Case discussion Case HistoryCase5yrs girl, Born in Hangzhou.Chief complaintCough x 5 d, and Fever x 3dHPI5 days ago, She developed non productive cough.Light cough, non productive, no tachypnea, no wheeze.3 days ago, She developed fever Max temperature is 40.3, 1-2 peaks/ day, usually at night Lethargy while fever, but refresh when fever gone. Cough became severe, and still nonproductiveTreated with cefaclor for 3 d without improvement. Poor appetite, sleep not well, no vomiting/ diarrhea, Past HistoryHealthyReceived routine Immunizations including BCG immunizationNo history of contact with active TB Birth History G2P2, 40+1wks, BW 3.78 KgFamily HistoryParents healthy Physical ExaminationGeneral: looked well, well perfusionVitals: T 40.8, P 130bpm, RR 42/pm, SpO2 88%, Chest: No rales on both sides CVS: normal heart sound, no heart murmurAbdomen: soft, flat, no mass, normal liver Neuro: normalSkin: no rashWhats your impression?Preliminary diagnosisPneumoniaBasis?Cough and fever; tachypneaConfirmation?Chest X-rayLabBlood WBC+DC： WBC 9.5109/L N 67% L32% Hb 118g/L PLT 138109/LCRP 20mg/L(normally 8)And then?Evaluation before treatmentDifferential diagnosisPossible pathogenSeverity and complications Basal condition( high-risk factors)Differential diagnosisBronchitis Pulmonary TuberculosisForeign bodies in trachea and bronchusEvaluation before treatmentDifferential diagnosisPossible pathogenSeverity and complications Basal condition( high-risk factors)Common pathogens for CAPBacteria VirusesAtypical OthersClinical features-RSV Bronchiolitis2 year with peak incidence 26 mPeak incidence in cold seasonsNo fever or low to moderate feverRhinorrhea and pharyngitis followed by nonproductive cough episodic wheezing (Bronchiolitis)Signs of expiratory dyspnea： prolonged expiratory time and wheezingEmphysemaAdenoviral pneumoniaPeak incidence 6 m2 yAbrupt onset and continued high fever Toxic with neurological disturbances earlySevere cough, dyspnea and wheezingRales and wheezing not detectable until 3 to 7 days after the onset of high fever. Adenoviral pneumoniaStaphylococcal aureusPeak incidence in infantsAbrupt onset and rapid progressionHigh fever, dyspnea and toxic appearanceSome accompanied by gastrointestinal disturbance, scarlet fever-like rashScattered rales being detectable earlyMPPeak incidence in school-aged childrenGradual onset of fever, rhinorrhea, and sore throat followed by coughOlder children: persistent fever and irritative, nonproductive cough with frothy white sputumfine moist rales usually lacking Young children: severe dyspnea, wheezingMP pneumoniaEvaluation before treatmentDifferential diagnosisPossible pathogen?Mycoplasma pneumoniaePreschool-aged child, fever and nonproductive cough, normal WBC, increased CRP, no improvement with cefaclor)Evaluation before treatmentDifferential diagnosisPossible pathogenSeverity and complicationsDetermining site of treatment (clinic, home or hospitalization) selection of antibioticsroute of administrationSeverity evaluation IDSA 2011Severity evaluationIDSA 2011Severity evaluationChina Guideline 2007Severity evaluation: severe?High feverTachypnea (RR 42/pm age 5)SpO2 88% on room airAny complications?Evaluation before treatmentDifferential diagnosisPossible pathogenSeverity and complications Basal condition ( high-risk factors)Basal conditionsHigh-risk factorsPreterm, neonate, LBWMalnutritionCHDPrimary or secondary immunosuppressionBasis of empirical therapy(preliminary evaluation)Impression: PneumoniaPossible pathogen: MPSeverity: severe, No complications?High-risk factors: NoEmpirical therapySite of treatment: ?Antibiotics:?Administration: ?Symptomatic therapy: ?Empirical therapyHospitalizationMacrolide antibioticsIntravenous administrationSymptomatic therapy: O2Whats next?Empirical therapyFurther investigation?Etiological investigationSeverity monitoringEtiological investigationetiologic investigation?MP: sputum MP-DNA PCR and serum MP-IgMSputum bacterium cultureVirus antigen detection by DFA (direct fluorescence antibody )Severity monitorBlood gas analysisOrgan injury and dysfunctionChest CT (complication)Summary1Evaluation before treatmentDifferential diagnosisPossible pathogenSeverity and complications Basal condition( high-risk factors)Summary2Empirical therapyBased on preliminary evaluationFurther investigation?Etiological investigationSeverity monitoringThanks!