Clinical Pathologic Conference

1

• Clinical Pathologic Conference

R1??? / ???????

2
Chief complaint

• A 5 year-old boy was admitted because of fever
  off and on with chillness, cough with whitish
  sputum and chest pain for 3 days.

3
Present illness

• About 1 week before this episode (10 days before
  arrival), he suffered from several times of
  watery diarrhea.
• He had chest wall injury while he was playing
  with his friend.
• 3 days before admission, fever off and on with
  chillness, cough with whitish sputum and chest
  pain were noted.

4
Present illness

• The pattern of chest pain
• -No relieve or aggressive factor
• -No radiating pain.
• -Did not improved despite of medication.
• 1 day before admission, dyspnea after climbing
  upstairs and palpitation was also noted.
• He was brought to ER on the day of admission, and
  short of breath, pale lips, pale conjuntivae were
  found and vomiting for 3 times at ER.

5
Present illness

• Throughout the whole course of present illness,
  he had no skin rash, headache, abdominal
  discomfort and urinary change.
• His appetite and activity were good.

6
Past,Personal and Family History

• Past history
• -Allergic rhinitis
• -Hydronephrosis, left.
• -Asthmatic bronchitis
• -Urethritis
• -Acute gastritis

7
Past,Personal and Family History

• Birth history
• -GA 38 weeks via C/S, Birth weight 3700 gm
• Developmental History normal
• No travel history.
• Family history Grandfather had been working at
  mine,
• (???) driver.
• No any family member
  has the same
• symptoms like him.

8
Physical examination

• Vital sign PR ? 132 /min (65-110), RR ? 36
  /min(20-25), BT 37 ºC
• HEENT Pale conjunctiva/ lip , grade 1/4 of
  tonsils,
• congested throat
• Chest wall A tender mass 2 3-cm in size at
  his fore-
• chest wall.
• Coarse breathing sound

9
Lab. data

• 0905(admission)
• B/R
• -WBC14,620 (5,5-15,5 x10 3)
• -RBC 4.72 x10 6 (3.9-5.3 x10 6 ) , Hct33.4
• -Hgb 11.3 ( 6mo-6 yr 10.5 - 14) Nelson 17 ed
  Table 439-1
• -MCV 70.9 (6 mo-6 yr 70-74) Nelson 17 ed
  Table 439-1
• -MCH 24 (24-30)
• -MCHC 33.8(31-37)
• -PLT 244 x10 3 (150-450 x10 3 )
• -Neut. ? 77.1 (54-62) LYM.25 (25-33)
  Mon.4.9 (3-7) Eos.0.5 (1-3)

10
Lab. data

• 0907(hospitalization)
• B/R
• -WBC10,380 (5,5-15,5 x10 3)
• -RBC 4.65 x10 6 (3.9-5.3 x10 6 ), Hct33.4
• -Hgb 11.0 ( 6mo-6 yr 10.5 - 14) Nelson 17 ed
  Table 439-1
• -MCV 69.7 (6 mo-6 yr 70-74) Nelson 17 ed Table
  439-1
• -MCH 23.7 (24-30)
• -MCHC 34(31-37)
• -PLT 234 x10 3 (150-450 x10 3 )
• -Neut. ? 65 (54-62) LYM.25 (25-33)
  Mon.8 (3-7) Eos.2 (1-3)

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Lab. data

• Mycoplasma AB lt 40 (-)
• CRP ?2.93 (0.17-1.07)
• BUN / Cr 10 / 0.4
• CPK 50 U/L(5-110) CK-MB 1 U/L 2 (1.7-7.9 )
• Glucose 158 mg/dL
• Na/ K/ Cl 136/?3.4/ 100
• Total Ca 9.3

12
Lab. data

• Urine routine
• - pH 6.0
• -Protein /-
• -RBC 0-1/ HPF
• -WBC ? 5-10/ HPF (Children 05/ hpf )
• -Spgr 1.017

13
Hospital course

• After admission, CxR was taken, and draws blood
  samples.
• He was discharged to home after a series of
  studies and treatment.

14
Problem list

• Major problems
• Chest pain
• Short of breath/ dyspnea
• Chest wall mass
• Fever, cough
• Vomiting
• Diarrhea

• Minor problem
• Pale conjuntivae/ lip
• Hyperglycemia
• Pyuria (U/R) ?

