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Pediatric PneumoniaPediatric Pneumonia
Pisespong Patamasucon,M.DPisespong Patamasucon,M.D
Pediatric Infectious DiseasesPediatric Infectious Diseases
Leading Etiologic Agents of Pneumonia Infants and ChildrenLeading Etiologic Agents of Pneumonia Infants and Children
AgeAge Bacterial Bacterial pathogenspathogens
Viral Viral PathogensPathogens
OtherOther
-NeonateNeonate Group B StreptocaccusGroup B Streptocaccus
Gram-negative Gram-negative bacilli( E.coli,K.pneumbacilli( E.coli,K.pneumoniae,Proteus oniae,Proteus spp.,others)spp.,others)
S.aureusS.aureus
RSVRSV
Herpes simplex Herpes simplex virusvirus
CMVCMV
AdenovirusAdenovirus
1-3 mo.1-3 mo. S.pneumoniaeS.pneumoniae
H.Infuenzae type bH.Infuenzae type b
RSVRSV C.trachomatisC.trachomatis
4 mo.-5 yrs4 mo.-5 yrs S.pneumoniaeS.pneumoniae
H.Influenzae type bH.Influenzae type b
Parainflenza Parainflenza virus1 and 3,virus1 and 3,
AdenovirusAdenovirus
Influenza viruses Influenza viruses A and BA and B
5 yrs and older5 yrs and older S.pneumoniaeS.pneumoniae M.pneumoniaeM.pneumoniae
C.pneumoniaeC.pneumoniae
Clues to The Etiology of Pneumonia Obtained Through Clues to The Etiology of Pneumonia Obtained Through History – TakingHistory – Taking
Type of Contact or Type of Contact or ProdromeProdrome
Disease or OrganismDisease or Organism
-Animal contact-Animal contact PsittacosisPsittacosis
TularemiaTularemia
Plaque, Q feverPlaque, Q fever
Geographic regionsGeographic regions HistoplasmosisHistoplasmosis
CoccidioidomycosisCoccidioidomycosis
Rickettsial infectionsRickettsial infections
Building constructionBuilding construction Aspergillus spp.Aspergillus spp.
Air conditioning cooling towersAir conditioning cooling towers Legionaires’ diseaseLegionaires’ disease
Clues to The Etiology of Pneumonia Obtained Through Clues to The Etiology of Pneumonia Obtained Through History – Taking ( con’t)History – Taking ( con’t)
Type of Contact or Type of Contact or ProdromeProdrome
Disease or OrganismDisease or Organism
- Long prodrome- Long prodrome M.pneumoniaeM.pneumoniae
C.pneumoniae or C.trachomitisC.pneumoniae or C.trachomitis
RSVRSV
- Preceding rash- Preceding rash MeaslesMeasles
N.meningitidisN.meningitidis
M.pneumoniaeM.pneumoniae
S.aureusS.aureus
Preceding focal abscess;intra-or Preceding focal abscess;intra-or extrapulmonaryextrapulmonary
S.aureusS.aureus
Pneumonia:Pneumonia:-- - EpidemiologyEpidemiology-- Diagnosis- Diagnosis-- Treatment- Treatment-- Prevention- Prevention
DiagnosisDiagnosis
-- -- Signs and symptoms -- CXRSigns and symptoms -- CXR
-- Physical Examination -- Culture-- Physical Examination -- Culture
-- Lab -- Antigen Detection-- Lab -- Antigen Detection
Diagnosis Practice for Acute Lower Respiratory Tract Infection Diagnosis Practice for Acute Lower Respiratory Tract Infection -P.E. -- Transtracheal AspirateP.E. -- Transtracheal Aspirate- CXR -- Lung tapeCXR -- Lung tape-Sputum -- ThoracocentesisSputum -- Thoracocentesis-CBC -- Antigen DetectionCBC -- Antigen Detection-Blood CISBlood CIS
Gold standard for Diagnosis of Pneumonia is to Obtain:Gold standard for Diagnosis of Pneumonia is to Obtain:1.1. Etiology agent from lung tissueEtiology agent from lung tissue
