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Chapter 40. Lower Respiratory Tract Infections in Children

A 3-month-old infant is seen in the emergency department with copious nasal drainage, cough, fever, wheezing, and respiratory distress. Pulse oximetry in room air shows SaO2 = 88%. A nasopharyngeal swab by immunofluorescent technique is positive for RSV. The patient is admitted for further observation. Which of the following treatments is most likely to be beneficial in this patient?

a. Aerosolized albuterol

b. Intravenous ampicillin plus gentamicin

c. Supplemental oxygen

d. Systemic corticosteroids

e. Aerosolized ribavirin

The most correct answer is c, supplemental oxygen.

Comfort measures predominate in the treatment of RSV bronchiolitis. Randomized clinical trials and Cochrane Database Reviews have not found any evidence for the benefits of bronchodilator therapy, corticosteroids, or nebulized ribavirin in pediatric bronchiolitis. In some circumstances, infants with a history of atopy or a strong family history of asthma or atopy (mother or father) may improve with albuterol. There is no indication for antibiotic therapy in the treatment of viral respiratory infections.

A 14-year-old boy is seen in an outpatient setting complaining of fatigue and fever for a week, with a dry cough beginning two days before the visit. On auscultation, crackles are heard over both lung fields. Mycoplasma infection is suspected. If true, which of the following would be an unusual coincident finding?

a. Maculopapular rash

b. Close contacts with respiratory illness

c. Positive cold agglutinin titers

d. Diffuse bilateral infiltrates on chest radiograph

e. Lobar pneumonia on chest radiograph

The most correct answer is e, lobar pneumonia.

About 10% of patients with Mycoplasma disease have a concomitant maculopapular rash in the course of their illness. Mycoplasma is highly communicable so that it is often passed from household member to household member or from classmate to classmate. Cold agglutinin titers at >1:32 occur in about one-half of patients with Mycoplasma pneumonia. The typical radiographic pattern is one of diffuse pulmonary infiltrates and not lobar consolidation.

An 11-year-old girl is admitted to the hospital with fever, shaking chills, chest pain, and hypoxia. A chest radiograph shows a right lower lobe pneumonia and the chest exam shows decreased breath sounds in the right base. A blood culture obtained on admission is positive for S. pneumoniae, sensitive to penicillin. The patient is treated with intravenous ampicillin, but the fever and oxygen requirement ...

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