A 4.5-year-old female came to the emergency room with a 2 week history of cough that was increasing in frequency.
She also had a fever with a maximum of 102 degrees Fahrenheit.
For the past 3 days she had some increasing shortness of breath and mild abdominal pain.
She did not want to eat solid food but was drinking.
The past medical history was negative. She was current on her vaccinations and had some colds and ear infections in the past.
The review of systems was negative.
The pertinent physical exam showed a tired-appearing female with respiratory rate of 44, temperature of 38 degrees Celsius, heart rate of 140 and normal blood pressure. Capillary refill was 3 seconds.
Height and weight were 25-50%. Her oxygen saturation by pulse oximetry was 97% on room air.
Her HEENT examination was normal except for suprasternal retractions and mild nasal flaring.
Lung examination showed no breath sounds on the left side and normal sounds on the right.
Heart examination revealed right-sided heart sounds with no murmurs. Peripheral pulses were normal.
Abdominal examination showed mild diffuse tenderness with no masses or hepatosplenomegaly or guarding.
The rest of the examination was normal.
The radiologic evaluation of a chest radiograph showed complete whiteout of the left hemi-thorax with deviation of the trachea and heart into the right thorax.
The laboratory evaluation showed a white blood cell count of 18.2 x 1000/mm2 with 12,000 polymorphonuclear cells, and 1400 bands. The platelets were elevated at 840 x 1000/mm2.
The C-reactive protein was 4.3 mg/dl. Total protein, albumin, amylase, and lipase were normal. A venous blood gas showed pH = 7.4, CO+2 = 37, O+2=48 and bicarbonate = 24.
The work-up included a chest computed tomography examination which showed a large left-sided pleural effusion. The left lung was completely consolidated and possibly necrotic with deviation of the left lung to the midline and right-sided deviation of the heart.
The diagnosis of pneumonia with empyema was made.
The patient’s clinical course included being taken to the operating room where 1.6 liters of frank pus was drained and a drainage tube placed. Culture was positive for Group A, beta-hemolytic streptococcus.
She was initially treated with intranvenous fluids and ceftriaxone, and later changed to penicillin with clinical improvement; subsequent chest radiographs showed marked decrease in the empyema and expansion of the left lung.
Treatment duration was to be decided based on clinical improvement.
Figure 39 – PA and lateral radiographs of the chest demonstrate complete opacification of the left hemithorax with tracheal and mediastinal shift to the right.
Figure 40 – Axial image from a CT scan of the chest performed with intravenous contrast demonstrates the left hemithorax opacification is due to a large left pleural effusion causing complete atelectasis of the left lung and mediastinal shift to the right. There was concern that a circular area of necrosis may be present within the atelectatic lung.
Pneumonia is a common infection world-wide. As the lung’s lobes or segments become consolidated in acute bacterial pneumonias, lung compliance and vital capacity diminishes and increased work of breathing occurs.
On physical examination the child may have tachypnea, retractions, nasal flaring, grunting, rales and tubular breather sounds are often heard. There may also be no adventitial breath sounds.
With increasing lung involvement, especially if complicated by concomitant pain or fatigue, the child’s oxygenation saturation may begin to fall often with increased CO+2 retention and possibly respiratory failure. Evaluation by pulse oximetry and/or blood gases can be helpful for monitoring pulmonary status.
Patients are often treated outpatient with 10-14 days of a second or third generation cephalosporin to cover common organisms. Radiographs will remain abnormal for 6-8 weeks despite clinical improvement.
Group A Streptococcus usually occurs after exanthems but can also occur in previously healthy children. Chest radiographs may show peribronchial thickening, lobar or segmental involvement and/or effusion. The most common complications are abscesses and empyema.
Children usually are treated for 10-14 days with oral penicillin but seriously ill children may need longer treatment.
Many different organisms can cause pneumonia. Most commonly in the United States these include:
- Viruses – including coronaviruses, adenovirus, influenza, parainfluenza, respiratory syncytial virus, rhinovirus, varicella, etc.
- Streptococcus, Group A
- Streptococcus pneumoniae
- Staphylococcus aureus – including methicillin-resistant types
- Mycoplasma pneumoniae
- Haemophilus influenzae, non-typable – H. influenza type b is less common due to vaccination
- Anaerobic bacteria
- Klebsiella pneumoniae
Nosocomial and immunocompromised hosts may also have:
- Pseudomonas aeruginosa
- Enterobacteriaceae species
- Escherichia coli
- Acinetobacteriaceae species
Complications of pneumonia include:
- Apnea or respiratory failure
- Bacteremia and/or sepsis
- Pleural effusion
- Hilar adenopathy
- Recurrent pneumonia
In the US and other developed countries, pneumonia is usually promptly treated without complications.
But world-wide, pneumonia causes 19% of all deaths in children under the age of 5 or about 2 million children/year.
This does not include neonatal deaths caused by pneumonia. If these were added, it is estimated that more than 3 million children/year would die of pneumonia.
Pneumonia is the number one cause of deaths in children under 5 years of age. It is estimated that 600,000 children’s lives could be saved with universal antibiotic treatment.
Prevention with immunizations for S. pneumococcus, H. flu type b and measles vaccine would also dramatically decrease the mortality and morbidity.
World-wide, cause-specific mortality rates in children under 5 years of age are:
- Miscellaneous neonatal deaths = 27%
- Pneumonia = 19%
- Diarrheal illnesses = 17%
- Neonatal severe infections (mainly pneumonia and sepsis) = 10%
- Malaria = 8%
- Measles = 4%
- Injuries = 3%
- HIV/AIDS = 3%
- Others = 10%
Questions for Further Discussion
1. What are the indications for hospitalization for pneumonia?
2. What are the indications for an immunology work-up in a patient with a recurrent pneumonia?
3. What are the indications for surgical intervention in a patient with complicated pneumonia?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
To view current news articles on this topic check Google News.
Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1980-1983.
Wardlaw T, Salama P. White Johansson E. Mason. Pneumonia: The Leading Killer of Children. Lancet. Lancet. 2006;368:1048-50.
Bradley JS, Nelson JD. Nelson’s Pocket Book of Pediatric Antimicrobial Therapy. 16th edit. Allianace for World Wide Editing. Buenos Aires, Argentina. 2006;37-44.
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.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competency 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.
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.
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
Associate Professor of Pediatrics, Children’s Hospital of Iowa
November 6, 2006