2.2. Blood cultureBlood culture
3.3. Detection of antigen from pleural fluidDetection of antigen from pleural fluid
Respiratory Rates (Breaths/minute) of Normal Respiratory Rates (Breaths/minute) of Normal childrenchildren
AgeAge Normal Rate- sleepingNormal Rate- sleeping Normal Rate-AwakeNormal Rate-Awake
MeanMean RangeRange MeanMean RangeRange
6-12 mo.6-12 mo. 2727 22-3122-31 6464 58-7558-75
1-2 yr.1-2 yr. 1919 17-2317-23 3535 30-4030-40
2-4 yr.2-4 yr. 1919 16-2516-25 3131 23-4223-42
4-6 yr.4-6 yr. 1818 14-2314-23 2626 19-3619-36
6-8 yr.6-8 yr. 1717 13-2313-23 2323 15-3015-30
Diagnostic Tools for pneumoniaDiagnostic Tools for pneumonia
CXRCXRSputum cultureSputum cultureBlood cultureBlood cultureUrine antigen test – CIE or latex Urine antigen test – CIE or latex
agglutinationagglutinationLung tapLung tapPleural fluid culturePleural fluid culture
Epidemiology,Clinical,and Laboratory Features of Epidemiology,Clinical,and Laboratory Features of Acute Pneumonia in Normal Infants and Children Acute Pneumonia in Normal Infants and Children
According to Etiologic AgentsAccording to Etiologic Agents
BacteriaBacteria VirusVirus MycoplasmaMycoplasmaHistorical cluesHistorical clues
- Age- Age Any,esp.infantAny,esp.infant AnyAny School School age,adolescentage,adolescent
- Temp.- Temp. Majority ≥ 39° CMajority ≥ 39° C < 39° C< 39° C Majority < 39° CMajority < 39° C
- Onset- Onset AbruptAbrupt Gradually Gradually worsening URIworsening URI
Gradually Gradually worsening coughworsening cough
- Others in home ill- Others in home ill InfrequentInfrequent FrequentFrequent Frequent,wk.apartFrequent,wk.apart
- Ass. Signs,- Ass. Signs,
symptomsymptom
Meningitis,otitis,Meningitis,otitis,arthritisarthritis
Myalgia,rash,conMyalgia,rash,conjunctivitisjunctivitis
Headache,sorethroHeadache,sorethroat,myalgiaat,myalgia
- Cough- Cough ProductiveProductive NonproductiveNonproductive HackingHacking
- Pleuritic chest - Pleuritic chest painpain
FrequentFrequent InfrequentInfrequent InfrequentInfrequent
Epidemiology,Clinical,and Laboratory Features of Epidemiology,Clinical,and Laboratory Features of Acute Pneumonia in Normal Infants and Children Acute Pneumonia in Normal Infants and Children
According to Etiologic Agents (con’t)According to Etiologic Agents (con’t)
BacteriaBacteria VirusVirus MycoplasmMycoplasmaa
Physical FindingsPhysical Findings
- Auscultatory- Auscultatory
Confined Confined rales,no rales,no rales.Occasionrales.Occasional dullness to al dullness to percussion,dimipercussion,diminished tubular nished tubular soundssounds
Diffuse,bilat. Diffuse,bilat. Rales.Wheezes Rales.Wheezes in young infantin young infant
Unilateral rales Unilateral rales in mostin most
-Toxicity-Toxicity Degree illness Degree illness > findings> findings
Degree illness Degree illness ≤ findings≤ findings
Degree illness Degree illness < findings< findings
Epidemiology,Clinical,and Laboratory features of Epidemiology,Clinical,and Laboratory features of Acute Pneumonia in Normal Infants and Children Acute Pneumonia in Normal Infants and Children
According to Etiologic Agents (con’t)According to Etiologic Agents (con’t)
