CASE SENARIOS, SLIDES AND DATA INTERPETATION (1) By Dr: ATTALLAH ABDULLAH AL MUTAIRY Consultant pediatric intensivist Head PICU 25/05/1436 (1) Rasheed was a full term baby boy presented with severe respiratory distress [RD] and cyanosis, immediately after birth, which required endo-tracheal intubation [ETI]. He required immediate intubation and mechanical ventilation. His AP chest X-ray film at that time is shown. (A)- Describe the radiological abnormality. (B)- What is your most likely diagnosis? (C)- What are your differential diagnosis? (D) - What are your treatment lines? (2) Ahmed is 12 year-old male who has been healthy. He presented to our ER with severe RD and near collapse after being beaten by one of his college in the school. He sustained a blunt trauma to the center of his abdomen. A nasogastric tube [NGT] was inserted and his AP chest X-ray film was taken and is shown below. (A)- Describe the radiological abnormalities. (B) - What is your most likely diagnosis? (3) Hytham is a 6 week-old female infant who had an episode of acute viral bronchiolitis with down-hell, rapid deterioration. He required high frequency oscillatory ventilation [HFOV] and inhaled nitric oxide [iNO]. At the onset of deterioration, his AP chest X-ray film is shown. (A) - Describe the radiological abnormality. (B) - What is your most likely diagnosis? (C) - What are the most common causes of such diagnosis? (4) Maram is an 8 month-old Jordanian female who had cardiopulmonary arrest [CPA] after a prolonged seizure [status epilepticus]. She was resuscitated successfully. She was put nothing per oral [NPO] and managed accordingly. After 48 hours of the CPA, NGT feeding was started and upgraded quickly. Twelve hours later, she developed vomiting, tense and rigid abdomen. Her bowel sounds were absent. She developed unstable vital signs and went in shock. Her AP erect, plain abdominal X-ray film is shown. (A)-Describe the radiological abnormality. (B) - What is your diagnosis? (C)- What is the cause of such a diagnosis? (D)- Can it be prevented? (5) Nihal is a 5 month-old Egyptain female who was born prematurely at 28 weeks of gestation and developed severe RDS or HMD, for which she received 2 doses of exogenous surfactant and required 8 weeks of high settings ventilatory support. She had grade (II) retinopathy of prematurity [ROP], which resolved spontaneously. On routine daily examination in the nursery, she was found to have painful swelling over the middle part of her left legs She was, also, found to have rachitic rosary and harrison sulci. She had no preceding Traumas and she was not handled roughly. The other parts of systemic examination (apart from the signs of prematurity complications) was un-revealing. The lateral plain X-ray film of her thigh, knee joint and left leg is shown. (A) What is the radiological finding shown? (B) What is the most likely cause? (C) How to treat? (6) Bodoor is a 9 year-old female who is know to have Middle East Syndrome (Sanjad- Saqqati Syndrome). She presented acutely to hour hospital with status epilepticus which was difficult to control. As a part of her evaluation, CT brain was done and is shown. She was find to have a Ca level of 1.45 mmol/L (the ionized fraction was 0.67 mmol/L). Her serum albumin level was 19 g/dl. As a part of her seizure investigation, CT brain was done and is shown. (A) Describe your abnormal findings in CT brain. (B) How much is her corrected Calcium level? (B) What could be the cause of such abnormal CT brain findings in this particular case? CASE 7 CASE 8 CASE 9 CASE 12 CASE 13 (4) TAIF is a 9 month-old Saudi female infant who presented with fever and SOB for 3 days. She was diagnosed as viral bronchiolitis. She was admitted to the ward and managed accordingly, however, she deteriorated rapidly over a short period of time and developed progressive RD and pulmonary hemorrhage. On examination, GCS; 10/15. She was jaundiced and her liver was 6 cm BCM and tender. Her tone was increased bilaterally and her DTRs were exaggerated. No other relevant points in the history or examination. She required immediate intubation and ventilator support with high settings using the inverse ratio ventilation [IRV], which creates a high intra-thoracic mean airway pressure [MAP]. Her vital signs on ventilator were; T; 38 C (armpit), HR; 70 bpm, RR; 45 bpm (paralyzed, sedated on the ventilator), BP; 165/95 (MABP = 120 mm Hg) and her SpO2 on 100 % of FiO2 was only 85 %. Her CBC revealed; WBCs; (55 % polymorphs), Hb; 11 g/dl, platelets; 35000/mm, CRP; 2.5 mg/dl, ESR; 17 mm/h, BUN; 15 mmol/L, creatinine, 179 micromol/L, Na; 146 mmol/L, K, 5.8 mmol/L, Ca; 2.2 mmol/L and PO4 of 2.2 mmol/L. Her LFTs and coagulation profile were; AST; 4760 U/L, ALT; 3950 U/L, serum amonia; 450 mg/dl, serum albumin; 19 g/L, PT; 63 seconds, aPTT; 65 s and INR of 2. On day 3 on ventilator, she was noticed to have a lump in her left neck (4 X 3 cm). It was soft and compressible with crepitus. Her AP chest X-ray film at that time is shown. CASE 14 (A)- Intercept the laboratory blood tests and what they indicate. (B)- What are the radiological findings shown and what are their explanation? (C)- What are the treatment of such radiological abnormalities? (D)- How to treat her other organ involvement (if any)? (15) Nawaz was a 3 month-old male who was admitted with acute viral bronchiolitis. He was managed accordingly with IVF, O2 therapy and bronchodilators with suctioning. On the 4 th day of admission at 12:00 non, he develop sudden onset of increasing RD, cyanosis and desaturation. He was found to be hypotensive. AP chest X-ray film at the time is shown. CASE 15 A.Describe the abnormality shown on the X-ray. B.What is your diagnosis? C.Is this expected in a patient with acute viral bronchiolitis and Why? D.What are the physical finding which may be apparent on the physical examination? E.Mention a very non invasive and rapid and bed side test which may make your diagnosis is very likely. F.What is the immediate treatment? (3) Maryam is an 18 month-old female presented with fever and abdominal pain for 3 days duration. She used to have recurrent and unexplained fever since early infancy. She, also, used to fall sick with low grade fever every 4 6 weeks. She failed to gain weight and grow like her other siblings. She has one documented episode of acute pyelonephritis, for which she required 2 weeks of in-patient hospital admission and IV antibiotics for 10 days. No other historical point of note. On physical examination, she looks unwell, under-built (weight < 3 th percentile for age). There was flank tenderness on the right renal angle. Her vital signs were; T; 38.9 C (armpit), HR; 145 bpm, RR; 25 bpm and BP of 110/65 (MABP = 80 mm Hg). Her CBC and differential count revealed; WBCs; 27400/mm3 (83 % polymorphs), Hb; 8 g/dl and platelets count of /mm3. Her CRP was 17 mg/dl and her ESR was 87 mm/h. Her RFTs and serum electrolytes were; BUN; 6.5 mmol/L, creatinine, 67 micmol/L, Na; 146 mmol/, K; 5.5 mmol/L, Ca; 2.4 mmol/L and PO4 of 2 mmol/L. The urine analysis and urine culture and sensitivity [C/S] results are pending. Among her radiological tests which was ordered is the one shown below. (A) What is the radiological investigation shown? (B) What is the abnormal finding shown? (C) What you expect to find in her urine analysis? (D) What is the explanation of Maryam chronic illness? (E) What are the other workup and investigations you are going to perform? THANK YOU