Pediatric Pneumonia

Pisespong Patamasucon,M.D Pediatric Infectious Diseases

Leading Etiologic Agents of Pneumonia Infants and Children

Age Bacterial pathogens
Group B Streptocaccus Gram-negative bacilli( E.coli,K.pneumoniae,P roteus spp.,others) S.aureus

Viral Pathogens
RSV Herpes simplex virus CMV Adenovirus

Other

-Neonate

1-3 mo. 4 mo.-5 yrs

S.pneumoniae H.Infuenzae type b S.pneumoniae H.Influenzae type b

RSV Parainflenza virus1 and 3, Adenovirus Influenza viruses A and B

C.trachomatis

5 yrs and older

S.pneumoniae

M.pneumoniae C.pneumoniae

Clues to The Etiology of Pneumonia Obtained Through History Taking Type of Contact or Prodrome
-Animal contact

Disease or Organism
Psittacosis Tularemia Plaque, Q fever

Geographic regions

Histoplasmosis Coccidioidomycosis Rickettsial infections

Aspergillus spp.

Building construction

Air conditioning cooling towers

Legionaires disease

Clues to The Etiology of Pneumonia Obtained Through History Taking ( cont) Type of Contact or Prodrome
- Long prodrome

Disease or Organism

M.pneumoniae C.pneumoniae or C.trachomitis RSV Measles N.meningitidis M.pneumoniae S.aureus

- Preceding rash

Preceding focal abscess;intra-or extrapulmonary

S.aureus

Pneumonia:
-- Epidemiology
--

Diagnosis -- Treatment -- Prevention

Diagnosis
-- Signs and symptoms
-- Physical Examination -- Lab -- CXR -- Culture -- Antigen Detection

Diagnosis Practice for Acute Lower Respiratory Tract Infection

-P.E.

CXR -Sputum -CBC -Blood CIS

-

-- Transtracheal Aspirate -- Lung tape -- Thoracocentesis -- Antigen Detection

Gold standard for Diagnosis of Pneumonia is to Obtain:

1. 2. 3.

Etiology agent from lung tissue Blood culture Detection of antigen from pleural fluid

Respiratory Rates (Breaths/minute) of Normal children

Age
Normal Rate- sleeping Mean 6-12 mo. 1-2 yr. 2-4 yr. 27 19 19 Range 22-31 17-23 16-25 Normal Rate-Awake

Mean 64 35 31

Range 58-75 30-40 23-42

4-6 yr.
6-8 yr.

18
17

14-23
13-23

26
23

19-36
15-30

Diagnostic Tools for pneumonia

CXR Sputum culture Blood culture Urine antigen test CIE or latex agglutination Lung tap Pleural fluid culture

Epidemiology,Clinical,and Laboratory Features of Acute Pneumonia in Normal Infants and Children According to Etiologic Agents
Bacteria
Historical clues - Age - Temp. Any,esp.infant Any

Virus

Mycoplasma
School age,adolescent Majority < 39 C

Majority 39 C < 39 C

- Onset
- Others in home ill - Ass. Signs, symptom - Cough - Pleuritic chest pain

Abrupt
Infrequent

Gradually worsening URI

Frequent

Gradually worsening cough

Frequent,wk.apart Headache,sorethro at,myalgia Hacking Infrequent

Meningitis,otitis, Myalgia,rash,co arthritis njunctivitis Productive Frequent Nonproductive Infrequent

Epidemiology,Clinical,and Laboratory Features of Acute Pneumonia in Normal Infants and Children According to Etiologic Agents (cont) Bacteria Virus Mycoplas ma
Physical Findings - Auscultatory Confined Diffuse,bilat. Unilateral rales rales,no Rales.Wheezes in most rales.Occasion in young infant al dullness to percussion,dimi nished tubular sounds Degree illness > findings Degree illness findings Degree illness < findings

-Toxicity

Epidemiology,Clinical,and Laboratory features of Acute Pneumonia in Normal Infants and Children According to Etiologic Agents (cont)
Bacteria Radiographic Findings - Initial examination - Progression virus mycoplasma Alveolarinterstitial patchy infiltration May be migratory

Hyperaeration Hyperaeration alveolar infiltrate interstitial infiltrate Frequent,rapid Infrequent

