Severe Pneumonia in Sickle Cell Disease with Vaso-Occlusive Crisis

• IV PCM 500mg 8 hourly for 2 days.
• IV Cef-SB 1g once daily for 3 days.
• Blood transfusion with packed cells 350ml.
• IV R/L 500mls in 2 hours.
• Syrup Ascorils 5ml 8 hourly.
• Tab folic acid 1 tab once daily.
• Oxygen therapy 5 litres/minute.

Monitoring/Progress:

• Admission SpO₂ was 80% on room air.
• SpO₂ improved to 99% on oxygen.
• Persistent lower limb pain was noted throughout the night.
• At 6:00 AM, SpO₂ was 94% on room air.

• Do CXR.
• IV fluids N/S 400mls 8 hourly.
• IV D10% 120mls 8 hourly.
• Tabs azithromycin 500mg for 3 days.
• IV PCM 360mg 8 hourly for 2 days.
• Alternate IV PCM with P.O morphine 5mls 8 hourly for 1 day.
• Tbs bisacodyl 5mg once daily for 3 days.

Monitoring/Progress:

• Pain persisted throughout the day and night.
• Nursing care and CXR were completed.
• Patient was transfused at 6PM, but no formal prescription was seen in the records.

• Do urinalysis.
• IV R/L 400mls 8 hourly.
• ORS PRN.
• IV gentamicin 120mg once daily.
• Continue ceftriaxone and azithromycin.
• IV Dynapar 37.5mg alternating with IV PCM.
• Tabs Grovit 1 tab BD for 5 days.

Evening Round:

• A lot of body pain was noted, but not scored.
• Oral morphine 5mls 6 hourly.
• Diclofenac gel 8 hourly.
• Bisacodyl 5mg.

Monitoring/Progress:

• SPO2 was 85% on room air.
• PR 122/min, RR 38/min.
• Post-transfusion Hb 10.2 g/dL.
• WBC 97,000 and ANC 24,000.

Diagnosis/Impression: Resolving ACS.

Management:

• Hold all iron syrups and tablets that the mother had prior to admission.
• Hold gentamicin.
• Keep on oxygen.
• Follow up urinalysis.

Monitoring/Progress:

• Child was ambulating but limited by limb pains.
• Tea-coloured urine noted.
• Reduced appetite.
• SPO2 86% on room air.
• Hyperactive precordium.
• Chest clear with mild chest indrawing.

Diagnosis/Impression: SCA with severe pneumonia, VOC, sepsis and hemolytic crisis.

Paediatrician’s Management Plan:

• Continue treatment.
• Transfuse till Hb 10 with 360ml packed cells.
• Hydrocortisone 50mg before transfusion.
• Repeat CBC.
• Plan to do workup and re-initiate HU on discharge.

Monitoring/Progress:

• Hypoxia, low Hb, worsening septic markers, distress and haemoglobinuria noted.
• Urinalysis: glucose +, proteins +, blood +.
• CBC: WBC 97,930; ANC# 16,650; Lymp 76,780; Mono 4,020; Hb 7.0 g/dL; PLT 133,000.
• Hepatomegaly extending to epigastrium with generalized tenderness.
• Crepitations in the left lung.

Diagnosis/Impression: Resolving ACS, VOC and hemolytic syndrome.

Management:

• Encourage plenty of oral fluids.
• Blood transfusion done after repeat CBC.

Monitoring/Progress:

• Still in pains.
• On oxygen.
• Passing tea-coloured urine.
• Very low appetite.
• RR 21 cycles.
• SPO2 99% on oxygen.
• PR 101/min.
• Bilateral equal air entry.
• Chest clear.
• CBC repeated: WBC 79.9, ANC# 12.96, Hb 7.9.

Diagnosis/Impression: Severe pneumonia, VOC, ACS and hemolytic crisis.

Management:

• Continue treatment.
• Encourage oral feeding.

Monitoring/Progress:

• Child on oxygen.
• Passing tea-coloured urine.
• Still had abdominal pain.
• Sick-looking but alert.
• SPO2 90% on room air.
• Basal crepitations in right lung.
• Generalized abdominal tenderness.
• No organomegaly.

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Day 6 on Ward — Doctor’s Review

Diagnosis/Impression: VOC, ACS, hemolytic crisis, resolving anemia and ?AGN.

Management:

• Tab zinc 20mg once daily for 10 days.
• Do CBC.
• Stool GeneXpert.
• Repeat urinalysis.
• Continue oxygen.
• Consult paediatrician on adding fluconazole.

