The following report is a case of severe malnutrion with bronchopneumonia and sepsis in a child who was treated at the Pediatric Department of the Prof

Case Report With all due respect to :

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to be presented on 9th Mei 2011

PERFORATED APPENDICITISandTETRALOGY of FALLOT in a Child

ByChristie Moningkey

Supervisor

Dr. David Kaunang, SpA(K)

Departement of Child HealthMedical School of Sam Ratulangi UniversityProf. Dr R.D. Kandou General HospitalManado2011INTRODUCTION

The acute abdomen refers to the clinical situation in which an acute change in the condition of the intra abdominal organs, usually related to inflammation or infection, demands immediate and accurate diagnosis. Acute abdominal pain is one of the most frequently encountered symptoms in patients seeking emergency department attention and is the most common presenting complaint in patients with surgical diseases of the abdomen. From the surgical point of view acute abdominal pain is the cardinal symptom of acute abdomen.1 Causes of abdominal pain in children 6 to 12 years of age could be associated with constipation, appendicitis, gastroenteritis, urinary tract infection or trauma.2Appendicitis is an inflammation or infection on the appendix, a small structure that is attached to the large intestine and serves an unknown purpose. It can easily become inflamed, usually after a piece of stool or food is trapped inside. Once inflamed, the appendix will swell, become infected and cause pain.3 Acute appendicitis was found to be the most common cause of acute abdomen, accounting for approximately 80% of emergency cases. Appendicitis has a male to female ratio of 3:2 .4 The most common symptom of appendicitis is acute and severe abdominal pain, especially on lower right. This symptom can be accompanied by other symptoms such as nausea, vomiting, abdominal swelling, constipation, inability to pass gas, low grade fever, and diarrhea. It is important to realize that in younger children with appendicitis may not have classic symptom, which lead to a higher rate of late and misdiagnosis in that age group. So, parents awareness for an unusual abdominal pain in their children was necessary.3,5Acute appendicitis needs immediate surgery. What the surgeon done is open the abdominal wall to remove the inflamed appendix. It is usually not a difficult procedure, if there was not complication.3 The complications of appendicitis include appendicular perforation, appendicular mass, appendicular abscess, gangrene of appendix with perforation resulting in peritonitis, portal pyemia leading to liver abscess and intestinal obstruction.5,6Tetralogy of Fallot represents approximately 10% of cases of congenital heart disease and is the common cause of cyanotic congenital heart disease. In 1888, Fallot described the anatomy as consisting of pulmonary artery stenosis, ventricular septal defect (VSD), deviation of the aortic origin to the right, and right ventricular hypertrophy.7 The cause of tetralogy of Fallot is unknown. This is probably related, to among others, rubella virus infection, coxsackie viruses, radiation and other diseases suffered by the mother during pregnancy. Other risk factors are maternal alcoholism, poor maternal nutrition, maternal of above age> 40 years old, the mother suffered from diabetes and family history of suffering from tetralogy Fallot.8, 9-11Clinical manifestations of Tetralogy Fallot reflect the degree of hypoxia. At the time when newborn babies are born, it is not usually sianotic. Babies begin to look blue after bisth. If the degree of stenosis increases, it will give rise to cyanosis. Finger percussion on most of the patients has started to appear after the age of 6 months. One important manifestation of tetralogy of Fallot is sianotik attack, which is characterized by sudden onset of shortness of breath, rapid breathing and deep, increasing cyanosis, weakness, and which can even be accompanied by seizures or syncope. Severe attacks can end in coma and even death. In children there are major symptoms of squatting (squatting) after patients doing some activities.12,13In infants of normal breast, but in older children may stand out due to right ventricular dilation. The first heart sound is normal, second heart sound is usually single. There is a loud ejection of systolic pulmonary region, which is weakened more and more as the degrees of obstruction increase.12,13In tetralogy of Fallot, it is found that an increase in hemoglobin and hematocrit is in accordance with the degree of desaturation and stenosis . Patients with tetralogy of Fallot with normal or low hemoglobin and hematocrit levels may suffer from iron deficiency. Generally, the heart does not enlarge. Located on the right aortic arch in 25% of cases. Small and elevated cardiac apex, pulmonary conical concave, and decreased pulmonary vascularity (picture of heart shoes). In the neonatal, ECG is not much different from normal children. In children, the T wave may be positive in V1, with QRS axis deviation to right and right ventricular hypertrophy. P wave is in high-conductivity II (P pulmonic).12,13Early diagnosis is very important in the handling of tetralogy of Fallot. Diagnosis based on history, physical examination, laboratory, chest radiograph, electrocardiography, echocardiography until catheterization cardiac.10,12

The following report is a case of Acute Appendicitis with Tetralogy of Fallot in a child who was treated at the Pediatric Department of the Prof. Kandou General Hospital Manado.

CASE REPORT

ZM an Indonesian boy, Minahasa tribe, 4 years 11 months old, was admitted to the Department of Child Health, Prof. Kandou General Hospital Manado on March 26th, 2011 with the main complaints of green vomiting, abdominal pain on the right lower and bluish in the fingers, toes and lips.