15
Questions?

• Correlation between chest injury and chest pain/
  chest mass?
• Chest mass location ? Rib, costochondritic joint,
  intercostal muscle or sternum?
• Chest wall mass Mobile or immobile? Warm/ heat?
  fluctuant ?
• Chest pain sudden onset or progressive?
• Needle aspiration (culture)? Mass biopsy ?
• Viral culture (throat)?
• CxR ? Patchy infiltration? Hilar
  lymphoadenopathy?
• Body weight loss? Night sweating? FHx of TB?
  Medication Hx?
• EKG ?
• Sputum culture?

16
Chest pain possible differential diagnosis

• Infectious costochondritis Tietze syndrome
• Pleurodynia
• Pneumonia Pyogenic Empyema Necessitatis
• Musculoskeletal chest wall pain Osteomyelitis

17
Dyspnea possible mechanism
Pediatric Respiratory Medicine
P370

• ?Pulmonary compliance Inflammation
• ?Airway Resistance
• Airway inflammation hyperreactivity
• ?Sensory Stimuli Chest wall
• ?Chemical Stimuli Hypoxemia, CO2, Acidosis

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Chest wall lesions in childhood

• A wide range of pathologies.
• I. Benign lesions include
• a. Lipoma /Lipoblastoma usually painless,
  occur in the
• 
  first 2 years
• b. Neurofibroma Painless, associated with
• neurofibrosis
  type I
• c. Lymphangioma Painless,associated with a
  variety
• of other
  syndromes such as
• 
  asplenia,Noonans syndrome, and
• tuberculosis.

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Chest wall lesions in childhood

• d. Haemangioma and AVM
• congenital lesions.
• e. Mesenchymal hamartoma
• benign lesion of infancy with most lesions
  presenting
• before 2 years of age.

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Chest wall lesions in childhood

• II. Malignant lesions include
• a. Neuroblastoma occur before 5 years of age,
• abdominal mass
• b. Rhabdomyosarcomacommon found in head/ neck
  or
• 
  extremities
• c. Ewings sarcoma, Askin tumour, Primitive
• neuroectodermal tumours
• all belong to the group of small round
  blue
• cell tumor of childhood.
• Usually presenting in the second decade
  of life.

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Chest wall lesions in childhood

• II. Manifestations of systemic diseases
• e. Leukaemia/ Lymphoma
• always be excluded in
  a child
• presenting with
  multiple bone lesions or
• bone pain,
  hematologic finding.
• f. Langerhans cell histocytosis

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Chest wall lesions in childhood

• III. Infections
• a. Tuberculosis
• -TB on the chest wall can occur as an
  isolated
• primary infection with no evidence of
  pulmonary
• disease
• - Spread to the chest wall from pulmonary
  infection
• may also occur althrough symptoms may be
  minor
• - Presentation may be similar to pyogenic
  abscess or
• simply an enlarging mass.

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Chest wall lesions in childhood

• b. Actinomycosis rare, may mimic TB with
  pulmonary
• infiltration and
  spread to the chest wall
• c. Aspergilosis in immunocompromised patients,
  usually
• by local invasion from
  the lung.
• d. Progenic abscess
• Staphylococcus,
  Klebsiella infection
• e. Other infection illness Strongyloidiasis
  (Strongyloides
• 
  stercoralis)?????

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Chest wall lesions in childhood

• IV. Other lesions
• a. Pseudo-lesions found in cildren of early
  teenage
• years
  presenting with a hard lump
• in
  costochondral cartilage.
• Usually no
  specific symptoms.
• b. Thoracic cage anomalies,osteochondroma,
• hemangiopericytoma

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Chest wall mass possibile DDx

• Tuberculosis
• Actinomycosis
• Pyogenic abscess
• Strongyloidiasis (Strongyloides stercoralis)

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Differential diagnosis

• Chest pain
• Infectious costochondritis
• Tietz syndrome
• Pleurodynia
• Pneumonia- Pyogenic Empyema
• Necessitatis
• Osteomyelitis

• Chest mass
• Tuberculosis
• Actinomycosis
• Pyogenic abscess
• Strongyloidiasis

• Dyspnea
• ?Airway Resistance
• Airway inflammation
• hyperreactivity
• ?Pulmonary compliance
• Inflammation