- Pleural fuild

May be large,rapidly progressive

Infrequent,small Infrequent,small ,not progressive ,not progressive

Epidemiology,Clinical,and Laboratory Features of Acute Pneumonia in Normal Infants and Children According to Etiologic Agents (cont)
Bacteria Virus Mycoplasma

Laboratory Findings - Peripheral WBC/cu.mm

Majority> 15,000.Granulo cytes predominate

Majority<15,000 Majority normal .Lymphocytes or less than predominate 15,000

- C-reactive protein
- Sed rate 30 mm/hr

Majority

Infrequent

Infrequent

Majority

Majority

Majority

Etiology of Pneumonia in infants and Children

Viral Agents Para 1,2,3 Influenza A,B Etc.

Winter

S.Pneumonia

Mycoplasma Summer RSV

C.Trachomatis
Strep. Gr.B E.coli CMV 1 Staph. 2Staph. C. pneumoniae

H.Inf.B.

1 mo.

3 mo.

6 mo.

1 yr.

3 yrs.

5 yrs.

10 yrs.

Prospective Studies of Perinatal Chlamydia Infection

Infants

City Mother San Francisco 5 Seattle 13 Denver 9 Boston 2 Seattle 12 Lund 9 Nairobi 22

Conjunctivitis(%)
18 44 44 33 33 22 37

Pneumonia (%)
16 -22 17 8 -12

Clinical Features of C. Trachomatis Pneumonia

Onset at 3 to 11 wks of age Cough greater than one week in duration Prior conjunctivitis Afebrile tachypnea with diffuse rales Hyperinflation and interstitial infiltrates on chest film Eosinophilia Increased IgM Increased IgA and IgG

9 8 7

Number of patients

6 5 4 3 2 1 0 1 5 6 7 8 9 10 11 12 13 14 Treatment day Treatment day when improvement first noted 2 3 4 Erythromycin Sulfisoxazole

Pneumococcal 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 rales Neck rigidity without meningitis may occur (RUL) WBC 15,000 - 40,000 Blood C/S positive only 30% Lobar consolidation (less common in infants) Para-pneumonic effusion is relatively common

Mycoplasma pneumoniae in the United States

Syndrome
Pneumonia Tracheobronchitis Asymptomatic Infections All infections

Incidence/year Total cases

2/1.000 46/1,000 12/1,000 500,000 11,500,000 3,000,000

15,000,000

Incubation Wks.-2 Symptoms: Headache,malaise Fever Sore throat Cough Signs: Sputum Dullness Rales -1
0

Clinical illness 1 2 3

Convalescence 4 5 6

Laboratory: Positive culture

x-ray

Diagnostic Tests for Mycoplasma pneumoniae

Test
Culture

Specimen

Sensitivity(%)
> 90

Specificity(%)
50-90

Comments
Not routinely available; slow-growing organism

Throat or NP swab, sputum, bronchial washing tissue PCR Throat or NP swab, sputum, broncial washings, tissue Serology cold agglutinins Serum Complement 9wks fixation Elisa

95

95-99

Not commercially available potencially useful for rapid diagnosis test Nonspecific;takes several wks to develop Paired acute-convalescent sera preferred;takes 4for seroconversion Diagnostic criteria Definite: 4-fold increase in titer

50 75-80

< 50 80-90

Chlamydia pneumoniae ( TWAR )

This organism cause pneumonia, bronchitis,sinusitis and pharyngitis and is a common cause of infection in children from the age 5 15 years. Of the three Chlamydia species, Chlamydia pneumonia is by far the most common cause of human infection

Clinical Finding in Pneumonia Associated with M.Pneumoniae,TWAR and Viral Respiratory Agents

/////////////////
Cough Sore throat

TWAR ( N=26 )

M.pneumoniae ( N=35 )

Viruses ( N=86 )

100% 50%

97% 48%

89% 50%

Horesness
WBC>10,000 Fever>106F Hospitalized

48%
25% 67% 4%

32%
21% 94% 3%

37%
37% 93% 5%

Outpatient

Inpatient
(septic, alveolar infiltrate, large pleural effusion or all)

0-20 days

0-20 days

Admit pt.
Afebrile; give PO erythromycin. Admit for fever or hypoxia PO amox or azithro. If >8 yrs, PO doxycycline (4mg/kg/day, 2 divided doses)

