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Abstract: This is a case of an 18-year-old adolescent who presented to our hospital with cough symptoms after a late night and exertion, along with febrile symptoms. Complete chest CT suggested pulmonary infection, and respiratory pathogenesis suggested positive IgM of Mycoplasma pneumoniae, and the preliminary diagnosis was mycoplasma pneumonia. During hospitalization, anti-infection, cough suppression and symptomatic treatment were given, and the patient’s symptoms were completely relieved and his condition basically recovered.
Basic information】Male, 18 years old
Disease Type】Mycoplasma pneumonia
Hospital】Wuhan University People’s Hospital
Date of consultation】March 2022
Treatment plan】Injectable medication (Azithromycin for injection) + oral medication (Jinhua Qingxian granules, Mimin pseudo-anesthetic oral solution)
Treatment period】7 days of inpatient treatment and outpatient follow up
Treatment effect】The patient’s cough and fever symptoms were completely relieved, and the inflammatory indexes returned to normal.
I. Initial consultation
The patient complained of cough, mostly dry cough, with fever, maximum temperature 38.2℃, with sore throat, general weakness, muscle aches, dizziness, no obvious cough, no hemoptysis, chest pain, dyspnea, no headache and other discomforts after staying up late and exerting himself 1 day ago. The fever was temporarily relieved after taking ibuprofen extended-release capsules at home. The patient visited the respiratory medicine clinic after relevant tests were performed in our fever clinic to exclude new crown infection. He had a history of physical fitness, no special medical history, no history of smoking or alcohol consumption, and denied any history of drug allergy. On examination, the patient was found to be mentally alert, with no significant abnormalities on cardiopulmonary auscultation.
II. Treatment history
After admission, routine blood tests, C-reactive protein and calcitoninogen tests were performed, indicating a significant increase in leukocyte and neutrophil counts, and a significant increase in inflammatory indexes, and respiratory pathogenic tests indicated positive IgM of Mycoplasma pneumoniae. The patient was given anti-infective Azithromycin for injection, Golden Flower Clear Sensory Granules and Mimin Pseudomonal Oral Solution for treatment. During the hospital stay, the patient was advised to take rest, avoid straining and staying up late, wear a good mask for good protection and avoid contact with other infected patients to prevent cross-infection. The chest CT and inflammation index were reviewed after anti-infection treatment.
III. Treatment effect
After 7 days of active anti-infection and symptomatic treatment, the patient’s blood tests showed that the inflammatory indexes were completely normalized, and the chest CT showed that the infectious lesions in the lungs were significantly absorbed and improved. The patient’s cough and fever were completely relieved, and he was discharged from the hospital. At the same time, the patient was advised to pay attention to rest outside the hospital, avoid exertion, cold and flu, strengthen nutrition, exercise appropriately to enhance physical fitness, and follow up with the respiratory medicine outpatient clinic.
IV. Notes
We are glad that the patient was cured after treatment, but mycoplasma pneumonia is a pneumonia caused by Mycoplasma pneumoniae infection, which is contagious and can be spread by droplet transmission and direct transmission. In daily life, the patient is advised to pay attention to rest on time, avoid staying up late and straining, avoid getting cold, pay attention to indoor air circulation, strengthen nutrition, eat more fresh vegetables and fruits rich in vitamins to enhance physical fitness, and at the same time exercise appropriately according to their own conditions, and pay attention to keeping warm when the weather changes and seasons change.
V. Personal insight
Mycoplasma pneumonia is prevalent in children and adolescents, and is contagious, with a regional epidemic character. Infants and young children, smokers, people with combined underlying diseases, malnutrition, and people with low immunity are at high risk for the development of mycoplasma pneumonia, and the elderly or frail patients with combined underlying diseases can be prophylactically vaccinated against pneumonia.
In this case, the young patient was considered to be suffering from a decrease in body resistance after staying up late and exertion, which led to the onset of mycoplasma pneumonia. After the diagnosis of mycoplasma pneumonia was confirmed by chest imaging and respiratory pathogenesis, the patient was actively treated with standard anti-infective therapy and was discharged after 7 days of hospitalization, which is a gratifying event.