BacteriaBacteria virusvirus mycoplasmamycoplasma
Radiographic Radiographic Findings Findings
- Initial - Initial examinationexamination
Hyperaeration ± Hyperaeration ± alveolar infiltratealveolar infiltrate
HyperaerationHyperaeration± interstitial ± interstitial infiltrateinfiltrate
Alveolar-Alveolar-interstitial interstitial patchy patchy infiltrationinfiltration
- Progression- Progression Frequent,rapidFrequent,rapid InfrequentInfrequent May be May be migratorymigratory
- Pleural fuild- Pleural fuild May be May be large,rapidly large,rapidly progressiveprogressive
Infrequent,smallInfrequent,small,not progressive,not progressive
Infrequent,smallInfrequent,small,not progressive,not progressive
Epidemiology,Clinical,and Laboratory Features of Epidemiology,Clinical,and Laboratory Features of Acute Pneumonia in Normal Infants and Children Acute Pneumonia in Normal Infants and Children
According to Etiologic Agents (con’t)According to Etiologic Agents (con’t)
BacteriaBacteria VirusVirus MycoplasmaMycoplasma
Laboratory Laboratory FindingsFindings
- Peripheral - Peripheral WBC/cu.mmWBC/cu.mm
Majority> Majority> 15,000.Granulo15,000.Granulocytes cytes predominatepredominate
Majority<15,000Majority<15,000.Lymphocytes .Lymphocytes predominatepredominate
Majority normal Majority normal or less than or less than 15,00015,000
- C-reactive - C-reactive proteinprotein
MajorityMajority InfrequentInfrequent InfrequentInfrequent
- Sed rate ≥ 30 - Sed rate ≥ 30 mm/hrmm/hr
MajorityMajority MajorityMajority MajorityMajority
Etiology of Pneumonia in infants and Etiology of Pneumonia in infants and ChildrenChildren
Strep.Gr.B
E.coli
RSV
C.Trachomatis
CMV 1° Staph.
H.Inf.B.
2°Staph.
C. pneumoniae
Mycoplasma
S.PneumoniaViral Agents Para 1,2,3
Influenza A,B Etc.
Winter
Summer
1 mo. 3 mo. 6 mo. 1 yr. 3 yrs. 5 yrs. 10 yrs.
Prospective Studies of Perinatal Prospective Studies of Perinatal Chlamydia InfectionChlamydia Infection
InfantsInfants
City Mother Conjunctivitis(%) Pneumonia (%)City Mother Conjunctivitis(%) Pneumonia (%)
SanSan
Francisco 5 18 16Francisco 5 18 16
Seattle 13 44 --Seattle 13 44 --
Denver 9 44 22Denver 9 44 22
Boston 2 33 17Boston 2 33 17
Seattle 12 33 8Seattle 12 33 8
Lund 9 22 --Lund 9 22 --
Nairobi 22 37 12 Nairobi 22 37 12
Clinical Features of C. Trachomatis PneumoniaClinical Features of C. Trachomatis Pneumonia
Onset at 3 to 11 wks of ageOnset at 3 to 11 wks of age Cough greater than one week in durationCough greater than one week in duration Prior conjunctivitisPrior conjunctivitis Afebrile tachypnea with diffuse ralesAfebrile tachypnea with diffuse rales Hyperinflation and interstitial infiltrates on chest Hyperinflation and interstitial infiltrates on chest
filmfilm EosinophiliaEosinophilia Increased IgMIncreased IgM Increased IgA and IgGIncreased IgA and IgG
0
1
2
3
4
5
6
7
8
9
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Erythromycin
Sulfisoxazole
Treatment dayTreatment day when improvement first noted
Num
ber
of p
atie
nts
Pneumococcal pneumoniaPneumococcal pneumonia
Most common in late winter or early spring during the peak of viral infection
Abrupt onset of fever Restlessness Respiratory distress following URI
