Endgames Case Review

Respiratory tract infection associated with seizures

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4659 (Published 04 September 2015) Cite this as: BMJ 2015;351:h4659
  1. Nathan J Brendish, clinical research fellow1,
  2. Sarah Williams, consultant paediatrician2,
  3. Saul N Faust, professor of paediatric immunology and infectious diseases13456,
  4. Marc Tebruegge, National Institute for Health Research clinical lecturer in paediatric immunology and infectious diseases34567
  1. 1National Institute for Health Research (NIHR) Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
  2. 2Department of General Paediatrics, University Hospital Southampton NHS Foundation Trust
  3. 3Academic Unit of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
  4. 4Department of Paediatric Immunology and Infectious Diseases, University Hospital Southampton NHS Foundation Trust
  5. 5Institute for Life Sciences, University of Southampton, Southampton
  6. 6NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust
  7. 7Department of Paediatrics, University of Melbourne, Parkville, Australia
  1. Correspondence to: M Tebruegge m.tebruegge{at}soton.ac.uk

A two year old girl presented to her local hospital with breathing difficulties. She was diagnosed with virus induced wheeze. On day one of admission she deteriorated and developed respiratory failure, which required ventilatory support and transfer to our paediatric intensive care unit. Figure 1 shows her chest radiograph on arrival. A multiplex polymerase chain reaction (PCR) panel performed on respiratory secretions identified a micro-organism. She was successfully extubated to nasal cannula oxygen two days later and transferred to a paediatric ward. Four hours after transfer she had a prolonged tonic-clonic convulsion. Owing to profound respiratory depression after two doses of lorazepam she required re-intubation and transfer back to the paediatric intensive care unit.

Fig 1 Supine chest radiograph taken on admission to the paediatric intensive care unit

Questions

  • 1. What abnormalities can be seen on her chest radiograph?

  • 2. What organism is most likely to be causing both her respiratory and neurological illnesses?

  • 3. Which imaging studies would be the most useful in determining the cause of her neurological illness?

  • 4. Which additional sample may help confirm the presumptive diagnosis?

Answers

1. What abnormalities can be seen on her chest radiograph?

Short answer

Marked diffuse interstitial changes are present in the lung fields bilaterally. An endotracheal tube and a nasogastric tube are in place.

Discussion

There are marked diffuse interstitial changes in both lung fields. The appearance of the radiograph is consistent with viral pneumonia, which is characterised by bronchial wall thickening, peribronchial shadowing, and perihilar linearity, but it is also consistent with “atypical pneumonia.”1 2

The majority of lower respiratory tract infections in children are caused by viruses; bacterial lower respiratory tract infections are less common.3 Common causative agents include rhinoviruses, respiratory syncytial viruses, influenza A and B viruses, parainfluenza viruses, human metapneumoviruses, and adenoviruses.3 4

Atypical pneumonia is caused by “atypical” bacteria, which include Chlamydia trachomatis and Mycoplasma …

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