An 11-month-old female was transferred because of an increasing pleural effusion. She had upper respiratory tract infection symptoms for 2 days and then began to have increased cough, deep breathing and a fever to 103.6° F. A chest x-ray showed left lower lobe pneumonia and a small pleural effusion. She was begun on oxygen, clindamycin and ceftriaxone, but continued to have respiratory distress. Another radiograph showed an increasing pleural effusion and vancomycin was begun along with azithromycin. Clindamycin was discontinued. Another radiograph showed increased pleural effusion, so she was transferred to the regional children’s hospital on day 2-3 of admission. The past medical history showed recurrent otitis media with placement of bilateral pressure equalizing tubes. The family history and review of symptoms were negative.
The pertinent physical exam showed an infant with a respiratory rate of 46 breaths/minute and a temperature of 40.1° C on 3 liters nasal canula. HEENT examination showed clear rhinorrhea and mild tracheal tugging. Chest examination showed decreased breath sounds at the left base and up approximately 50% of the chest. There were dull sounds to percussion in the same area. Mild end expiratory sounds were heard that stopped after coughing in the left lung. There were mild intercostal retractions. The rest of the examination was negative. The laboratory evaluation at the outside hospital showed a C-reactive protein of 10.4 mg/dl, and a white blood cell count of 11.8 x 1000/mm2 with 50% polymorphonuclear cells and 10% left shift. Blood cultures were eventually negative. The diagnosis of left lower lobe pneumonia with pleural effusion was confirmed. The radiologic evaluation of a computed tomography of the chest on day 3-4 showed a pneumonia and non-loculated pleural effusion. The patient’s clinical course showed that she continued on her antibiotics and on day 3-4 had decreased fever, decreased oxygen requirement and improvement of her respiratory distress. Vancomycin was discontinued and the patient was discharged on day 5-6, after a chest radiograph showed stabilization of the effusion. She received a total of 10 days of ceftriaxone and 5 days of azithromycin. At followup 8 weeks later, her chest radiograph was normal.
Figure 82 – PA and left lateral decubitus radiographs of the chest demonstrate a moderate-sized free flowing left pleural effusion and associated left lower lobe airspace disease.
Figure 83 – CT scan of the chest performed with intravenous contrast shows a left-sided pleural effusion on soft tissue windows (above) and associated left lower lobe pneumonia on lung windows (below). There is no enhancement of the pleura to suggest emphyema and no lung abscess was seen.
Pneumonia is an inflammation of the lung parynchema with consolidation of the tissue and filling of the alveolar air space with exudate, fibrin and inflammatory cells. It is the most common cause of pediatric death in the world and is described as the “forgotten killer of children” by UNICEF and the WHO. This is particularly true in developing countries. But while the United States and other developed countries see fewer deaths and morbidity related to pneumonia, complications of pneumonia still occur.
The most common organisms causing outpatient pneumonias in the U.S. are: Chlamydia pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Streptococcus pneumoniae, and a variety of respiratory viruses. Vaccines to combat pneumonia are available and include: Haemophilus influenza B, influenza, measles, pertussis, and varicella. Use of respiratory syncytial virus immunoglobulin in certain premature infants to prevent RSV pneumonia and its complications is also considered standard of care in the U.S..
Complications of pneumonia include:
- Pulmonary functioning
- Respiratory distress
- Pulmonary failure including adult respiratory distress syndrome
- Acute asthma exacerbation
- Primarily pulmonary parenchyma
- Necrotizing pneumonitis
- Pulmonary abscess
- Lung cavitation, fibrosis, and bronchiolitis obliterans
- Granuloma formation
- Primarily pleural space
- Pleural effusion with or without loculations
- Tension pneumothorax with diminished cardiac output
- Infectious disease
- Bacteremia and sepsis
- Secondary bacterial pneumonia after primary viral pneumonia
- Hilar adenopathy with compression
- Need for imaging procedures – ultrasound, chest tomography
- Need for surgical procedures – chest tube, thoracotomy, pleural decortication
- Pregnancy related complications including increased maternal death and premature birth
Questions for Further Discussion
1. What are some risk factors for increased pneumonia complications?
2. What are indications for inpatient and/or surgical treatment of pneumonia?
3. What is the epidemiology of seasonal influenza and novel Influenza A, H1N1 in my own location?
- Disease: Pneumonia
- Specialty: Allergy / Pulmonary Diseases | Infectious Diseases | Radiology / Nuclear Medicine / Radiation Oncology
- Age: Infant
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
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Tan TQ, Mason EO Jr, Wald ER, Barson WJ, Schutze GE, Bradley JS, Givner LB, Yogev R, Kim KS, Kaplan SL. Clinical characteristics of children with complicated pneumonia caused by Streptococcus pneumoniae. Pediatrics. 2002 Jul;110:1-6.
Madhi SA, Levine OS, Hajjeh R, Mansoor OD, Cherian T. Vaccines to prevent pneumonia and improve child survival. Bull World Health Organ. 2008 May;86(5):365-72.
Kamangar N, Rager C, Sharma S. Pneumonia, Bacterial. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/300157-overview (rev. 8/21/2009, cited 5/12/10).
Bennett JN, Domachowske J. Pneumonia. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/967822-overview (rev. 2/26/2010, cited 5/12/2010).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital