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Pleuritis in a young male

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This is gonna be a little different than a normal scenario, as I do not have the final diagnosis. I just thought this was an interesting case, and it was fun going through the differential diagnosis.

A 16y/o 155lb male was shoveling a bin of old oats at 1400hrs. There was some mould in the bin, as well as rats/mice. He was not wearing a mask.

At 1800hrs he had sudden onset pleuritis and SOB.

His mother gave him an advil (500mg) and told him to lay down.

At 1830 the pleuritis became worse (9/10) and he was notably tachypneic due to splinting his breathing. He was quite lethargic and generally weak.

His mother brought him to the ER:

HR: 140

BP 90/42

Temp 39.8

RR 36

Sp02 98% room air

Skin diaphoretic & flushed

A&O X4

9/10 chest pain midsternal nonradiating pleuritic in nature.

Auscltation= quiet on the left, but clear. Right apex clear but some crackles noted in the base. Overall, very hard to hear bases as patient will not take full breaths.

Pt was given 1G Tylenol, and fever was gone within 30min. A 500ml bolus was administered and vitals changed to:

HR 110

BP 100/44

Temp 36.4

RR 36

Sp02 98%

What would you do for this patient?

What kind of hospital would be most approprate?

Differential Diagnosis?

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This kid needs a pediatric center with ICU management in case he goes into respiratory failure. With that high RR, he's going to fatigue out on us pretty soon. Prep for crashage!

Need to do imaging to see if there's fluid we can pull off via thoracentesis to help with the high respiratory rate. Also, need to give some pain control so he wants to breathe more fully... perhaps some Fentanyl, since we don't want his BP to drop for too long and it's short acting? Glad the fever came down... monitor that for recurrence... keep maintenance fluids going... that diastolic is still a tad low.

My top three differentials:

  • Rodent droppings may mean hantavirus. Chills, fever, SOB, hypotension... all fits. Especially for early stage.
  • Could be a toxicity from exposure to mold or fungus, resulting in the pleuritis, SOB and hypotensive reaction... not so sure on the fever though.
  • Could be an exposure to a pesticide, accounting for the hypotension, SOB, flushed skin, lethargy and weakness.

What do we do? Pretty much supportive care, unless there's a pesticide we can identify and give an antidote for.

That's all I got...

Wendy

CO EMT-B

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I think Wendy is spot on for early stages of hantavirus or mold exposure.

Need to be really early suspicion on that. Pediatric critical care facility. A rural general care facility will more than likely not be this kids best friend if it turns out the be hanta or airborn fungus amongus illness.

Remember the four corners virus outrbreak, I believe that the killer of the people was not the virus(well it was in the end) but it was really the slow to realizaton care that they received initially at the smaller low acuity care facilities they were seen at initially if I remember reading about those cases right.

So having a high index of suspicion in this type of case and err on the side of caution.

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He is going to need a hospital with ICU capability at least so lets get on the telephone machine to the orange clad ones who arrive from the sky to whisk away the patients I can't handle. Phew, I do love the retrieval team, massively limits my medico-legal liability by providing an out for people who I look at and go "WTF?" at.

Anyway, it could be some weird ass virus or mold exposure but I'd not think a mold exposure would produce such severe symps so quickly?

For right now I'd give him a little bit of midazolam to see if we can settle him to reduce his distress and try some non invasive ventilation.

How about a chest x ray?

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I'd like to get a more in depth history if I could. Was this the patient's first time doing that kind of work, or is he regularly exposed to those same conditions? If not, a diagnosis of hantavirus is unlikely, given the rapidity of onset. Any trauma associated or past medical history? Any significant family history? Meds? Known allergies?

He's tachycardic, so my suspicion for cholinergic exposure is low.

Let's give him some supplemental oxygen to help decrease his tachypnea and dyspnea, establish a second IV site if we don't already have one, and get him to a facility with a pediatric ICU. Aside from that, it's going to be mostly supportive care.

Number one on my list of differentials is a hypersensitivity reaction following mold/dust exposure.

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I'd like to get a more in depth history if I could. Was this the patient's first time doing that kind of work, or is he regularly exposed to those same conditions? If not, a diagnosis of hantavirus is unlikely, given the rapidity of onset. Any trauma associated or past medical history? Any significant family history? Meds? Known allergies?

He's tachycardic, so my suspicion for cholinergic exposure is low.

Let's give him some supplemental oxygen to help decrease his tachypnea and dyspnea, establish a second IV site if we don't already have one, and get him to a facility with a pediatric ICU. Aside from that, it's going to be mostly supportive care.

Number one on my list of differentials is a hypersensitivity reaction following mold/dust exposure.

Ah yes, young lieutenant bieber, I did not read the rapidity of the symptoms and I would still not take this kid to the doc in the box 5 bed ER but I would still defer transport to the big hospital with the peds ICU because of the rodent droppings, mold and other crap and the cornucopea of symptoms and other crap that is going on with him.

Plus the kids' more than likely going to be transferred out anyway if he's taken to the small facility and well that would be me anyway so why put me on the road twice in one day so I'll opt for one trip and one set of bills for this kid. Worst case scenario is that the kid gets to go home from the big city hospital. Plus he probably gets' to go to a retaurant that he normally wouldn't get to go to as well.

Plus I get to eat at my favorite BBQ restaurant in the city too.

But if my index of suspicion is correct, and it might be in this case then I've saved the world once again.

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What are his ECG results?

Was there any means of production of carbon dioxide or monoxide in the cilo?

What are the results of his blood culture?

What are the results of his CBC?

What are the results of his C reactive protein test?

The rapid onset does not fit somehow. I feel sure we are missing something

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How deep was the bin of oats? Was he on top of the oats and if so could he have gone down into the oats and had to force his way back up out of the oats after being under the oats, a drowning in the oats.

That would account for the sudden onset of the short of breath. It could also account for the pain, as he may have pulled something on his fighting to get out of the oat bin.

The quiet lung sounds could be that their might be a clog of oats in one of his airway tubes.

Probably not but who knows. I'd think he'd be a lot sicker if the above scenario happened but this could be the early onset of a soon to be very very sick kid.

I'm anxious to hear the answers to questoins already raised.

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What are his ECG results?

Was there any means of production of carbon dioxide or monoxide in the cilo? No

What are the results of his blood culture? They drew labs, but he was flown out before the results were in

What are the results of his CBC? As above

What are the results of his C reactive protein test? As above

The rapid onset does not fit somehow. I feel sure we are missing something Perhaps, but I am not holding back. As I said, I am sharing all I know.

Note: Although I did not get to see the chest x-ray, the family clinic Dr. stated it looked like a "widespread bilateral bronchial pneumonia". You can interpret that however you like.

The oats were mouldy, but there was no trauma involved (asphyxiation of fall, etc)

I asked if the oats had been treated (farmer slang for chemical applied to the product) but he denied any pesticides/treatments.

He has shoveled oats in the past.

I am trying to get a final Dx on this kid, really interesting imo

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Very interesting case, without knowing the results of the CXR or chest CT if taken the differentials can be many. If called to a scene in this case, I would provide supportive care as many have suggested. Looking at some of his symptoms does the pain change upon inspiration/expiration? Does it extend to shoulder or abdomen - common refferal pain for pleurisy. My thinking with the sudden onset would less likely be from bacteria/virus and more along the lines of these i.e. Pulmonary Embolism, pneumothorax, does patient of history of TB, pulmonary tumor? Maybe a pneumomediastinum? Interesting case thank you for presenting. Would like to hear the follow up on patient if you're able to give.

Edited by flightmedic608

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