• ?Sensory Stimuli
• Chest wall
• ?Chemical Stimuli
• Hypoxemia, CO2, Acidosis

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1. Tietze syndrome infectious costochondritis

• Inflammation of the costal cartilages
  (Costochondritis) with a large, tender, fusiform
  (spindle-shaped), nonsuppurative swelling at the
  costochondral or chondrosternal junction.
• 
  Principles and Practice of Pediatric Infectious
  Diseases, 2nd ed
• Etiology
• -Exact cause unclear
• -Most often idiopathic
• -Associated with excessive exercise, chest
  injury or a preceding viral respiratory illness
  (postinfectious)

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1. Tietze syndrome

• Epidemiology
• -Generally occurs in late teens to early
  twenties, but has been described in young
  children.
• S/s sharp pain in anterior chest wall, may
  radiate to
• back or upper abdomen.
• varies in intensity and quality.
• PE Tender by palpation at local site or
  movements of
• the arm or shoulder.
• May show evidence of tachypnea,
  tachycardia or
• systolic HTN.
• Distortion of local soft tissue.

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1. Tietze syndrome

• Diagnostic workup
• -Made with historical and physical clues.
• -Biopsy increased cartilage and lack of
  inflammatory
• fibrosis.
• Management
• NSAIDs, Injections into the painful area with
  triamcinolone are sometimes curative.
• Question Fever ? preceding viral respiratory
  illness?

30
2. Pleurodynia Nelson 17ed p1045, Principles and
Practice of Pediatric Infectious Diseases, 2nd ed
P1183

• Etiologic agents are most frequently
  coxsackieviruses B3 and B5, as well as
  coxsackieviruses B1 and B2 and echoviruses 1 and
  6.
  Nelson 17ed p1045
• Sex Males are affected more than females. Half
  of these patients are younger than 5 years, and
  30 are younger than 1 year.
• Coxsackievirus B usually causes an asymptomatic
  or brief upper respiratory tract or gastroenteric
  infection. Nelson 17ed p1045
• The virus has an incubation time of 1 week in the
  GI tract and subsequently involves the target
  organs through hematogenous dissemination.

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2. Pleurodynia Nelson 17ed p1045, Principles and
Practice of Pediatric Infectious Diseases, 2nd ed
P1183

• Prodromal symptoms such as malaise, myalgias,
  headache and diarrhea are followed by sudden
  onset of fever and pain.
• Principles and Practice of
  Pediatric Infectious Diseases, 2nd ed P1183
• Involvement of the intercostal and other muscles
  of respiration results in enhanced pain with deep
  breathing and a sensation of pleuritic pain
  that can result in splinting of the chest and
  rapid, shallow breathing.
• Principles and Practice of
  Pediatric Infectious Diseases, 2nd ed P1183
• Pain, typically located in the chest or upper
  abdomen, and is spasmodic and can be
  excruciatingly severe. Nelson 17ed p1045
• During spasms, respirations are usually rapid,
  shallow, and grunting, pale, sweaty, and
  shock-like appearance.Nelson 17ed p1045

32
2. Pleurodynia Nelson 17ed p1045, Principles and
Practice of Pediatric Infectious Diseases, 2nd ed
P1183

• Causes necrosis of the striated intercostal
  muscles in patients with pleurodynia.
• Muscle tenderness can be detected by direct
  palpation less commonly, localized swelling is
  observed ( Sylvest, 1934 )
• Associated symptoms related to the viral
  infection may include the following
• -Upper respiratory tract symptoms, including
  sore throat, rhinitis,
• and cough.
• -Constitutional symptoms, including headaches
  (50), fever,
• and malaise

33
2. Pleurodynia Nelson 17ed p1045, Principles and
Practice of Pediatric Infectious Diseases, 2nd ed
P1183

• -GI symptoms, including nausea, vomiting,
  diarrhea (50), and in children, abdominal pain
  (usually in the epigastric area)
• Diagnosis
• -Viral cultures(throat) isolation of
  coxsackievirus B in cell cultures .
• -RT-PCR(throat)
• -Histologic Findings Necrosis of the striated
  intercostal muscles is visible .
• -Serum creatine kinase is usually elevated
  because of muscle necrosis.
• -CxR reveals clear lung fields less than 10
  of patients have a pleural friction rub or
  pleural fluid evident on chest radiographs.