Physical exam & Labs
Diminished B. S or fine, crackling ralesNeck rigidity without meningitis may occur
(RUL)WBC 15,000 - 40,000Blood C/S positive only 30%Lobar consolidation (less common in
infants)Para-pneumonic effusion is relatively
common
Mycoplasma pneumoniae in the United Mycoplasma pneumoniae in the United StatesStates
Syndrome Incidence/year Total casesSyndrome Incidence/year Total cases
Pneumonia 2/1.000 500,000Pneumonia 2/1.000 500,000
Tracheobronchitis 46/1,000 11,500,000Tracheobronchitis 46/1,000 11,500,000
Asymptomatic 12/1,000 3,000,000Asymptomatic 12/1,000 3,000,000
InfectionsInfections
All infections 15,000,000All infections 15,000,000
Incubation Clinical illness Convalescence
Wks.-2 0-1 1 2 3 4 5 6
Symptoms:
Headache,malaise
Fever
Sore throat
CoughSigns: Sputum
Dullness
Rales
Laboratory: Positive culture
x-ray
Diagnostic Tests for Mycoplasma pneumoniaeDiagnostic Tests for Mycoplasma pneumoniae Test Specimen Sensitivity(%) Specificity(%) CommentsTest Specimen Sensitivity(%) Specificity(%) Comments
Culture Throat or NP swab, > 90 50-90 Not routinely available;Culture Throat or NP swab, > 90 50-90 Not routinely available;
sputum, bronchial slow-growing organismsputum, bronchial slow-growing organism
washing washing
tissue tissue
PCR Throat or NP swab, 95 95-99 Not commercially availablePCR Throat or NP swab, 95 95-99 Not commercially available
sputum, potencially useful for rapidsputum, potencially useful for rapid
broncial washings, diagnosis testbroncial washings, diagnosis test
tissuetissue
Serology cold agglutinins 50 < 50 Nonspecific;takes severalSerology cold agglutinins 50 < 50 Nonspecific;takes several
wks to developwks to develop
Serum 75-80 80-90 Paired acute-convalescentSerum 75-80 80-90 Paired acute-convalescent
Complement sera preferred;takes 4-9wksComplement sera preferred;takes 4-9wks
fixation for seroconversionfixation for seroconversion
Elisa Diagnostic criteriaElisa Diagnostic criteria
Definite: 4-fold increase inDefinite: 4-fold increase in
titertiter
Chlamydia pneumoniae ( TWAR )Chlamydia pneumoniae ( TWAR )
This organism cause pneumonia,This organism cause pneumonia,
bronchitis,sinusitis and pharyngitis bronchitis,sinusitis and pharyngitis
and is a common cause of infection and is a common cause of infection
in children from the age 5 – 15 years.in children from the age 5 – 15 years.
Of the three Chlamydia species,Of the three Chlamydia species,
Chlamydia pneumonia is by far the Chlamydia pneumonia is by far the
most common cause of human infection most common cause of human infection
Clinical Finding inClinical Finding in Pneumonia Associated with Pneumonia Associated with M.Pneumoniae,TWAR and Viral Respiratory AgentsM.Pneumoniae,TWAR and Viral Respiratory Agents
////////////////////////////////// TWARTWAR
( N=26 )( N=26 )
M.pneumoniaeM.pneumoniae
( N=35 )( N=35 )
VirusesViruses
( N=86 )( N=86 )
CoughCough 100%100% 97%97% 89%89%
Sore throatSore throat 50%50% 48%48% 50%50%
HoresnessHoresness 48%48% 32%32% 37%37%
WBC>10,000WBC>10,000 25%25% 21%21% 37%37%
Fever>106°FFever>106°F 67%67% 94%94% 93%93%
HospitalizedHospitalized 4%4% 3%3% 5%5%
Outpatient
0-20 days Admit pt.
