Diskusi kasus MANDIRI ENDOKRIN PROGRESS (1).pptx

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1. Low T3,FT4 and TSH in neonatal pneumonia Robert Moderator: dr. Catur Suci Sutrisnani , Sp.PK , Subsp.E.M .(K)

2. DATABASE Boy neonate, 27-day-old Chief complaint: shortness of breath History of present illness: Patient was reported of having shortness of breath since birth, not resolved until the day of admission to RSSA. He was born via Sectio Cessarean from G2P1A0 mother in her 32 nd week of pregnancy due to PROM + severe oligohydramnion . Amniotic fluid was turbid, APGAR score 4-5. He was seen grunting, cyanotic, and had shortness of breath a while after being born. 2

3. History of Present Illness: He was initially treated with CPAP, changed to continuous nasal flow but failed to wean off. He had poor feeding and poor sucking. Pregnancy and Birth History: Mother did not realize of her pregnancy until 6 th month, consumed necessary vitamins ever since. Patient was born 1400 gr, 39 cm. 3 DATABASE

4. General appearance Look severly ill B W: 1890 gr , H: 39 cm , Weight for age: <-3SD Vital sign HR: 146 bpm, RR: 55 tpm SpO2: 99% on continuous flow nasal canule Temp : 37.6 ° C Head and neck Anemic +, icteric -, cyanosis -, dyspnea + No lymph node enlargement Wet mucosal 4 PHYSICAL EXAMINATION

5. Thorax Cor : ictus visible and palpable at ICS V MCS, S 1 S 2 regular Pulmo : symmetrical, S=D, vesicular, Rh +/+ , Wh -/-, subcostal retraction Abdomen Soft, normal bowel sound, no d istension No liver or spleen enlargement, fast turgor Extremity Edema (-/-) non-pitting Warm acral, CRT < 2 sec 5 PHYSICAL EXAMINATION

6. Examination 25/10 Reference Hemoglobin 9.7 13.9 – 19.1 g/dl Erythro cyte 2.97 4.0 – 6.0 x 10 6 /µl Hematocrite 26.3 38.0 – 48.0 % MCV 88.6 89.4 – 99.7.0 fl MCH 32.7 29.9 – 34.1 pg MCHC 36.9 32.0 – 36.0 g/dL RDW 15.0 14.3 – 16.8 % Leu kocyte 13.94 7.8 – 15.9 x 10 3 /µl Thrombo cyte 90 248 – 566 x 10 3 / μ L Diff Count (%) 0/0/-/46/39/15 0.7-5.4/0.0-1.0/42.5-71.0/20.4-44.6/3.6-9.9 6 LABORATORY EXAMINATION Hematology

7. Examination 25/10 Reference PT 11.8 9.4 – 11.3 s Control 11.3 INR 1.14 <1.5 APTT 27.1 24.6 – 30.6 s Control 26.7 7 LABORATORY EXAMINATION Hemostatic

8. 8 LABORATORY EXAMINATION Clinical Chemistry Examination 23/10 Reference AST 25 < 58 U/L ALT 9 < 56 U/L Serum Albumin 3.43 3.8 – 5.4 g/dL Ureum 63.5 11 – 36 mg/dL Creatinine 1.99 < 0.98 mg/dL eGFR ( schwartz ) 8.0 Natrium 118 132 – 142 mmol/L Kalium 4.35 3.4 – 6.0 mmol/L Chloride 84 97 – 108 mmol/L

9. 9 LABORATORY EXAMINATION Blood Gas Analysis Examination 24/10 Reference pH 7.50 7.35 – 7.45 pCO 2 34.2 35 – 45 mmHg pO 2 72.6 80 – 100 mmHg HCO 3 26.9 21 – 28 mmol/L Base Excess 3.5 (-3) – (+3) O 2 saturation 93.5 >95% Lactic acid 4.2 Artery: 0.5 – 1.6 mmol /L Vein: 0.6 – 2.2 mmol/L Uncompensated respiratory alkalosis dd/ mixed vein

10. 10 LABORATORY EXAMINATION Immunoserology Examination 25/10 Reference Procalcitonin 4.03 < 0.5 ng/mL: low risk for sepsis < 0.5 ng/mL: high risk for sepsis T3 Total 0.35 1.95 – 6.04 ng/mL FT4 0.77 0.89 – 2.20 ng/dL TSH 0.42 0.72 – 11.0 μ IU/mL Vitamin D 25-OH 25.5 ≥ 30 ng/mL