34
2. Pleurodynia Nelson 17ed p1045, Principles and
Practice of Pediatric Infectious Diseases, 2nd ed
P1183

• Illness usually lasts 36 days, but can last up
  to a couple of weeks.
• Illness may occasionally be associated with
  meningitis, orchitis, myocarditis, or
  pericarditis.
• Management
• -Analgesics and limitation of physical
  activity are helpful in reducing pain, which is
  generally most severe on presentation and then
  progressively diminishes during the course of
  illness (which is typically 4 to 6 days but which
  may last as long as 3 weeks) ( Warin et al.,
  1953)
• Question Serum creatine kinase within normal
  range

35
3. Tuberculosis Principles
and Practice of Pediatric Infectious Diseases,
2nd ed

• I. Bony tuberculosis
• Osteomyelitis is otherwise most frequently found
  in the metaphysis of long bones, although the
  ribs, pelvis and skull may be infected.
• In children in countries in which TB is
  prevalent, osteomyelitis is a significant cause
  of crippling deformity.
• Trauma does not predispose to tuberculous
  osteomyelitis

36
3. Tuberculosis Principles
and Practice of Pediatric Infectious Diseases,
2nd ed

• Bony TB may be accompanied by sinus tracts or
  soft tissue masses.
• Diagnosis
• -May be difficult because lesions can appear
  osteolytic or sclerotic on radiography.
• -Biopsy acid-fast bacilli (AFB) stains,
  culture or PCR

37
3. Tuberculosis Principles
and Practice of Pediatric Infectious Diseases,
2nd ed

• II. Tuberculous abscesses 
• May form in most soft tissues, including muscle .
• This is usually secondary to contiguous spread of
  infection but may follow hematogenous
  dissemination.
• The classic abscess site is in the psoas muscle,
  and such an abscess can occur with or without
  localizing signs
• Cough, diarrhea and vomiting can be happened, but
  rare and chronic when the pulmonary and
  gastointestinal were involved.
• Question Contact history? insidious enlarging
  mass? Chronic
• steroid usage? Body weight
  loss? Night weating?

38
4. Actinomycosis Nelson Textbook of
Pediatrics, 17th

• Actinomyces israelii , a slow-growing,
  gram-positive bacteria that are part of the
  normal oral flora in humans.
• Infection caused by these bacteria is termed
  actinomycosis, which is a chronic, granulomatous,
  suppurative disease characterized by peripheral
  spread with extension to contiguous tissue in the
  formation of numerous draining sinus tracts.
• 7 of the patients lt10 yr of age. The youngest
  patient in this series was 28 days old.

39
4. Actinomycosis Nelson Textbook of
Pediatrics, 17th

• Actinomycosis is usually not an opportunistic
  infection, disease has been described in patients
  receiving corticosteroids and those with
  leukemia, renal failure, congenital
  immunodeficiency diseases, and HIV infection
• three important sites of Actinomyces infection in
  order of frequency are cervicofacial, abdominal,
  and thoracic
• Pulmonary actinomycosis may present as fever,
  productive cough, chest pain, and weight loss.
• Infection frequently dissects along tissue planes
  and may extend through the chest wall or
  diaphragm, producing numerous sinuses.

40
4. Actinomycosis Nelson Textbook of
Pediatrics, 17th

• Diagnosis confirmed by examining purulent sinus
  tract drainage for sulfur granules, and by
  appropriate cultures.
• The differential diagnosis of pulmonary
  actinomycosis includes lung abscess and
  tuberculosis.
• Tx mainstay of treatment for actinomycosis is
  prolonged antibiotic therapy (Penicillin) and an
  appropriate surgical approach to sinus tracts and
  abscesses.

41
4. Actinomycosis Nelson Textbook of
Pediatrics, 17th

• Question Chronic process, underlying
• immunocompromise status diarrhea?
  Vomiting?

42
5. Pneumonia- Pyogenic Empyema Necessitatis

• Pyogenic Empyema Necessitatis
• A rare complication of empyema is a
  collection of inflammatory tissue that usually
  extends directly from the pleural cavity into the
  thoracic wall forming a mass in the extrapleural
  soft tissues.
• The hallmark of empyema necessitatis is a mass
• The most common etiologies are tuberculosis and
  actinomycosis.