Monitoring/Progress:

• SPO2 92% off oxygen.
• Persistent cough.
• Not in active distress.
• Still passing tea-coloured urine.
• Tender cephalohematoma noted.
• Bilateral equal air entry.
• Tender hepatomegaly.

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Repeat Investigations After Day 6 Review

CBC:

• WBC 76.07.
• ANC# 13.55.
• Lymp 58.05.
• Mono 4.1.
• Hb 10.1 g/dL.
• PLT 141.

Urinalysis:

• 10–15 pus cells.
• Proteins +.
• Glucose not detected.

Other Tests:

• Stool GeneXpert negative for MTB.
• RFTs normal.
• LFTs: ALP ×9, AST ×2.5, direct bilirubin 1.65.
• HIV negative.

Diagnosis/Impression: Resolving pneumonia and septicaemia.

Paediatrician’s Management Plan:

• IV Flucamox 600mg 8 hourly.
• Try weaning off oxygen the next day.
• Initiate on HU.
• Hold fluids.
• Hold IV PCM and Dynapar.
• Tab Ibumex 300mg 8 hourly.

Monitoring/Progress:

• Child still had distress and hyperleukocytosis.
• Hb 10.1 g/dL.
• Residual pain on the thigh.
• A+, J+.
• Tachypneic.
• B/V sounds bilaterally.
• Tender hepatomegaly.
• CNS: actively moving all limbs.

Clinical Note: Much better on treatment. Flucamox was out of stock.

Management:

• IV cloxacillin 600mg 6 hourly.
• Evening round: Fluconazole tab 200mg BD was also out of stock.

Monitoring/Progress:

• At night, child spiked fevers with increased neck pain.

Management:

• Workup for hydroxyurea reviewed.
• Continue antibiotics.
• Continue oral analgesics.
• Hydroxyurea to be initiated at 500mg once daily, 7 days a week.

Monitoring/Progress:

• Fevers reported throughout the night.
• SPO2 94% on room air.
• PR 115 bpm.
• Good lung expansion; child could blow very well in the balloon.
• At night, fevers spiked again.

Clinical Impression: Improvement noted, no more pain, but fever spikes at night and dry cough persisted.

Management:

• Do CBC.
• Syrup Mucolex 5ml BD.

Monitoring/Progress:

• SPO2 96% on room air.
• Afebrile.
• Poor nutrition status.
• CBC: WBC 40.45, ANC 18.37, Lymp 18.45, Hb 9 g/dL, PLT 411.
• At night, fevers with hip pain.
• Fevers persisted throughout the morning with severe painful limbs and joints.

Diagnosis/Impression: Resolving ACS with septicaemia.

Management:

• For paediatrician review.

Monitoring/Progress:

• Fair condition.
• Spiking fevers at night with limb pains.
• Afebrile during review.
• No jaundice.
• Mild pallor.
• SPO2 95% on room air.
• PR 118 bpm.

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Day 11 — Paediatrician’s Review

Clinical Impression/Concerns: Spiking fevers, elevated WBC/ANC, ALP >1000, wasting, persistent cough, bilateral hip pain and bronchial breathing on the right side.

Management Plan:

• Repeat B/S.
• Hep B screen done: negative.
• IV Cef-SB 1.9g OD.
• IV cloxacillin 600mg 8 hourly for 3 days.
• Tabs Calcivita 1 tab daily for 2 weeks.
• Repeat ALP in one month.
• Start hydroxyurea on discharge if ANC >2, PLT normal and Hb >6.

Key Constraints:

• Financial limitations.
• Calcium and phosphate labs deferred.
• Antibiotics adjusted to Cef-SB plus cloxacillin instead of meropenem.

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Day 11 — Evening Round and Psychosocial Support

Management/Intervention:

• Counseling provided to mother on disease and interventions.

Monitoring/Progress:

• Child still weak.
• Coughing with hip and joint pains.
• B/S showed no mps seen.
• Nurse reported that the mother was psychologically sick.
• Mother confessed that the child was sick for a week before seeking care due to financial constraints.
• Mother appreciated the relevance of hydroxyurea.

Diagnosis/Impression: Resolving ACS.

Management:

• Syrup Ascoril.
• Continue other care.
• Discharge the following day if no fevers.

Monitoring/Progress:

• Better.
• No fevers.
• Actively coughing.
• Ambulatory.
• Eating well.
• Evening round: no fevers, child stable.

Discharge Medications and Plan:

• Tabs amoxiclav 375mg BD for 5 days.
• Tabs Dynapar 1 tab 8 hourly for 5 days.
• Syrup Mucolex 5mls 8 hourly for 5 days.
• Caps HU 500mg once daily, received for free from external program.
• Continue other care.
• Review after 6 days.