11. 11 Babygram (25/10) Neonatal pneumonia

12. THERAPY IV fluid 150 cc/kg -> 270 cc/day O2 CNO mode SNIPPV BU Flow 8 lpm PEEP 4-6 FiO2 FiO2 30% Fins 1 L/min IV Cefoperazone sulbactam 2x45 mg IV Aminophylline Loading 20mg, maintanance 2x5.5mg PO Furosemide 3x3 mg PO Captopril 3x0,625 mg PRC 35 cc, 3 times with 24 hours interval 12

13. Data Interpretation History Taking: A neonate 27-d.o-boy with Shortness of breath,grunting and cyanotic, poor feeding and poor sucking, history of premature birth, mother The mother did not consume any vitamins during pregnancy Physical Examination: Anemic, Dyspnea, Grunting, Retraction, Rhonki bilateral, Laboratory Examination: Anemia NN, Trombocytopenia , Hipoalbuminemia , Azotemia, Hiponatremia , Hipochloremia , Hipoglycemia , Lactatemia, Uncompensated respiratory alkalosis dd/mixed vein, Increased Procalcitonin, Decreased T3,FT4, and TSH Radiology: Chest X-ray: Pneumonia 13

14. Data Interpretation Patient was assessed with: Shortness of breath dt Neonatal pneumonia Susp. Non-Thyroidal Illness dt Susp. sepsis Normochromic normocytic anemia dt Anemia of prematurity Renal insufficiency dt Susp. AKI dt Susp. Sepsis Electrolyte imbalance dt renal loss dd/ low intake Hypoalbuminemia dt Hypercatabolic state dt PCCL 1 dd/ Low intake 14

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17. Neonatal Pneumonia Pneumonia is commonly encountered by emergency department and primary care clinicians. Childhood pneumonia remains a significant cause of morbidity and mortality in developing countries Worldwide, the overall annual incidence of pneumonia in children younger than 5 years is 150 million to 156 million cases

18. 19 Subjective: Boy neonate 27d.o Shortness of breath since birth, cyanotic at birth, turbid amniotic fluid, Bilateral ronchi , subcostal retraction Laboratory: Normal leukocyte, elevated procalcitonin, uncompensated respiratory alkalosis dd/ mixed vein CXR: neonatal pneumonia Shortness of breath dt Neonatal pneumonia Suggestion: Sputum culture Monitoring: CBC,Procalcitonin , BGA DATA INTERPRETATION

19. Anemia of Prematurity 20 Pathophysiology of Anemia During the Neonatal Period, Including Anemia of Prematurity. Neoreviews . Widness , et al. 2008. Immediately following birth, all infants universally experience a decrease in hemoglobin(Hb) that results in varying degrees of anemia. The rapidity with which this anemia develops and its ultimate severity are determined by a combination of multiple physiologic and nonphysiologic processes.

20. Anemia of Prematurity 21 Pathophysiology of Anemia During the Neonatal Period, Including Anemia of Prematurity. Neoreviews . Widness , et al. 2008. Preterm infants are especially vulnerable to these processes for two reasons. First, the severity of the developmental postnatal decrease in Hb is most pronounced in the least mature infants, placing them at high risk of developing clinically significant anemia. Second, as a group, preterm infants are particularly prone to developing severe cardiorespiratory and infectious illnesses , the diagnosis and management of which requires frequent laboratory assessment, resulting in heavy phlebotomy loss.

21. Anemia of Prematurity 22 Pathophysiology of Anemia During the Neonatal Period, Including Anemia of Prematurity. Neoreviews . Widness , et al. 2008.

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23. 24 Subjective: Boy neonate 27d.o Poor feeding, shortness of breath Physical Exam: Anemic BW 1400gr, Length 39cm Laboratory: Normochromic normocytic anemia , normal leukocyte, thrombocytopenia Normochromic normocytic anemia dt Anemia of prematurity Suggestion: Reticulocyte,SI , TIBC,Peripheral blood smear Monitoring: CBC DATA INTERPRETATION

24. Sepsis is a leading cause of death among children worldwide. The Phoenix Sepsis Score is a new clinical criterion designed to identify sepsis and septic shock in children under 18 years with suspected infection. Sepsis definition is now operationalized by 2 or more points in the Phoenix Sepsis Score (indicating life-threatening organ dysfunction of the respiratory, cardiovascular, coagulation, and/or neurologic systems) in a child with suspected or confirmed infection. Sepsis

