Review Ar ticle Journal of Paediatric Respirology and Critical Care

Review on paediatric necrotising pneumonia and its pulmonary
co-morbidities
Danial Wai-Tai KO
Department of Paediatrics, Queen Elizabeth Hospital, Hong Kong

Abstract
Necrotising pneumonia (NP) is defined as destruction of normal lung parenchyma with the presence
of areas of decreased contrast-enhancement +/- small air or fluid cavitations. Apart from the complication
of sepsis, it can also be associated with other pulmonary co-morbidities including parapneumonic
effusion/empyema, bronchopleural fistula and lung abscess. Most literature have reported
Streptococcus pneumoniae and community-acquired methicillin resistant Staphylococcus aureus as
the commonest pathogens. Mycoplasma pneumoniae, however, is becoming another important
causative agent, especially in the setting of increased prevalence of macrolide-resistant strain.
Contrasted computer tomography thorax remains the gold standard for the diagnosis of NP, but its
role may be substituted in the near future by thoracic ultrasonography with no concern of radiation
risk. Intravenous antibiotic is the main line of treatment and surgery has only ancillary role in managing
the complications. Though NP has significant morbidity in its acute stage, which usually leads to
prolonged hospitalisation, extended course of antibiotics or even necessity of surgical intervention,
its long-term prognosis is found to be excellent with low mortality, based on full clinical recovery and
minimal residual changes in follow-up imaging. More studies are however required to have better
assessment on the functional outcomes of children affected.

Keywords: Child, necrotising, pneumonia

Introduction thorax. Different studies had minor variations in their
working definitions but the main features are similar as
Nowadays, dramatic increase in incidence of paediatric follows.2-5
necrotising pneumonia (NP), after the introduction of - Areas of consolidation without loss of volume
7 polyvalent pneumococcal conjugate vaccine (PCV-7) - Destruction of normal parenchyma with the presence
followed by the selection of more virulent non-vaccine of areas of decreased contrast-enhancement
serotypes of Streptococcus pneumonia,1 was reported - Plus or minus presence of multiple small air or fluid
as well as the worldwide epidemic of community- cavities
acquired methicillin resistant Staphylococcus aureus - Excluding abscess, the features of which include
(C-MRSA). Though paediatric community-acquired prominent rim of contrast-enhancement in the
pneumonia has good prognosis in general, the same periphery
situation may not be true in severe NP. In this article
the relevant publications on paediatric necrotising Parapneumonic effusion and empyema are actually
pneumonia will be reviewed. within a continuum. Parapneumonic effusion (PPE) is
the presence of pleural effusion in association with the
underlying pneumonia.6 Empyema is usually defined
Definitions of necrotising pneumonia, when there is macroscopic appearance of purulent
parapneumonic effusion and empyema and pleural fluid, but in broader definition it also includes
pulmonary complications the condition in which bacteria is identified in the pleural
fluid.6
In nearly all studies, necrotising pneumonia was defined
mostly by findings in the computer tomography (CT) of Bronchopleural fistula (BPF) is defined as the presence
of persistent communication between the pleura and
Email: kodanial@gmail.com the underlying necrotic lung tissue.7 Pneumatocele is a

20

there were 4859 consultations of pneumonia in complicated with necrotising pneumonia or empyema 21 . In Utah's study. after the launch of the universal Nevertheless.67 (95% CI 3. Six hundred Finally lung abscess is defined as the well-delineated and thirty-five patients (13%) required hospitalisation area of intrapulmonary fluid density or cavity with air. all of which number from three cases per year in the interval 1993. A recent French study in one tertiary Paediatric Hospital When compared with PCV-7 group. serotype 3 has become the the rise in the incidence. (13. air-filled cyst inside the lung parenchyma.13 Serotype 14.90-13. p=0.025).2%). but also their pneumonia were mostly 2011. covered by PCV-7.3%). 2 Since then the publications have been Streptococcus pneumoniae accumulating but they were mainly case reports or As shown in the Table 1a.5 The strongest pathogens identified. with thick (>2 mm) enhancement wall. requiring chest tube insertion (OR 5. 95% However. It can be seen that there is no prospective study on population basis to evaluate the true incidence of NP. Streptococcus pneumonia is the most 1a and 1b have listed some important findings extracted important pathogen causing necrotising pneumonia.1 The authors divided the study period intubation rate (75% versus 29%).4% necrotising pneumonia.11-12. 10 1. 12 When their confirmed NP also saw a drastic increase in case compared with the 7 NP in the control group. the percentage of complicated pneumonia. Over PCV-7 strains on their role in all paediatric invasive the total study period of around nine years. the serotype 19A led to more evidence demonstrating an increase in both the number complicated disease with longer hospital stay (19 days of culture-positive pneumococcal pneumonia and the versus 13 days). 1997-2000 and 2001-2006. and 41 (0. CI 1.9 Furthermore the percentage of pneumonia complicated with NP actually doubled from 4.03-47.11-51. fluid level. December 2014 Review Ar ticle thin-walled. ranked the fourth causing IPD (95% CI) 1. followed by 19A. not included in PCV-7.8%). and undergoing surgical procedure (OR defined as the presence of empyema or necrotising 3. showed rapid rise from 25% in 1995 to 70% from Texas' researchers also reported 4 cases of NP all in 2002.and post-PCV-7 era to intensive care unit (75% versus 29%) as well as higher were compared. separated by the demarcation line of the year 2000 when PCV-7 One Taiwan's study also compared the PCV-7 and non- vaccine was first launched in the United States.0%) and 23F (16.0.2 days versus 17 days). remained the of NP was detected from 5 of 39 cases (13%) in the most important strain identified in IPD (23. with odd ratio (OR) 3.7%). more admission study in Utah when data in pre.25). 95% CI peak in 2000 followed by modest slip to to 2002. Tables experience. Another study in Children's Hospital Boston on caused by the more virulent serotype 19A. 95% CI 0. A significant escalation in the percentage Taiwan.28.5% to 9% when comparing the two periods 2006-2009 and 2009-2011.34 [95% confidence interval 3.14). Epidemiology and incidence Reports on necrotising pneumonia in children were Microbiology scanty before 1990s with the first case report published in 1994. Data from one Taiwan tertiary university hospital causing NP with OR 14. prolonged duration of intravenous percentage of paediatric NP actually came from the antibiotics (19.57). from the relevant published articles on necrotising/ Furthermore the non-PCV-7 serotypes including necrotizing pneumonia limited to paediatric population serotypes 3.8 their Paediatric Emergency Department.38.11 Between May 2006 and April versus 38. important serotypes causing the disease after the start of PCV-7 vaccination. especially after the launch of most important strain of Streptococcus pneumonia PCV-7. The serotype period. the non-PCV-7 provided a better estimate on their local incidence of serotypes had more pulmonary manifestation (63. 4. 124 cases pneumococcal disease (IPD) over 12 year at the time of culture-positive paediatric pneumococcal pneumonia when the compliance of PCV-7 was still poor in were retrieved. several retrospectives studies indicated immunisation of PCV-7. A letter to the Editor pneumonia. have become the (birth-18 years). followed earlier time to 28 of 85 cases (33%) in the post-PCV-7 by serotypes 6B (19.8%). Volume 10 No.8%) children was later diagnosed to have NP. were retrieved from the past hospital record with no 1996 to 14 cases per year in 2003-2004. 1 showed that there was gradual growth in the annual Furthermore the serotypes 3 was also found to have number of pneumococcal pneumonia from 1995 to the higher risk in developing empyema (OR 5.59. as well as the local retrospective studies of small patient number.03]. into two groups. Second commonest member in the non-PCV- 7 group associated with IPD was serotype 19A (3.39-86.

