIVE   < = 1 

Co-trimoxazole          SENSITIVE       <= 10 

Linezolid                      SENSITIVE 

 Teicoplanin                 SENSITIVE 

 Amoxyclav                  SENSITIVE 

Cephalexin                   SENSITIVE 

on Day 5 of mechanical ventilation due to financial crisis & emotional disturbances patient attenders were  not satisfied and lost hope of child becoming normal so they decided to take her child to Government childrens hospital and left against medical advice.

on the way to government childerns hospital the baby suddenly collapsed by the time they reached the hospital the baby was decleared dead....