43
5. Pneumonia- Pyogenic Empyema Necessitatis

• 1-year-old boy with Streptococcus pneumoniae
  empyema necessitatis and review previously
  reported . Pediatr Infect Dis J - 01-FEB-2004
  23(2) 177-9
• Symptoms as the underlying disease, fever, chest
  pain, chest wall mass,cough and short of breath
  may be occur.
  Pediatr Infect Dis J - 01-FEB-2004
  23(2) 177-9
• The mass might be painful and fluctuant.

44
5. Pneumonia- Pyogenic Empyema Necessitatis

• Diagnosis
• -Chest radiograph
• Pleural effusion, with thickening of the
  pleura at the
• involved site, may be an enlargement of the
  overlying
• ribs with a thick, calcified pleural rind.
• -CT scan
• may show a thick-walled, possibly
  well-encapsulated, pleural
• mass that protrudes through the chest
  wall.(Virtually diagnostic
• of empyema necessitatis)

45
5. Pneumonia- Pyogenic Empyema Necessitatis

• Questions Rare chronic complication of
  pneumonia,
• decreased breath sounds, dull
  percussion on
• physical examination,
  vomiting, diarrhea?

46
6. Pyogenic abscess

• Pyogenic abscesses involving Staphylococcus or
  Klebsiella infection of the chest wall may also
  occur and may be due to central line or
  catheter-related sepsis in immunocompromise.
• Large multifocal lesions may develop .
• Question diarrhea, vomiting? Cough? No
  predisposing
• factor? Not multifocal mass?

47
7. Osteomyelitis Rib or sternum Nelson
17ed P2297

• Most cmmon in young children, more common in boy
  than girl(21)
• The majority of infection in otherwise healthy
  children are hematogeneous origin.
• Long bone is principlly involved in osteomyelitis
  (2.9 in chest bones)
• Blunt trauma, bacteremia, illness, malnutrition,
  immune system deficiency have been described as
  predisposing conditions.

48
7. Osteomyelitis

• Etiology S. aureus is the most frequently
  isolated pathogen excluding patients with
  hemoglobinopathies, such as SCD, where Salmonella
  sp. is more likely .
• Primary viral infections of bone are exceedingly
  rare, but accompanied viral syndrome, suggesting
  immune-mediated pathogenesis.
  Nelson 17ed P2298
• - Extremely rarely, the viruses which cause
  chickenpox and
• smallpox have been found to cause a viral
  osteomyelitis.
  
  

49
7. Osteomyelitis

• Clinical features may including chills,
  fever,chest pain,tenderness,swelling and erythema
  over the involved bone. Scand J Infect
  Dis 1999 31 98100.
• Insidious onset of nonspecific symptoms
  associated with gradual painful swelling over the
  bone area.
• Pediatr Infect Dis J 2001 20 54750

50
7. Osteomyelitis

• Diagosis
• -CBC leukocytosis with left shift, and a
  thrombocytosis may be present.Pediatric Clinics
  of North America 43 933-947, 1996
• -ESR and CRP are the nonspecific sign of
  inflammation.
• -Culture taken from the bone, either
  surgically or by needle aspiation.
• -CT or Three phases bone scan
• Question More insidious process? Chickenpox?
  Smallpox?

51
8. Strongyloidiasis (Strongyloides stercoralis)

52
8. Strongyloidosis (Strongyloides stercoralis)

Pulmonary disease secondary to larval migration
through the lung rarely occurs and may
resemble Löffler's syndrome (cough, wheezing,
shortness of breath, and transient pulmonary
infiltrates accompanied by eosinophilia).
Nelson 17ed P1160
53
Clinical manifestations of strongyloidiasis in
southern Taiwan.
J Microbiol
Immunol Infect - 01-MAR-2002 35(1) 29-36

• The most frequent clinical findings were diarrhea
  (74), fever (70), abdominal pain (59), cough
  (37), dyspnea (33), and constipation (26).
• The common initial laboratory abnormalities were
  leukocytosis (81), anemia (67), liver function
  impairment (52), and eosinophilia (44).
• Most of the patients had comorbid conditions,
  including malnutrition in 20 (74),
  corticosteroid dependence in 15 (55), chronic
  obstructive pulmonary disease in 9 (33), chronic
  liver disease or cirrhosis in 8 (30), and peptic
  ulcer disease in 7 (26).