ND not documented. 2 malignancy. PPE.8yr Healthy 1 GAS.9 days +/- (Turkey) study (9mth-14yr) positive diplococci 4.15.2 days(SD) 1 haemolytic anaemia. 6yr. 22 . 2 MP. bronchopleural fistula. MRSA. 4 heart disease. IQR. antibiotic. follow-up. ND MP Up to 20 days 5yr.3 days(SD) in pleural fluid Tseng (Taiwan) 20 2005 Case report 1 2yr Healthy C-MRSA 15 days Chiu (Taiwan) 22 2006 Case report 1 7yr Healthy MP Around 30 days Hsieh (Taiwan)## 31 2006 Retrospective 15 Mean 49mth Healthy SP Median 9 days review (9-85mth) (4-30 days)@ Sawicki (USA) 5 2008 Retrospective 80 Median 3. 7yr Healthy SP ND Wong (Taiwan) 3 2000 Restrospective 21 Mean 28. GAS. methicillin-sensitive SA. 9yr Lematre (France) 11 2013 Retrospective 41 Median 14mth Not 13 C-MRSA. MP. interquartile range. 4yr.3mth Healthy 3 SP.1(SD) 13 culture-negative Congiz (Turkey) 26 2004 Case report 1 7 yr Healthy GAS ND Wang ( Taiwan) 23 2004 Case report 5 3yr. Median 7 days review (1mth-16yr) immunocompromised 7 SP. Summary of published articles on necrotising pneumonia (NP) in children Study Reference Year Type Number Age Premorbid Pathogens Duration of fever Kerem (Israel) 2 1994 Case report 4 1. 2 SA. SA. C-MRSA. 2yr. standard deviation.5yr except one IgG2 deficiency McCarthy (USA) 40 1999 Case report 3 1. 1. AB. 3 gram 8. SD. pulmonary function test. chest drain. 42 culture-negative (52%) Obando (Spain) 27 2009 Case report 1 12yr Healthy C-MRSA + H1N1 flu A 23 days Kalaskar (USA) 12 2009 Case report 4 2. Streptococcus pneumoniae. Journal of Paediatric Respirology and Critical Care Table 1a. 4.14yr Hsieh (Taiwan)** 10 2004 Retrospective 40 Mean 52. ND review +/. ** Study on complicated pneumonias (with empyema or NP) out of 71 pneumococcal pneumonias. methicillin-resistant SA. HIB.2yr) 2 immunocompromised also (IQR 3-9 days) MSSA/MRSA. year. SP 13. yr. Median 6 days review (IQR 2. community acquired MRSA. Mycoplasma pneumoniae.8-4. (1-25 days) 1 Fusobacterium nucleatum Abbreviation: SP. 7.3mth 5 asthma. 2 HIB.6yr 53 healthy.4-6. ## Study on NP out of 56 pneumococcal pneumonias. 18 SP( 22%). FU. 8. mth. Group A Streptococcus. 5yr. MSSA.3yr.9yr. Staphylococcus aureus. @ Days of fever from hospital admission. CD. Haemophilus influenzae type B.5yr.5yr. VATS. 4 SP serotype ND 3 healthy 19A Pascual 30 2010 Case report 1 15yr Healthy but Mycoplasma ND (Switzerland) sexually active hominis Yazer (Canada) 28 2011 Case report 1 5yr Mild asthma SP+ H1N1 ND Moreira Silva 29 2012 Case report 1 28mth Healthy Acinetobacter ND (Portugal) Iwoffii Wang (China) 24 2012 Case report 5 3yr. video-assisted thoracoscopic surgery.5 days+/- review (9-144mth) 2 genetic. Healthy MP 3 -20 days 6yr. 1 metabolic Hacimustafaoglu 4 2004 Prospective 36 Mean 3. Normal immunity SP 9-20 days 2. month. parapneumonic effusion.1yr 1 asthma. BPF.3yr. PFT.