25. Phoenix Score = 2

26. Sepsis and Organ Dysfunction 27

27. 28 Subjective: Boy neonate 27d.o Poor feeding, shortness of breath since birth Physical Exam: Warm acral, CRT <2 s Urine output not measured Tachycardia, Tachypneu Laboratory: Azotemia with low eGFR Hyponatremia, normal kalium, hypochloremia , thrombocytopenia Phoenix score : 2 Renal insufficiency dt Susp. AKI dt Susp. Sepsis Suggestion: Urine electrolyte Bilirubin T/D/I Urine output Monitoring: Ureum , creatinine, eGFR DATA INTERPRETATION

28. Hypoalbuminemia Hypoalbuminemia is a common problem among persons with acute & chronic medical conditions At the time of hospital admission, 20% of patients have hypoalbuminemia 29 Causes of hypoalbuminemia Decreased or abnormal synthesis Malnutrition, cirrhosis, hepatititis, chronic liver disease Increased catabolism Major injuries, malignancy, fever, pancreatitis, hyperthyroid Increased loss nephrotic syndrome, burns ,gut losses, hemorrhage & post surgical procedures Altered albumin distribution Ascites, CHF, overhydration Increased capillary permeability sepsis, SIRS, stress response http://emedicine.medscape.com/article/166724-clinical#a0218

29. 30 Subjective: Boy neonate 27d.o Poor feeding, shortness of breath Physical Exam: No edema Laboratory: Hypoalbuminemia, normal AST and ALT Elevated procalcitonin Hypoalbuminemia dt Hypercatabolic state dt PCCL 1 Suggestion Total protein, SPE Monitoring Serum albumin AST, ALT DATA INTERPRETATION

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31. Non Thyroidal Illness Syndrome 32 Non-thyroidal illness syndrome (NTIS), also known as euthyroid sick syndrome, refers to a condition characterized by abnormal thyroid function test results in patients suffering from non-thyroidal illnesses. This syndrome manifests as alterations in thyroid hormone levels without any preexisting dysfunction of the hypothalamic-pituitary-thyroid axis. Prevalence of NTIS A study showed that approximately 60.7% of neonates with sepsis had NTIS.

32. Systemic Stress: In patients with critical illnesses such as sepsis, the body experiences significant stress. This stress triggers the release of pro-inflammatory cytokines like interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF- α), which play a role in regulating thyroid hormone metabolism.   Regulation of the Hypothalamic-Pituitary-Thyroid (HPT) Axis Changes in TSH Although TSH levels often remain within normal ranges or may show slight increases, the response to critical illness can lead to decreased secretion of TSH from the pituitary gland. This occurs due to the influence of cytokines and changes in negative feedback from low thyroid hormone levels. 33

33. Alterations in Thyroid Hormone Metabolism Decreased Conversion of T4 to T3: One of the primary mechanisms in NTIS is the reduction in deiodinase activity, the enzyme responsible for converting T4 into T3 in peripheral tissues. IL-6 inhibits the function of type 1 and type 2 deiodinases, leading to a significant decrease in T3 levels. Interaction Between Endocrine and Immune Systems Cytokine Effects on Thyroid Hormones: Cytokines not only affect the production of thyroid hormones but may also alter the sensitivity of target cells to these hormones. This creates a complex relationship between the immune and endocrine systems that contributes to NTIS. 34

34. 35 Subjective: Boy neonate 27d.o Poor Feeding, Shortness of breath since birth Physics Examination Tachycardia, Tachypneu , Fever Laboratory: Low T3 Total, low FT4, low TSH Phoneix score : 1 Susp. Non-Thyroidal Illness dt Susp. sepsis Suggestion: - Monitoring: T3 Total, FT4, TSH DATA INTERPRETATION

35. Conclusion It has been discussed 27-d.o-boy with: Shortness of breath dt Neonatal pneumonia Susp. Non-Thyroidal Illness dt Susp. sepsis Normochromic normocytic anemia dt Anemia of prematurity Renal insufficiency dt Susp. AKI dt Susp. Sepsis Electrolyte imbalance dt renal loss dd/ low intake Hypoalbuminemia dt Hypercatabolic state dt PCCL 1 dd/ Low intake 36

36. Conclusion Suggestion: Sputum culture, Reticulocyte, SI, TIBC, Peripheral blood smear,Urine Electrolyte, Urine output,Total protein, SPE,Bilirubin T/D/I Blood Culture. Monitoring: CBC, Procalcitonin , BGA, T3 Total, TSH, FT4, Ureum , creatinine, Serum albumin, AST, ALT 37

37. Thank You