3wks-3mos Afebrile; give PO
erythromycin. Admit for fever or hypoxia
4mos-4yrs PO amox or azithro. If
>8 yrs, PO doxycycline (4mg/kg/day, 2 divided doses)
Inpatient (septic, alveolar infiltrate, large pleural
effusion or all)
0-20 days IV amp/gent with or
w/o IV cefotaxime
3wks-3mos Give IV cefotaxime or
ceftriaxone
4mos-4yrs IV cefotaxime,
ceftriaxone, if pt not well consider IV azithromycin*
Pleural Empyema In ChildrenPleural Empyema In Children
Stages of infectionExudative (allows needle aspiration)
Fibrinopurulent (may be loculated)
Organizing
Treatment optionsExudative Repeated needle aspiration (1-5 days)
Exudative or Chest tube drainage
fibrinopurulent
Organizing Decortication
If >50% limitation of lung shown by CT scan
After 2-4 weeks of medical management
tachypnea, asymmetry of chest wall
expansion, fever,or leukocytosis remain
Characteristics of Different Types of Pleural EffusionsCharacteristics of Different Types of Pleural Effusions
Clinical Clinical ConditionCondition
Type of Type of effusioneffusion
Predominate Predominate Cells in Cells in EffusionEffusion
Glucose Glucose Level(mg/dL)Level(mg/dL)
pHpH
EmpyemaEmpyema ExudateExudate PMN PMN cells>50,000/cells>50,000/mm3mm3
<30<30 <7.00<7.00
Parapneumonic Parapneumonic effusioneffusion
ExudateExudate PMN PMN cells<50,000/cells<50,000/mm3mm3
>30>30 <7.20<7.20
TuberculosisTuberculosis ExudateExudate LymphocytesLymphocytes 30-6030-60 7.00-7.00-7.307.30
Congestive heart Congestive heart failurefailure
TransudateTransudate LymphocytesLymphocytes >60>60 >7.40>7.40
HypoalbuminemiaHypoalbuminemia TransudateTransudate Lymphocytes(Lymphocytes(few)few)
<60<60 >7.40>7.40
Malignancy,SLEMalignancy,SLE ExudateExudate Lymphocytes,Lymphocytes,malignant malignant cellscells
VariableVariable VariableVariable
Reported frequency of pleral effusion in pneumoniaReported frequency of pleral effusion in pneumonia
Etiology Frequency(%)Etiology Frequency(%)
S.aureusS.aureus
Strep.pneumoniaeStrep.pneumoniae
H.InfluenzaeH.Influenzae
Group A StreptococcusGroup A Streptococcus
Mycoplasma pneumoniaeMycoplasma pneumoniae
AdenovirusAdenovirus
72-7672-76
5757
49-7549-75
86-9186-91
2121
11-3311-33
Algorithm for EmpyemaAlgorithm for Empyema
Pleural effusionPleural effusion
Thoracentesis
Gram stain-neg Gram stain-pos
Observe Chest tube
Resolution Increasing fluid
Resolution Non-resolution
Open drainageDecortication
Which of the following statements regarding Which of the following statements regarding pneumonia in children is true?pneumonia in children is true?
A .Specific microbial pathogen usually can be A .Specific microbial pathogen usually can be identifiedidentified
B. All children who have pneumonia should be B. All children who have pneumonia should be hospitalized for observation and treatmenthospitalized for observation and treatment
C. Pneumonia is a rare cause of child mortality C. Pneumonia is a rare cause of child mortality worldwideworldwide
D. Radiographs of the chest always should be D. Radiographs of the chest always should be obtained to determine the causeobtained to determine the cause
E. Viral agents are the most common causes of E. Viral agents are the most common causes of pneumonia in older infants and childrenpneumonia in older infants and children
You are evaluating an 8 year old boy who has 7 day history You are evaluating an 8 year old boy who has 7 day history of malaise and worsening cough. His mother reports that of malaise and worsening cough. His mother reports that he has had low grade fever. PE reveals a well appearing he has had low grade fever. PE reveals a well appearing
boy with normal RR and pulse ox. Lung exam reveals boy with normal RR and pulse ox. Lung exam reveals bilateral crackles without wheezing . Chest x-ray show bilateral crackles without wheezing . Chest x-ray show
bilateral interstitial infiltrates without effusion. bilateral interstitial infiltrates without effusion.