Nil Full recovery ND (Switzerland) pericardial effusion pericardiectomy Yazer (Canada) ND Empyema.5% mortality Hacimustafaoglu 26 days+/.5%) 7. 3 weeks in CD Nil 3 full recovery. chest X-ray. year. 2 segmentectomy. community acquired MRSA. Nil 19 normal CXR. @ Days of fever from hospital admission. follow-up. BPF ND CD Nil Minimal respiratory symptoms ND Moreira Silva (Portugal) ND PPE(mild) 25 days Nil Nil Full recovery 2yr Wang (China) 17-35 days PPE Up to 4 weeks CD Nil ND but one with persistent Up to consolidation in CXR 180 days up to 180 days after FU Lematre Median 16 days Empyema. Some up to multiple abscess 1 patient 2 residual lung damage 8mth (1 pneumatocele. PPE. 1/40 NP alone. CD Nil Full recovery ND Hsieh Median 18 days Empyema (93%) 16-38 days 93% CD. others fully recovered or decortication Tseng (Taiwan) 8 days Empyema 8 days CD Death Death on day 8th Nil Chiu (Taiwan) 22 days PPE (massive) 10 days VATS. interquartile range. . GAS. BPF. MP. Group A Streptococcus. BPF 20-22 days 2 decortication. Staphylococcus aureus. 7 minimal fibrosis. MSSA. CD. HIB. 23 . C-MRSA. 3 weeks VATS. FU. not documented. parapneumonic effusion. abscess. Median 174 (IQR 9-17 days) (range 3-95) thoracotomy/ 12 with FU PFT: days (IQR77- decortication. AB. 2mth (Turkey) 9 days (SD) BPF (55%) excision. Summary of published articles on necrotising pneumonia (NP) in children Study Hospitalisation Complications Duration of Other Mortalithy Outcome FU time day relevant AB treatments Kerem (Israel) 12-26 days PPE. 1 partial atelectasis of left lingular) Hsieh (Taiwan)** 25. BPF Mmedian 27days CD. fistula repair.5% Mortality. 3 VATS hydropneumothorax. Median 42 days 3 CD+ later Nil No deaths ND (France) (7-43 days) pneumothorax. decortication. open Nil Full clinical recovery. video-assisted thoracoscopic surgery. lung abscess 2 abscess debridement residual pneumatocele Congiz (Turkey) 8 days Empyema 8 days CD Death Death on 8th day Nil Wang (Taiwan) ND PPE (Massive). ND. (31-60 days) VATS. yr. Haemophilus influenzae type B. Mycoplasma pneumoniae. CD Nil Full recovery except CXR: ND pneumothorax mutliple small pneumatoceles and residual pleural thickening Kalaskar (USA) 15-28 days ND 23-35 days VATS Nil Full recovery ND Pascual 19 days PPE. chest drain. at outset pneumatocele Abbreviation: SP. December 2014 Review Ar ticle Table 1b. 2 with small BPF. 4 mildly deranged 360 days) partial lung resection Obando (Spain) 28 days Empyema. 1 death FU CXR in 10 patients: 1-6mth (Taiwan)## (5-40 days) 53% VATS 2 total resolution. SD. methicillin-sensitive SA. 6mth pneumothorax. 1 cicatrizing atelectasis Sawicki (USA) Median 12 days PPE. 14-35 days 9 VATS. ND 24/40 3/40 ND except ND 12. CXR. empyema 6 weeks 2 CD Nil Full recovery except 1 Up to CXR with pleural thickening 12mth McCarthy (USA) 10-15 days PPE. 4.2 days+/.0 days (SD) 12/40 NP+empyema thoracotomy (7. loculations. bronchopleural fistula. MRSA. Volume 10 No. antibiotic. ## Study on NP out of 56 pneumococcal pneumonias. standard deviation. VATS. VATS. Empyema/PPE (94%). pulmonary function test. SA. Nil CT done at 6 weeks in ND 1 abscess debridement+ 1 patient: small pneumatocele decortication+closure of BPF and residual pleural thickening Wong (Taiwan) ND Empyema. month. Streptococcus pneumoniae. PFT. ** Study on complicated pneumonias (with empyema or NP) out of 71 pneumococcal pneumonias. 2 weeks CD. ND 66% requiring lung 6% 5. IQR. methicillin-resistant SA. mth.

Importantly. prolonged fever occurred up (13. Panton-Valentine the French single center study on 41 children with NP. Fortunately.30 Staphylococcus aureus The second commonest bacteria causing necrotising pneumonia in the literature is Staphylococcus aureus.14 Mycoplasma pneumoniae Serotype 14 declined from 36% to 15.25 as well as the necessity of surgical treatment. it February 2006 to February 2008.21 No recent articles in the literature have the results in this study should be interpreted cautiously reported the current local situation of paediatric as none of the IPD patients were reported to have Staphylococcus aureus pneumonia. the only article published in 1993 stated that reaching the statistical significance (p=0. the immunisation of parapneumonic pleural effusion actually required chest Prevnar-7 has actually selected the two more virulent drain insertion 23 and video-assisted thoracoscopic non-vaccine serotypes 3 and 19A. leukocidin-positive Staphylococcus aureus. the massive To summarise all the studies. was long hospital stay ranged from 17-35 days.24 Third.4-93. the proportion of In Wong's study.9% become an important cause of NP around this region.2%). 27. though no mortality was reported so far. following rather related to selection of more resistant-strains after Haemophilus influenzae and Streptococcus extensive antibiotic usage. there the concept of serotype replacement.59). as well as massive From Taiwan's study in 2000 including 21 cases. the emergence of serotype 19A has posed Miscellaneous pathogens a threat of multiple antibiotic resistance.16-20 From pneumonia in paediatric population. including Acinetobacter species 29 and Mycoplasma hominis. 11 tracheal and bronchial mucosa.23 and one from China 24 also remained similar (from 91. According Staphylococcus aureus ranked the third of the to the authors. Other pathogens reported in the literature also included most of the common serotypes reported to cause NP group A Streptococcus. one being methicillin-sensitive complicated pneumonia (necrotising pneumonia or whereas another methicillin-resistant. serotype 3 two out of eight culture-positive NP were caused by was identified to carry the highest risk of developing Staphylococcus aureus. The 19A serotype was also found to have the to 20 days even after starting erythromycin and there highest drug resistance. but those serotypes included in PCV-13 reports from Taiwan 22.23. Pathogenesis of necrotising pneumonia especially community acquired methicillin resistant Staphylococcus aureus (C-MRSA). has been 13 cases were caused by C-MRSA followed by showed to induce extensive necrotic ulcerations of the 7 children with Streptococcus pneumoniae. (p<0. The three case reports Another similar study in China analysed all hospitalised however revealed the clinical features quite different children <5 years with pneumococcal pneumonia from from the usual self-limiting atypical pneumonia. However from the author's experience. on the other hand.28 as well as those rare bacteria pneumococcal conjugated vaccine. On the other hand. Furthermore 19A described NP related to this bacteria.3 Subsequently two further case 65. nor are there any received prior PCV-7.8 (95% CI: 1.12 The serotype 3 was a recent article reporting an increase in the also results in more necrotising pneumonia or empyema.24 Second.9%).01). has whereas 19A rose exponentially from 0 to 12. few One local study also analysed the change in serotypes necrotising pneumonia are caused by C-MRSA. First.20 With respect to the local than uncomplicated one (12. down to the predominant serotype was 19F (55. the emergence of serotype 19A was commonest bacteria in childhood pneumonia. prevalence of macrolide-resistant MP in Hong Kong.26 co-infection with human swine nowadays are still protected by the newer 13-valent influenza (H1N1). though not incidence.7%.282).5% to were caused by MP. 15 The most predominantly affected the younger age.9% versus 0%). number of cases remained small. For those younger than 5. which carries the It is still debatable about the pathogenesis of necrotising gene for Panton-Valentine leukocidin (PVL). The reported one fatal case of C-MRSA with severe sepsis serotype 19A also caused more complicated pneumonia and necrotising pneumonia.9% compared with 55. case reports of paediatric NP caused by C-MRSA in Hong Kong.7% (p<0.2%). It should be reminded that pneumoniae. two cases of necrotising pneumonia PCV-7 covered serotypes decreased from 89.6%). Journal of Paediatric Respirology and Critical Care (78.3 Tseng et al also empyema) with OR 8.22 Furthermore. followed by 19A age of three. involved in IPD for all ages (from less than 5 to greater than 65 years) after initiation of PCV-7 immunisation. which has supported surgery (VATS) with decortication.024-75. though the total was associated with penicillin/erythromycin resistance.01) Mycoplasma pneumoniae (MP). haemorrhagic necrosis of inter-alveolar septa in one 24 .

