S12.1 Case conference: A child with recurrent pneumonia
and abdominal distension
Presented by Academy of Medicine, Singapore
Chairperson: Professor Louis Chung-kai Low
President, Hong Kong College of Paediatricians
Professor, Department of Paediatrics, The University of Hong
Kong
Deputy Head, Department of Paediatrics & Adolescent Medicine,
The University of Hong Kong
Speaker: Professor Seng-hock Quak
MBBS MMed (Paediatrics) MD FRCP (Glas) FRCPCH FAMS
Associate Professor
Head of Department of Paediatrics, National University of
Singapore
Chief of Department of Paediatrics, The Children’s Medical
Institute, National University Hospital
Head & Senior Consultant, Paediatric Gastroenterology,
Hepatology and Liver Transplantation Services
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Synopsis
Quak Seng Hock, Department of Paediatrics, National University Hospital,
Singapore.
NZL was first referred to National University Hospital at the age of 2 years 8
months for abdominal distension. She was born at term by forceps delivery with
a birth weight of 3.33 kg. The parents were not consanguineous. The
peri-natal period was uneventful except for phototherapy of 2 day duration for
neonatal jaundice. She had her routine childhood vaccinations without problems.
Her developmental milestones were appropriate for her age.
Her problem started at the age of 23 months when she was admitted to the
paediatric surgery department for right thigh cellulitis with right inguinal
lymphadenitis. Intravenous ampicillin and cloxacillin were given and the cellulitis
subsided. No laboratory investigation was done.
One week later, she was
admitted to another hospital for vomiting and diarrhea. This was managed as for
acute gastroenteritis with dehydration. However, she developed frequent watery
stools with abdominal distension and was put on lactose free milk with some
improvement.
Her main complaint at 2 years 8 months was abdominal distension. Her weight
was 13.5 kg (25 th percentile), height 93 cm (25 th percentile). No pallor but
gaseous abdominal distension noted. No palpable mass. No organomegaly.
Hb 13.4 g/dl, WBC 4.32 x 10 9/L (N =72.2%, L = 11.9%, M = 11.3%, E = 4.2%, B =
0.5%). She was managed as for aerophagy with symptomatic treatment. Her
parents reported that she passed out a lot of gas everyday and she opened the
bowel 1-2 times daily. Her stools were reported as ‘soft and formed’. However,
her abdominal distension remained.
At 3 years 4 months, she was hospitalized in another hospital for some 12 days
for severe diarrhea and pneumonia. On further questioning, she had been
treated by general practitioners for multiple episodes of “bronchitis” in the past
few months.
She was hospitalized at about 4 years of age for another episode of pneumonia
and investigated:
WBC 10.54 x 10 9/L (N = 83.7%, L = 4.5%, M = 8.4%, E = 0.8%, B = 1.6%), Hb
15.4 g/dl, Platelet 350 x 10 9/L, Albumin 24 g/L, total bilirubin 2 µmol/L, AST 50 u/L,
ALT 41 u/L, ALP 140 u/L, LDH 609 u/L, IgG 3.48 g/L (4.20 – 10.90), IgA 0.621 g/L
(0.200 – 1.55), IgM 0.5 g/L (0.5- 1.9), Serum sodium 141 mmol/L, Potassium
3.3 mmol/L, Chloride 116 mmol/L, Bicarbonate 16 mmol/L, Urea 2.7 mmol/L,
creatinine 50 µmol/L, urine total protein 0.17 g/L (<0.20).CXR showed right middle
lobe pneumonia.
Further investigations were done and the diagnosis was confirmed.