54
8. Strongyloidosis (Strongyloides stercoralis)

• Question, no pruritus, absence of anemia, no
• peripheral hypereosinophilia,
  abdominal pain
• (common), chest pain (rare)

55
Final diagnosis

• 1. Pleurodynia (Dx. Procedureviral culture,
  histiologic examination by biopy)
• 2. Tietze syndrome (Dx. Procedure Biopsy PE
  Location)
• 3. Primary viral infectious osteomyelitis.
• (Dx. Procedure aspiration culture/ virus
  isolation, CT, bone scan)
• 4.Tuberculous abscesses (Dx. Procedure AFS, PCR
  or culture)

56
1. Chest pain

• Tender mass on fore-chest.
• Erythematous change ? Warm sensation?
• Precipitating factors trauma. Acute respiratory
• infection
  (cough, fever).
• exrcise? Weight lifting ?foreign body
  ingestion?caustic
• ingestion? Underlying illness Kawasaki
  disease, CHD?
• Family Hx of cardiac disease? Peptic ulcer
  disease?
• or rheumatoid disease?

57
1. Chest pain

• Cardiac involvement
• - Palpitation, dyspnea after climbing upstair
• -Risk factor
• FHx of myocardial infarction or
• hypercholesterolemia (-)
• CHD (-)or acquired heart disease
• Syncope (-)
• Pain with exercise (-)
• Hx of Kawasaki disease(-)

58
1. Chest pain

• Cardiac involvement
• -Physical finding
• Heart murmur(-), Persistent tachycardia(-),
  
• increased intensity of S2 (-), gallop
  rhythm(-),
• friction rub(-), or decreased femoral
  pulses(-).

59
1. Chest pain

• Cardiac involvement
• -Examination
• EKG Ventricular hypertrophy? ST-Twave change?
  
• Arrhythmia?
• CxR cardiomyopathy?

60
1. Chest pain

• Cardiac involvement possible idebtify
• -Coronary artery abnormalities
• -Arrhythmia
• -Cardiomyopathy
• -Myocarditis/ pericarditis
• -Outflow obstructions
• -Mitral valve prolapse

61
1. Chest pain

• Pulmonary involvement
• -Pain of muscle strain (related to cough)
• -Pleural irritation or pleurisy
• -Diaphragmatic irritation (pneumonia,
  bronchitis)
• -Asthma
• -Thoracic tumor
• -Foreign body aspiration
• -Pulmonary embolism
• -Mediastinal causes pneumomediastinum,
  mediastinitis, or tumor

62
1. Chest pain

• Pulmonary involvement
• -S/s cough, fever, short of breath.
• -Exam CxR?SaO2

63
1. Chest pain

• Musculoskeletal involvement
• Tender on palpation and Hx of chest injury
• -Muscle overuse (-)
• -Trauma () involving the pectoral, upper back
  or shoulder muscle.

64
1. Chest pain

• Musculoskeletal involvement possible identify
• -Muscle sprain.
• -Costochondritis
• -Slipping rib syndrome
• -Xiphoid process
• -Tietze syndrome

65
1. Chest pain

• Gastrointestinal involvement
• Watery diarrhea, Vomiting
• -Endoscopy ?
• -Upper GI series ?
• -pH probe study or trial of antacids ?

66
1. Chest pain

• Gastrointestinal involvement possible identify
• -Peptic ulcer disease
• -Esophagitis, esophageal spasm, foreign body
  in esophagus
• -gastritis
• -Caustic ingestizxons.
• -Others pancreatitis, cholecystitis,
  subdiapragmatic abscess

67
1. Chest pain

• Other cause of chest pain
• -Hyperventilation or stress
• -Lightheadness, dizziness, paresthesia,,
  chest pain
• -High anxiety, psychopathologic process
• -Thelarche
• -Gynecomastia
• -rare herpes zoster infection,
  nephrolithiasis, fibrocystic disease,
  adenocarcinoma of breast , chest syndrome of
  sickle cell disease

68

• cold chest wall mass may present a diagnostic
  challenge. The differential diagnosis of such a
  chest wall mass would include actinomyces, cold
  abscess due to Mycobacterium tuberculosis, or
  possibly malignancy.