25 .66-38. leading to parenchymal destruction.79 (1. 7 Coagulation necrosis was the complicated pneumonia and lobar pneumonia.06-28. as exhibited by performed the autopsy in their only mortality case and left-shifted neutrophilia and elevated CRP. CI: confidence interval. namely no-underlying diseases. another paper was published and it included retrospective review.04 Presence of immature polymorphs in peripheral blood 5.18 Multivariate analysis further calculated that Only one study investigated the potential risk factors the adjusted relative hazard associated with death for leading to the complicated pneumococcal pneumonia. CI 1. 4 then cavitations.037 OR: odd ratio. nor the penicillin resistant patients with necrotising pneumonia complicated with strains were found to have significant difference between bronchopleural fistula.70) 0.0-43.71 (1. The gangrene subsequently cytokine-immune response from the host toward the evolved to liquefaction of pulmonary parenchyma and pathogens. 10 detected in 11/12 cases. adjusted hazard ratio 4.81 (1. lung resection was performed in 12 Streptococcus pneumonia.002 3.99) 0.38-8. two rather contradictory findings from that retrospective study was that neither the serotypes of In another article.51). 19 Severe 5 characteristics associated with complicated leukopenia (</=3000/ml) increased the mortality with pneumonia as tabulated (Table 2).16 However it is still unclear how presence of immature PMN and elevated CRP.04-73) 0. Risk factors associated with complicated pneumonia Univariate analysis Multivariate analysis Risk factors OR (95% CI) P OR (95% CI) P Age >36 months 2.035 No underlying disease 7. 40 developed parenchymal larger population of 148 patients with median age of 22 necrosis or empyema. most children with NP were healthy draining to the infarcted region.38 (95% CI 1.05-7.60-34. Univariate analysis identified years (interquartile range 3. investigated PVL-positive Staphylococcus aureus necrotising pneumonia in 50 patients with median age 14.48 (1.25) 0.08-12.5 (95% CI: 2.64-20.45 (95% latter three conditions.56) 0.96-30. The presence of prior influenza illness increased the risk of However further multivariate analysis only isolated the severe leukopenia with adjusted odd ratio 4.79-14. the same authors inflammatory towards the pathogens.3% (4/12) and 66. was serotype 14 and none of the cases was caused by Furthermore vasculitis and thrombosis formation were serotype 3. Volume 10 No.10-24.24 (1. The identification of the above three it has been postulated to be related to one unknown conditions actually supports the notion that the host virulent factor secreted. Table 2.01 5. total WBC count >1000-3000 /ml and 0-1000 were 7.14 (1. They postulated that without impaired immunity. to be Streptococcus pneumonia causes tissue destruction and risk factors.04 5. The risk factors Risk factor for the development of necrotising identified in deceased group when compared with the pneumonia/complicated pneumonia survived group included airway haemorrhage and leukopenia.63) 0.5 years (range 1 month .67-11. identified histologically in 33.74) 0.88).7% (8/12) respectively.038 Thrombocytopaenia 8. the French researchers microscopic ischemic necrosis.02) with necrotising pneumonia or empyema10 Out of 71 respectively.037 C-reactive protein >12 mg/dL 5. These findings further support the With respect to PVL-positive Staphylococcus aureus theory of macroscopic pulmonary gangrene and necrotising pneumonia.31 Furthermore. Nonetheless. is probably identified pulmonary gangrene in the right middle lobe the key element for the tissue injury.67 (1. December 2014 Review Ar ticle post-mortem study.99 which was defined to be culture-positive and associated (95% CI 1. Eight of those twelve patients Actually the predominant serotype isolated in that study were also detected with co-existent suppurative necrosis. Six year later from the same French confirmed pneumococcal pneumonia in their 8-year institution.7 years).83 (1.43) and 7. as and intravascular thrombi in the pulmonary artery shown in Table 1a. It further supports the pulmonary gangrene might be infrequently associated postulation that NP is developed out of the exaggerated with pneumococcal NP.78 year). 4.93) 0. Furthermore.

