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01-10-09, 11:21 PM
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Pneumonia in a 3-Year-Old Boy After Falling Into a Well
A 3-year-old boy is presented to the emergency department (ED) of a regional hospital in northeast Thailand 4 days after falling into a well. He was found by his brother, who went looking for him after he could no longer hear the sound of the boy playing. The boy is not able to swim. Although the patient's relatives estimate that he was in the water for no longer than 5 minutes, they believe that he may have aspirated a significant amount of water. He did not lose consciousness and appeared to recover completely within minutes of being rescued. Three days later, however, the boy developed a fever and cough, and he was noted to be more drowsy than usual; these symptoms prompted his family to bring him to the ED. The child has never been to a hospital before, is normally fit and well, and is on no regular medications. The patient comes from a family of rice farmers and often plays in the paddy fields near his home. Both parents and siblings are well-appearing, and there is no family history of diabetes, thalassemia, or renal disease.

On physical examination, the boy is noted to be drowsy, but he is obeying instructions from his mother. His temperature is 102ºF (38.9ºC), his respiratory rate is 36 breaths/min, and his pulse rate is 132 bpm and regular. The patient's blood pressure is not recorded, and a pulse oximetry reading is not available in this setting (because of a lack of equipment). He is not clinically cyanotic or jaundiced, and there are no peripheral signs of chronic disease. The patient is noted to have a moderately increased work of breathing, with use of the accessory muscles of respiration; in addition, widespread fine crackles are audible over the chest bilaterally. The heart sounds are normal, with no rubs or murmurs. There is no palpable lymphadenopathy, no visible skin lesions, and no palpable organomegaly. The abdominal examination is unremarkable.

The patient is placed on supplemental oxygen, which leads to some improvement in his respiratory status. An intravenous (IV) line is placed and initial laboratory investigations are performed. The results of the investigations show a blood count with a hemoglobin of 8.7 g/dL (87 g/L), a mean corpuscular volume of 60.1 µm3 (60.1 fL), a platelet count of 196 × 103/µL (196 × 109/L), and a total white blood cell (WBC) count of 4.51 × 103/μL (4.51 × 109/L; 53% neutrophils [0.53], 32% lymphocytes [0.32], and 12% monocytes [0.12]). On a complete chemistry panel, he is noted to have a sodium of 134 mEq/L (134 mmol/L), a potassium of 3.0 mEq/L (3.0 mmol/L), a chloride of 98 mEq/L (98 mmol/L), a bicarbonate of 24 mEq/L (24 mmol/L), a blood urea nitrogen (BUN) of 8 mg/dL (2.9 mmol/L), and a creatinine of 0.3 mg/dL (26.5 µmol/L). No arterial blood gas or glucose measurements are available. The admission chest radiograph (Figure 1) demonstrates bilateral diffuse infiltrates. The decision is made to initiate broad spectrum antibiotic therapy, with intravenous ceftriaxone and metronidazole, and the patient is admitted to the hospital.

What common soil-borne disease must be covered by the empirical antimicrobial therapy for this patient?
Hint: Note the contact with surface water and that the location is in northeast Thailand.
a. Burkholderia pseudomallei
b. Salmonella enterica serotype typhi
c. Vibrio cholerae
d. Streptococcus pneumoniae
e. Klebsiella pneumoniae

01-10-09, 11:23 PM
Here is Figure

01-10-09, 11:26 PM
Answer a is correct!
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