History of illness (given by his mother)The patients experienced green vomiting since 3 days before admission. Vomiting occurs 3 times a day with a volume of approximately 1/4 cup aqua. Patient experienced the abdominal pain since 3 days before admission. Initially, abdominal pain was felt in the pit of the stomach and then spread to the lower right abdomen. The abdominal pain was felt continuously. The patient has not been defecating and farting since 2 days before admission. The patients had fever since 3 days ago, it was high, continuous, and decrease with antipyretic drugs. No seizures and no chills was found. At this time the patient had no fever. Patients had also experienced blue on fingertips, toes and lips since infant. Since infant also patients expierenced shortening of breath or tiredness when drinking milk. When making excessive activity or after exercise, the patient feels tired, and was decreased by the squat position. Patients also looked pale but so far the parents did not notice any paleness in the patients. There was no abnormalities found in the urination.

History of prenatal care and birthDuring the pregnancy, her mother had regular antenatal care and had tetanus toxoid immunization twice. This patient was born spontaneously by a midwife, head presentation, immediately cried, aterm, no cord coil, no meconium stained, no jaundice, and cyanosis on the fingertips, toes and lips. Birth weight was approximately 3500 grams.

History of past illnessCoughing, shortness of breath and bluish repeated on the fingertips, toes and lips already experienced by patients from infancy. He also had diarrhea and common cold.

Developmental milestonesSocial smile: 3 monthsTurning in prone position: 5 monthsSitting: 7 monthsCrawling: 9 monthsStanding: 10 monthsCalling mama/papa: 12 monthsWalking: 11 months

History of feedingBreast feeding: birth 3 monthsMilk formula: 3 2 yearsMilk formula + Milk porridge: 2 3 monthsSoft rice porridge: 3 10 monthsSoft rice: 11 months now

ImmunizationShe received basic immunization completely as recommended

Pedigree

= the patient

Social, Economic and Environmental conditionsHe is the second boy in the family. His mother is 29 years old, has a high school graduation, works as a housewife. His father is 31 years old, a high school graduation, works as a swasta. Their house is a permanent house with toilet and bathroom inside the house, 2 rooms occupied by 4 adults and 2 children. The electricity source is from PLN and drinking water from deep well. Garbage is burned regularly.

Physical Examination (March 26th, 2011)General conditions : Look sick, compos mentis Body weight 13 kg Body height 98 cm BMI z-Score : 13,53 (Kg/m2) Good nutritional statusVital signs: Blood pressure: 90/60 mmHg Pulse rate: 120 x/min Respiratory rate: 32 x/min Temperature: 37.2 CHead: oval shape, thin hairEyes: conjunctiva anemia +/+, sclera icterus -/- pupil isochor with diameter 3 mm, responds to lightsEars: no secretesNose: no secretes, no nasal flaring.Mouth: cyanosis lips (+), no dental caries, tonsils T1/T1 without inflammatory sign, pharynx without inflammatory signNeck: no lymph node enlargementChest: symmetrical respiratory movements, no retractionHeart: heart rate : 120 x/m, regular There was a loud systolic ejection grade IV/6 PM ICS II-III linea para sternal sinistra Lungs : bronchovesicular breath sound, no rales, no wheezing.Abdomen: flat, soft, with decreased bowel sound, tenderness (+) Psoas sign (+), Obturator sign (-), Darm countur (-) lever and spleen was not palpableExtremities: warm, capillary refill time less than 2 seconds, clubbing finger (+), cyanosis on the fingertips and toes (+)Genitalia: male, no abnormalityRT: Sphincter was tight, ampulla fulled with feces, no pain, no mass

Laboratory DDR: (-) Hemoglobin: 14.2 g/dL Hematocrit: 41.5% Leukocyte: 14300/mm3 Thrombocyte: 260000/mm3 Electrolyte: Sodium: 129 mEq/L Potassium: 3.3 mEq/L Chloride: 100 mEq/L

Urinalisis- Specific Gravity: 1.015- pH: 6.0- leukocyte: 0-1- eritrocyte: 0-1- epithel: (+)- nitrite: (-)

Working diagnosis Suspect acute appendicitis Suspect Congenital Heart Disease (CHD) Cyanotic Electrolyte Imbalance (Na.129, K.3.3)

Treatment IVFD RL (Darrow) 46 ml/hour = 15-16 gtt/min Inj. Cefotaxime 3x500 mg iv Aspar K 3x325 mg pulv Oral aff Cross match plan for transfusePlanning Consult to surgery department Consult to division of pediatric cardiology Thorax photo EKG

Result : Cardiomegaly CTR : 63 %

EKG

At. 09.30 am Result consult from surgery departement :Dx : Acute appendicitisAssessment : Appendectomy Cito Result consult from division of pediatric cardiologyDx : Congenital Heart Disease (CHD) Cyanotic ec Suspect Tetralogy of fallotAssessment : - Patients should be operated with any risk- EKG Normal limit- Check complete blood after surgery, if Hb