26 . Finally. However when the that additional findings obtained from CT thorax did additional Colour Doppler technique was applied. the Great pneumothorax will also hinder the detailed lung Ormond Street Hospital for Children. there was a delayed consolidation/parapneumonic effusion (PPE). 6 thorax study on 9 children.4 In a Switzerland's management of pleural infection in children. some surgeons still prefer to will usually not alter the conservative approach for request CT scan as a road-map before they proceed management on those patients.33 There is Nevertheless. Thus with the vast four extra cavity-necrosis. according to the authors' comments. the not alter the management plan nor provide any identification of vessel signals in pericavitary prognostic value. Thus they concluded pulmonary complications.38 USG is not easily only be picked up by the very experienced paediatric performed in uncooperative children.35 especially in the management of co- diagnosed by CT. Those additional CT may be in near future widely utilised as the primary tool findings.9 In that study. differentiating between empyema and lung abscess for However in treating empyema. 32 In evaluation of detection of the associated into different management approach: antibiotic alone. It can always be argued that the results Despite the above discussion. complications. dose especially in children who still have higher number of active dividing cells than adult. specificity parenchyma only. it detected by CXR and CT. CT was more sensitive in detecting 100%. Moreover. the United Kingdom peripheral pulmonary air-fluid lesions. or even parapneumonic effusion in 5 children confirmed by CT. its specificity and positive predictive values both of routine use for all suspected cases is not 100%. CT thorax still has its may be biased as the subtle findings of CXR might unique role for more difficult cases. the Table 1b has pointed out. out of 25 patients with consolidation was found excellent in diagnosing CXR abnormality showing simple opacification in lung peripheral lung abscess with sensitivity 94%. Only one case and all was diagnosed by CT solely. that there was no additional role for CT when those children with empyema were already managed with Important role of CT thorax in equivocal/complicated combination of chest tube drainage with intrapleural cases and pre-operative assessment urokinase. but with low sensitivity surgery (VATS) on paediatric empyema suggested of 40% and 47% respectively. CXR also missed 2 cases of chest tube drainage plus intrapleural fibrinolytic. Journal of Paediatric Respirology and Critical Care Tool of diagnosis Growing potential of thoracic ultrasonography Ultrasonography (USG) of thorax has gained a more Role of CT for the diagnosis of NP important role nowadays in the management of In most studies. necrotising pneumonia pathology which is situated in areas not easily mostly has an excellent prognosis with full clinical accessible by USG (e. could for investigating the suspected NP and detecting other still be managed conservatively. to VATS/decortication. when CXR findings were compared u l t r a s o n o g r a p h y i s i n d i c a t e d t o d i ff e r e n t i a t e with those of contrasted CT. even the confirmation of NP by CT-findings be identified. one more pneumatocele and predictive value 94% respectively. In (CXR) for diagnosis in the presence of multiple cavities British Thoracic Society (BTS) guidelines on the on the background of consolidation. positive predictive value 100% and negative one additional cavitation. simple detection of cavitary necrosis in three children by 5-9 versus complicated PPE. However as the imaging beneath the air layer. but no lung abscess were advancement in the field of thoracic ultrasonography. surgical intervention. report from Taiwan showed that the presence of peripheral hypoechoic spaces (PHES) was specific Though CT thorax should be the investigational tool sonographic features for childhood NP with the of choice in diagnosing necrotising pneumonia. adjacent to scapula) cannot recovery.36 However the low sensitivity of 35% of PHES recommended in view of its considerable radiation could not exclude NP in its absence.g.34. Presence of radiologists in that tertiary children hospital. and to guide the algorithm days. 37 The study randomised controlled trial on conservative approach showed that the ultrasound findings of complex-septated (percutaneous chest drain insertion plus intrapleural effusions and passive atelectasis both were specific urokinase) versus video-assisted thoracoscopic (specificity 100%) for empyema. necrotising pneumonias were pneumonia. there was an adult study (aged 33-79 no study on the role of CT thorax guiding on the years) proving the usefulness of thoracic ultrasound in management of isolated necrotising pneumonia. Some papers also used chest X-ray existing complicated pleural effusion/empyema. Its role on the diagnosis of NP Three cases of BPF were only identified in that series has not been well established currently.

both conditions co- prognosis in that study was not satisfactory as 15 existed simultaneously. on paediatric NP. (septic shock. when compared with no-BPF Most patients diagnosed to have necrotising pneumonia group. 86% were found to have appreciable bacteria (7%).11 Pneumatoceles can be detected as early complication or late sequel. and prolonged Table 1b. nine were more commonly associated with the patients had chest-drain inserted also for PPE and two pneumatoceles. a pneumonia is nearly universally associated with PPE/ study investigated the 394 children admitted to one empyema.0007). On the contrary.40 27 . had longer duration of pleural drainage (median usually suffer from other complications. as showed in 14 versus 6 days. In the literature review as shown in Table Bronchopleural fistula 1.39 8. pneumatoceles as small and residual findings in contrast CT thorax.3% (33/394 cases) were found to pleural culture of Streptococcus pneumoniae . 55% of the follow-up chest X-rays were relatively common as patients with NP had BPF.27. days. Pneumatoceles are thin-walled. Volume 10 No. With respect to necrotising pneumonia. The definitive diagnosis depends on hand. including lung report. two patients had PPE while empyema was pneumonia complicated with empyema and/or found in the remaining two children both with positive pneumatocele. out of 112 children with culture-confirmed In most studies investigating necrotising pneumonia. resulted from alveolar and bronchiolar abscess.4 Twenty percent resolved mentioned in 4 reports. acute by chest drainage without surgery. disseminated intravascular coagulopathy. parenchyma to the adjacent pleura. in many patients suffered from and necrotising pneumonia concurrently. Those with BPF.5 Nineteen cases (24%) had bacteria pneumatoceles resolved spontaneously but four cases cultured from pleural fluid and 5 cases was positive for including one tension pneumatocele and three ruptured pneumococcal antigen in pleural fluid. The authors did not describe which pathogens successfully treated conservatively with antibiotics. 3.5 Twenty. This complication Staphylococcus aureus was the predominant pathogen should be suspected when the pneumothorax exists (13/21 cases) in all positive culture in NP followed by in the background features suggestive of necrotising Streptococcus pneumoniae (7/21 cases). On the other pneumonia. 3 One-third commonest three bacteria in all culture-positive pleural (7/21) of the patients needed surgical intervention for fluid were Streptococcus pneumoniae (18%). However. pneumatoceles were present in 4 (9.8 It is Parapneumonic effusion and empyema well known to be associated with Staphylococcus aureus PPE and empyema are within a continuum. pneumatoceles and lung lung parenchyma.23. respiratory distress syndrome). though in that study the most of the 9 patients had complicated PPE. which allow unilateral air entry into the interstitial tissue through the check-valve effect. Nevertheless all BPF could be treated successfully acute renal failure/fluid-electrolyte disturbance. pneumococcal pneumonia. In addition to those secondary to severe sepsis hospitalisation (median 19 versus 13 days. In the earliest paediatric report including 4 Brazilian university hospital with the diagnosis of patients. In a French study cysts required drainage. air-filled cysts inside the bronchopleural fistula. there are important pulmonary complications that needed to be managed Pneumatoceles simultaneously. including parapneumonic empyema. necrosis. December 2014 Review Ar ticle Pulmonary complications/co-morbidities one percent (10/47) on pleural drainage developed BPF. from the 11 out of 21 NP to 90 mm. 18 of them (16%) were abscess was excluded and was treated as a separate detected to have BPF.40 Further from one case patients with BPF required surgery. pneumatoceles as an acute complication was only The presence of bronchopleural fistula actually implies reported in one article.7%) patients.11 Out of 41 cases in the French the extension of tissue necrosis from the lung study. 4.7 All of them also had empyema disease entity. p=0.001). In another Lung abscess study.32 From the Turkey study. 2 have pneumatoceles with diameter ranging from 5 mm In Taiwan's study in 2000. From Boston's study including 80 cases Staphylococcus aureus (10%) and Gram negative of paediatric NP.3. the data from lucent lesions coalesced to lung abscess over 3-4 the Boston study showed a better outcome. The "complicated" pneumonia. the percentage of empyema in NP was 63% (26/41 cases). Twenty-eight children had their pleural effusion. p=0. the empyema.23. the authors suggested that multiple small resection in 12 cases.40 on conservative management (with small fistula) while 80% required surgical intervention. Necrotising pneumonia.

