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!!!