3wks-3mos

IV amp/gent with or w/o IV cefotaxime Give IV cefotaxime or ceftriaxone IV cefotaxime, ceftriaxone, if pt not well consider IV azithromycin*

3wks-3mos

4mos-4yrs

4mos-4yrs

Pleural Empyema In Children

Stages of infection
Exudative (allows needle aspiration) Fibrinopurulent (may be loculated) Organizing

Treatment options
Exudative Exudative or fibrinopurulent Organizing Repeated needle aspiration (1-5 days) Chest tube drainage 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 Effusions

Clinical Condition Empyema Type of effusion Exudate Predominate Cells in Effusion PMN cells>50,000/ mm3 PMN cells<50,000/ mm3 Lymphocytes Lymphocytes Glucose Level(mg/dL) <30 pH

<7.00

Parapneumonic effusion Tuberculosis Congestive heart failure Hypoalbuminemia Malignancy,SLE

Exudate

>30

<7.20

Exudate Transudate Transudate Exudate

30-60 >60

7.007.30 >7.40 >7.40 Variable

Lymphocytes( <60 few) Lymphocytes, Variable malignant cells

Reported frequency of pleral effusion in pneumonia

Etiology
S.aureus Strep.pneumoniae H.Influenzae Group A Streptococcus Mycoplasma pneumoniae Adenovirus

Frequency(%)
72-76 57 49-75 86-91 21 11-33

Algorithm for Empyema

Pleural effusion
Thoracentesis
Gram stain-neg
Observe Resolution

Gram stain-pos
Chest tube

Increasing fluid Resolution Open drainage

Non-resolution Decortication

Which of the following statements regarding pneumonia in children is true?

A .Specific microbial pathogen usually can be identified B. All children who have pneumonia should be hospitalized for observation and treatment C. Pneumonia is a rare cause of child mortality worldwide D. Radiographs of the chest always should be obtained to determine the cause E. Viral agents are the most common causes of pneumonia in older infants and children

You are evaluating an 8 year old boy who has 7 day history of malaise and worsening cough. His mother reports that he has had low grade fever. PE reveals a well appearing boy with normal RR and pulse ox. Lung exam reveals bilateral crackles without wheezing . Chest x-ray show bilateral interstitial infiltrates without effusion.

Most likely pathogen is:

A. Haemophilus influenzae B. Mycobacterium tuberculosis C. Mycoplasma pneumoniae D. Respiratory syncytial virus E. Streptococcus pneumonia

An 8 week old girl presents to ER with increased work of breathing x 1 day. Temp of 101.1 F, difficulty breastfeeding due to nasal congestion. RR 70, pulse ox 90% on RA. Lung exam reveals bilateral wheezes and crackles. CXR shows increased perihilar markings bilaterally and right middle lobe opacity.

Most likely cause of her symptoms is;

A. Adenovirus B. Bordetella pertussis C. Chlamydia trachomatis D. Group B Streptococcus E. Respiratory syncytial virus

#4
Main Cause of Necrotizing Pneumonia is:
A. B. C. D. E.

Streptococcal hyaluronidase Teichoic acid Pneumolysin Fibrinolysin Ponton-valentine leukocidine

#5
The following microorganisms are frequent causes of pleural effusion EXCEPT:
A. B. C. D. E.

S. aureus Strep pneumoniae Group A streptococcus Haemophilis influenzae type B Mycoplasma pneumoniae

#6
Characteristics chlamydial pneumonia include the following EXCEPT:
A. B. C. D. E.

Afebrile History of conjunctivitis Staccato cough Eosinophilia Present at 4-6 months of age

#7
Distinguish features of exudate from transudate are as follows EXCEPT:
A. B. C. D. E.

Pleural fluid: serum protein ratio > 0.5 Pleural fluid LDH > 200 IU/ml Pleural fluid: serum LDH > 0.6 Pleural fluid protein > 3 gm/ml Leukocyte count > 1,000/CU/mm

Features Differentiating Exudative & Transudative Pleural Effusion

Transudate

Exudate
>50,000/ mm <7.2 >3.0 g/dL >0.5 >200 IU/L >0.6 <60 mg/dL

WBC pH Protein Protein ratio LDH LDH ratio Glucose

<10,000/mm >7.2 <3.0 g/dL <0.5 <200 IU/L <0.6 60 mg/dL

TIME TO WAKE UP!!!