or at least 10 more days after excellent with very low mortality and minimal morbidity. the usual practice in my institution is to give a In the literature review.42 In contrast.43 The suggestion is based on the evidence that CXR done at 2 months.6 Conservative management guidelines on management of community-acquired through chest drain insertion plus intrapleural fibrinolytic pneumonia in children. in the form of segmentectomy. From BTS statements. No randomised abscess in non-responding patients treated with control trial is available to guide the evidence-based intravenous antibiotics.42 recommendation on this disease management. it only should be considered first. but subsequent PFT at 2 months' time had performed as the last resort. With respect to the morbidity. excision abnormalities.2 Out of the four patients. CXR at 2 months in another patient only in some uncommon circumstances when the sepsis detected pleural thickening with no parenchymal cannot be controlled after appropriate antibiotic. all recovered clinically up This is also in accordance with the recommendations to the follow-up period of 12 months in the first paediatric from IDSA42 and American Pediatric Surgical Association case report. but longer if there is residual disease. the mortality of NP was found to similar duration of antibiotics to treat both conditions as be very low. 28 . Journal of Paediatric Respirology and Critical Care Management of necrotising pneumonia and Consequently.5% to 7. Adjunctive treatment for empyema thoracis Both British Thoracic Society (BTS) and Infectious There has been no change in the approach of the Diseases Society of America (IDSA) did not state clearly management of empyema since the publication of the how long the antibiotics are required for NP in their latest BTS guidelines in 2006. Apart from those isolated case reports. Thus the duration of antibiotic treatment is still controversial. together with the associated decortication for local empyema causing atelectasis.4. resolution of fever. the mortality was 6. the debridement is the first line treatment and surgical recommendation on the antibiotic duration for empyema debridement will be reserved for those failed cases as was written explicitly. one had follow-up (APSA).7 or excision of large pneumatocele which imposes heavy pressure effect on Antibiotic treatment the adjacent healthy lung tissues. In another article focusing on invasive pneumococcal Role of surgery on NP disease.10 The causes afebrile and has improved clinically. The main The management of NP including treating the indications for the surgical intervention include pneumonia itself. 46 imaging-guided The main treatment for NP remains to be medical aspiration or insertion of drainage catheter for lung therapy with intravenous antibiotics. 6 Then oral antibiotics are continued on discharge for 1-4 more Prognosis weeks.44 Nevertheless. BTS suggests that intravenous the last resort.5%. the role of surgery in the management pulmonary co-morbidities of necrotising pneumonia is mainly to treat the associated pulmonary complications.45 normalised. (PFT) showing decreased lung volume during the acute lobectomy or even bilateral lobectomy.7% and all the death had It has already been a generally accepted approach that concurrent bacteremia. only follows: two relative large studies including 36-40 children A total of 4 weeks. or 2 weeks after the patient is reported the mortality from 5. The management can be the surgical excision of diseased lung with persistent divided into medical versus surgical interventions. discharge. bronchopleural fistula. The APSA also adopts may be required until the fever settles. and the VATS will only be mentions that prolonged course of intravenous antibiotic proceeded in those failed cases. of death were not discussed in details in both reports.42 As the NP and empyema usually co-exist.43 antibiotics are continued until the child is afebrile or at least until the chest drain is removed.4 pulmonary complications. which still detected drainage of necrotic lung tissue actually led to the pneumatoceles but the lesions resolved in 6 months after development of bronchopleural fistula. IDSA gives similar recommendation of 2-4 weeks’ duration of The prognosis of the necrotising pneumonia is usually antibiotics for empyema. may be illness. One patient had pulmonary function test of the necrotic tissue.13 surgical intervention for NP per se should be avoided as NP usually has an excellent outcome in children.41 IDSA does not the same approach and recommends that the chemical discuss the antibiotic strategy for NP.