Most likely pathogen is:Most likely pathogen is:A. Haemophilus influenzaeA. Haemophilus influenzaeB. Mycobacterium tuberculosisB. Mycobacterium tuberculosisC. Mycoplasma pneumoniaeC. Mycoplasma pneumoniaeD. Respiratory syncytial virusD. Respiratory syncytial virusE. Streptococcus pneumoniaE. Streptococcus pneumonia
An 8 week old girl presents to ER with increased work of An 8 week old girl presents to ER with increased work of breathing x 1 day. Temp of 101.1 F, difficulty breastfeeding breathing x 1 day. Temp of 101.1 F, difficulty breastfeeding due to nasal congestion. RR 70, pulse ox 90% on RA. Lung due to nasal congestion. RR 70, pulse ox 90% on RA. Lung exam reveals bilateral wheezes and crackles. CXR shows exam reveals bilateral wheezes and crackles. CXR shows
increased perihilar markings bilaterally and right middle increased perihilar markings bilaterally and right middle lobe opacity.lobe opacity.
Most likely cause of her symptoms is;Most likely cause of her symptoms is;A. AdenovirusA. AdenovirusB. Bordetella pertussisB. Bordetella pertussisC. Chlamydia trachomatisC. Chlamydia trachomatisD. Group B StreptococcusD. Group B StreptococcusE. Respiratory syncytial virusE. Respiratory syncytial virus
#4#4
Main Cause of Necrotizing Pneumonia Main Cause of Necrotizing Pneumonia is:is:
A.A. Streptococcal hyaluronidaseStreptococcal hyaluronidase
B.B. Teichoic acidTeichoic acid
C.C. PneumolysinPneumolysin
D.D. FibrinolysinFibrinolysin
E.E. Ponton-valentine leukocidinePonton-valentine leukocidine
#5#5
The following microorganisms are The following microorganisms are frequent causes of pleural effusion frequent causes of pleural effusion EXCEPT:EXCEPT:
A.A. S. aureusS. aureus
B.B. Strep pneumoniaeStrep pneumoniae
C.C. Group A streptococcusGroup A streptococcus
D.D. Haemophilis influenzae type BHaemophilis influenzae type B
E.E. Mycoplasma pneumoniaeMycoplasma pneumoniae
#6#6
Characteristics chlamydial pneumonia Characteristics chlamydial pneumonia include the following EXCEPT:include the following EXCEPT:
A.A. AfebrileAfebrile
B.B. History of conjunctivitisHistory of conjunctivitis
C.C. Staccato coughStaccato cough
D.D. EosinophiliaEosinophilia
E.E. Present at 4-6 months of agePresent at 4-6 months of age
#7#7
Distinguish features of exudate from Distinguish features of exudate from transudate are as follows EXCEPT:transudate are as follows EXCEPT:
A.A. Pleural fluid: serum protein ratio > 0.5Pleural fluid: serum protein ratio > 0.5
B.B. Pleural fluid LDH > 200 IU/mlPleural fluid LDH > 200 IU/ml
C.C. Pleural fluid: serum LDH > 0.6Pleural fluid: serum LDH > 0.6
D.D. Pleural fluid protein > 3 gm/mlPleural fluid protein > 3 gm/ml
E.E. Leukocyte count > 1,000/CU/mmLeukocyte count > 1,000/CU/mm
Features Differentiating Exudative & Transudative Pleural Effusion
TransudateExudate
WBC <10,000/mm³ >50,000/ mm³ pH >7.2 <7.2 Protein <3.0 g/dL >3.0 g/dL Protein ratio <0.5 >0.5 LDH <200 IU/L >200 IU/L LDH ratio <0.6 >0.6 Glucose ≥60 mg/dL <60 mg/dL
TIME TO WAKE UP!!!