Cleveland RH. Ultrasonography of thorax has gained an important role in the management of empyema and It is still arguable that clinical and radiological resolution necrotising pneumonia and will probably replace CT as are not equivalent to absence of functional pulmonary the primary investigation. Sonnappa S. Korgenski K. Thorax 2005. Lee CY. appropriate age group (including preschoolers). deranged pulmonary function tests.30:740-4. Pulmonary pneumatocele: pathology too earlier to predict the long-term pulmonary capacity and pathogenesis. Bonacorsi necessity of surgical intervention. Valim C. Kerem E. Lu FL. of those children recovered from NP. Branski D. the longer-term follow up. Lai SH. Furthermore. follow-up CXR films within already covered by PCV 13 currently. Bacteremic necrotizing pneumococcal pneumonia in children. Huang LM. Katz S. 31(6):1285-91. Rudenski B. children. Fraser RS. mild obstructive pattern in 2004. which also revealed complete is Streptococcus pneumoniae with potential serotypes resolution. However. Pavia AT.93(9):1172-7. the BTS Standards of Care Committee. Out of 80 patients studied in Boston’s study.32 In another study including the functional outcomes on this disease. Liu HP. Naudin J. Necrotising pneumonia is an increasingly detected complication of pneumonia in children. The current evidence.31 strains. Mason studies have already suggested that CXR may not be a EO. Lu CY. CT still detected pneumatoceles studies are required to have better understanding on in 25% (2/8) of the patient.5 Only a few mortality. as well as normal CXR. Pneumococcal necrotizing pneumonia in Utah: appropriate tool for detecting permanent lung damage. Lemaître C. Chiu CH. Balfour-Lynn IM. necrotising pneumonia can impose a 6. Bender JM. Thorax 2008. one with pneumatocele while another with persistent atelectasis. Abrahamson E.23 All the above 1. had follow-up CT thorax. as well as bronchopleural fistula among children in Taiwan. Calder AD. Hsieh YC.159 can only be performed for those older and cooperative (9):684-8. Am J Respir Crit Care Med 1994. Hartley J.46 However too liberal use of CT thorax as evaluation is (9):1346-52. extended course of antibiotics or even 11. Daly J. the better imaging technique et al. also discouraged in view of the profound radiation risk. Wong KS. 4.38(6):830-5. Volume 10 No. Ampofo K. Intravenous antibiotic deficit. Quigley MJ. Lai JY. Necrotizing pneumococcal pneumonia with such as CT with low radiation dose protocol. measurement in assessing the functional status but it Necrotising pneumonitis in children. Colin AA. In Switzerland study surgery is reserved for managing its complications. However in long run.5 Normal Ercan I. Angoulvant F. Pediatr better modalities of pulmonary function tests for the Infect Dis J 2011. Huang YC.150(6):1275-7. Hacimustafaoglu M. Eur J Pediatr 2000. 10. Bar Ziv Y. Lee PI. Stanojevic S. it is still 8. Necrotizing pneumonia in children. Am J Roentgenol 1988.63(10):897-902. Huang YC. Pulmonary function test is definitely a better 3. Wang CW. The most common pathogen. Parikh D. Acta Paediatrica PFT was found in 8 patients. the management of pleural infection in children. Sawicki GS. Jaffe A. Role of routine computed tomography in paediatric pleural empyema. Kleid D. Makhoul J. Celebi S. Hsieh YC. 9. Wong KS. To summarise. Eur Respir J 2008. More on radiologic imaging. CXR is not sensitive enough to treatment is still the first line treatment for NP and detect residual structural lesions. Paediatric Pleural Diseases Subcommittee of of acute complications. Clin Infect during its acute stage. normal follow-up CXR as well as normal to mildly 60 Suppl 1:i1-21. Lin TY. however. Owens CM. Yeow KM. et al. DLCO 5. King significant morbidity on paediatric population in terms S. all 80 children had full its prognosis is suggested to be excellent with low clinical recovery.149(1):242-4. especially fibrotic changes in all nine patients with the imaging in the setting of emergence of macrolide-resistant performed. Gurpinar A. Gabor F. Mycoplasma 1-3 months showed complete resolution or only minimal pneumoniae is another important bacteria. Conclusions Clinical manifestations and molecular epidemiology of necrotizing pneumonia and empyema caused by Necrotising pneumonia can have significant morbidity Streptococcus pneumoniae in children in Taiwan. study was not performed in that study. 4. Cohen G. in this locality. only 12 patients had PFT done in their follow-up. five patients suffering from necrotising pneumonitis caused by Mycoplasma pneumoniae. In Taiwan's study. without 7. two patients had residual lung damage detected by follow-up CT thorax References 6-8 months after the illness. hospitalisation. et al. BTS guidelines for suggests an excellent outcome with full clinical recovery. Hsueh PR. 2. Sarimehmet H. which may lead to prolonged Dis 2004. 3 patients and mild restrictive pattern in 1 patient. Necrotizing pneumonia in children: report 29 . does serotype matter? Clinical Infectious Diseases 2008. December 2014 Review Ar ticle Based on the Boston's study. S.

Turk J Pediatr 2008. Imaging of cavitary necrosis in complicated childhood Staphylococcus aureus infection. Gudinchet manifestations in children with invasive community-acquired F. Hammerman WA. Macdonald N. Yao KH. 24. 14. et al. Ince T. Patamasucon P. Acinetobacter 15. McKean 25. pneumoniae in pediatric patients: report of five cases and Pediatr Surg Int 2006. . Tunik MG.10:335. First Edition: HERMES. Vaccine 2011. Mycoplasma hominis necrotizing 16. Cheng AF. Lina G. Heresi GP. Pediatr Infect Dis J 2004. Pediatr Infect Dis J 2013. Lee SY. Respiratory Medicine. BMC Infect Dis 2013. Morais L. Li S. Harnden A. resistance in Chinese children hospitalized for pneumonia. Harris M. Ultrasound in peripheral pulmonary air-fluid lesions. Wang LB. Fatal sepsis and necrotizing pneumonia in a child due to Peripheral hypoechoic spaces in consolidated lung: a specific community-acquired methicillin-resistant Staphylococcus diagnostic sonographic finding for necrotizing pneumonia in aureus: case report and literature review. Tsung JW. Darge K. Tsai KD.167(2):187-8. Ho TS. acquired pneumonia caused by Staphylococcus aureus 34. Chiou YH. Cataneo AJ. Tsai MH.22(2):186-90. Dumitrescu O. M. Xu D.39 massive pleural effusion.112(9): documented paediatric case.23(6):564-7. Serotypes and antimicrobial 28. Prospective evaluation of V. et al. Hulten KG. et al. 2013:166-75. Kara A. van Straten M. Marques L. 27. McCarthy VP. Pediatr Radiol 2009. Scand J Infect Dis children. 36. Color Epidemiology and etiology of pneumonia in children in Hong Doppler imaging as an aid in differentiating empyema and Kong (Abstract). Fournet JC. 40. Hafen G. Chiu CY. Cengiz AB. Lee KH. Caglar M. Kalaskar AS. 30. Kwong L. Lucas MA. Wang SR. abscess. Chan YH. Cataneo DC. community-acquired pneumonia: risk in children and young adults. Issartel B.50(1):58-62. community-acquired pneumonia in a healthy child. Severe leukopenia in Staphylococcus point-of-care ultrasonography for the diagnosis of pneumonia aureus-necrotizing. Que TL. British Thoracic Society Standards of Care acquired pneumonia caused by macrolide-resistant Committee. Ho PL. Hsia TC. Murphy JR. Sicot N. Obando I. Hsueh PR. 1995-2009. Valderrabanos ES. susceptibilities of invasive Streptococcus pneumoniae before Severe necrotizing pneumonia in a child with pandemic and after introduction of 7-valent pneumococcal conjugate (H1N1) influenza. et al. Lina G. Ang I. Cotting J. Chiu SS. 13. Yazer J. Clin Infect Dis 2005. 2005. Hsiao CH. Moreira Silva G. Chiang lethal necrotising pneumonia in young immunocompetent BL. Vanhems P.17(5):407-9. Neth OW. 20. Tam JS. Arch Dis Child 2010. USA. Emerg Infect Dis 2009. Chen HJ. 12.29(17):3270-5. JAMA Pediatr 2013. (6):527-37. Huang IF.359(9308):753-9. for the diagnosis of pneumonia in children: prime time for 45(3):315-21. Hsieh YC. ERS Handbook on Paediatric D. Lopushinsky S.28(3):217-21.29(12):2296-301. 22.40(1-2):69-71. Pediatr Int Pulmonol 1999. 23. et al. Giacomantonio M. Deng L. 305-6. vaccine. Vanhems P. Hong Kong management of community acquired pneumonia in children: 30 . 2012. Schnyder P. Kunyoshi V. Vanhems P.167:119- factors and impact on survival. 25.17(5):894-6. Necrotizing pneumonitis caused by Mycoplasma pneumonias with empyema and/or pneumatocele in children. Wong KS. Floret In: Eber E. Cheng 39. Chest 2009. Lin WJ. et al. Wang Y.135(6):1426-32. Necrotizing pneumococcal pneumonia in childhood. Hanquinet S. Severe community. Huang JF. the role of pulmonary gangrene. Khanafer N. Di Bernardo S. Meyssonier 35. Cotting J. review of literature. British Thoracic Society guidelines for the Mycoplasma pneumoniae in a 6-year-old boy. Ciet P. Necrotizing pneumococcal pneumonia in children: patients. Eur Radiol 2002. Shah VP. Tsao PN. Wei BH. Mycoplasma pneumoniae 38. Tseng MH. Association between Staphylococcus aureus strains Infect Dis 2010. eds. Chen TP. Imaging of parapneumonic pleural infection complicated by necrotizing pneumonitis with effusions and empyema in children. Jaton K.32(10):1146-9. Coote N. 37. LauYL. Rev Port et al. Chen CH. Sung RY. Complicated MF. Oppenheimer SJ. Tristan A. Childhood Necrotising pneumonia due to influenza A (H1N1) and invasive pneumococcal disease caused by non-7-valent community-acquired methicillin-resistant Staphylococcus pneumococcal vaccine (PCV7) serotypes under partial aureus clone USA300: successful management of the first immunization in Taiwan.54(2):293-7. Pediatr Pulmonol 2006. 18. Wanger A. Computed tomography. Calder A. et al. 583-90.13:359. (7):623-9. Houston. Pulmonary 32. Clin Infect Dis 2007. Liu CC. J Paediatr Child Health 2004. Millan JA. BMC et al. Owens CM. pleuropneumonia in a previously healthy adolescent.37(6-7):504-7. Ultrasonography of the lungs and pleurae containing Panton-Valentine leukocidin. 33. Gillet Y. Eur J Pediatr 2006. Vaccine 2011. et al.95(4): 561-8. Wang JY. Lin YC. Chiang LM.41 17. Lancet 2002. Yu YH. CMA 2011. Bes M. Lai SH. streptococcus.18(2):96-8. Pneumococcal serotype distribution and antimicrobial Pneumol 2012.12(2):391-6. Tiddens H. Wang SY. Pediatr associated necrotizing pneumonitis in children. Gucer S. 26. et al. Severe necrotizing pneumonia in children. Zhao GM. 29. Senra V. Wang SM. JAMA Pediatr 2013. Factors predicting mortality in necrotizing community. Hodina M. Lung DC. Clin Infect Dis 1993. Tu CY. Gillet Y. Chiu CY. Mason EO Jr. Kanra G. Dishop MK. Texas. Chen Z. Zheng YJ. Wootton Fatal necrotizing pneumonia caused by group A SH. Vandenesch F. center. Bes M.41(5): pneumonia. Mycoplasma pneumoniae. routine use. Shen CF. 19. Hong Kong.15:1696-8. Huang YH. Wang RS.183(2):215-9. Lamberth LB. carrying gene for Panton-Valentine leukocidin and highly 31. 41. Gonzalez BE. Chen A. Clark J. Perez MH. 21.165:275-7. J Formos Med Assoc 2013. Midulla F. Chan RC. Lu JJ. Fletcher P. Hsieh KS. Journal of Paediatric Respirology and Critical Care of 41 cases between 2006 and 2011 in a French tertiary care Med J 2011. Pascual A. Gaines T.

empyema in children: a comprehensive review from the APSA 42. Shah SS. Andrade Ede O. Fishman SJ. Harrison C. Surgical treatment of children with necrotizing pneumonia. APSA Outcomes and Clinical Trials complicated by early and late pneumatoceles. Bloom DA. Colin AA. Islam S. December 2014 Review Ar ticle update 2011. the Pediatric Infectious Diseases Society and the Infectious 45. Can Respir J Committee. Pediatric Infectious Diseases Society and 47(11):2101-10.53:e25. Necrotizing pneumonia Huang EY. et al. Diseases Society of America. 2011-2012.66 Suppl 2:ii1-23. The management 44. Thorax 2011. Chen C. Al-Saleh S. Calkins CM. et al. Outcomes and Clinical Trials Committee. The diagnosis and management of 2008. Clin Infect Dis 2011. 43. 4. 46. Alverson B. et al. Carter ER. Cox P. Hoffer FA. Byington CL.29(2):87-91. Downard CD. Goldin AB. J Bras Pneumol 2010. Silva Mdos S. 31 .36(6):716-23. Tavares E. Bradley JS. Volume 10 No. Pediatr Radiol 1999. the Infectious Diseases Society of America.15(3):129-32. 76. J Pediatr Surg 2012. Netto JC. Grasemann H. Lung abscess of community-acquired pneumonia in infants and children versus necrotizing pneumonia: implications for interventional older than 3 months of age: clinical practice guidelines by therapy.