diagnostic approach of recurrent

DIAGNOSTIC APPROACH OF RECURRENT /PERSISTANT PNUEMONIA IN CHILDREN

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This month we are going discuss something about the diagnostic

approach in recurrent pneumonia in children.

In hospital practice recurrent and persistent pneumonia is a

relatively common problem in children and there is very few literature

available on this subject. Even though a number of conditions are

known to cause recurrent and persistent pneumonia in children, little

is known about these groups of cases. Recurrent pneumonia is defined

as two episodes of pneumonia in one year, or more than three episodes

at any time with radiographic clearance between two episodes.

Persistent pneumonia is characterized by persistence of symptoms and

roentgenographic abnormalities of more than a month. It is often

difficult to determine whether pneumonia is persistent or recurrent,

unless there has been a symptom-free interval during which chest

radiographs have documented clearing of the pneumonia infiltrations.

Bacterial pneumonia may appear to be a recurrent infection, if

infection is persistent because therapy was inappropriate for the

underlying pathogen; or else, because the duration was inadequate as a

result of non-compliance. Even when chest radiographs are available,

there may be problems in distinguishing between persistent and

recurrent pneumonia. Variability in the technical quality and

positioning of chest radiographs may result in misinterpretation of

resolution of the pulmonary pathologic process. Reappearance of

radiological densities in the same area on subsequent films may be

attributed to recurrence, whereas the densities actually represent

persistence of previous pulmonary lesions.

Clinical Evaluation:

A careful history, through physical examination and review of chest

radiograph helps clinicians for further evaluation. The age of onset

of pneumonia is important factor in the evaluation of underlying

etiological agents. The possibility of associated congenital anomaly

or hereditary disorder is greater soon after birth. Particular

attention should be paid to the sequence of events leading to

diagnosis of pneumonia, such as nature and pattern of cough, presence

and duration of fever; physical finding is such as crackles or wheeze.

Nature and pattern of cough is helpful in the evaluation. E.g., A

brassy cough is suggestive of tracheal irritation; a croupy cough

implies involvement of glottis or subglottis; Paroxysmal cough is

associated with foreign body in the respiratory tract. The history of

cough and its relationship to feeding or swallowing is important for

detecting swallowing dysfunction or defects, GER or poor feeding

techniques. It is important to inquire about any family history of

asthma, allergic disease, cystic fibrosis, congenital anomalies or

recurrent infection suggesting immunnological disorders. Infants below

1 year of age are vulnerable to persistent or recurrent pneumonia due

to the bad child rearing practices like oil bath, blowing into the

nose and throat clearing maneuvers by the attendants who are routinely

giving bath to children. CBC and Mantoux test are done routinely in

all cases. Leucocytosis with toxic granules in leucocytes is

suggestive of bacterial pneumonia. A positive Montoux test should

warrant further work up of tuberculosis. It is important to document

specific area of pulmonary infiltrates on all chest radiography and

classify the pulmonary infiltrates into those that are unilobar or

involve multiple lobes.

Evaluation of recurrent / persistent unilobar / pneumonia:

The differential diagnosis of a child with persistent or recurrent

pneumonia involving a single lobe of the lung may be due to

intra-luminal obstruction, extra-luminal bronchial obstruction and

structural malformation of the bronchus, the intraluminal obstruction

being the commonest. In children, the most often cause of intraluminal

obstruction is a foreign body. First step in diagnostic workup is the

Flexible Fiber-optic Bronchoscopy (FFBS). It is useful both in

diagnosis and therapy. Broncho Alveolar Lavage (BAL) or biopsy is

performed in other cases of intralobar obstructions (I.e. bronchial

adenoma or lipoma). A tracheal bronchus can be diagnosed by FFBS. If

bronchoscopy is normal or not revealing any abnormality, CT scan is

performed to identify the extraluminal cause of bronchial obstruction.

When there is a space occupying lesion in CT Scan, a bronchogenic cyst

or sequestered lobe is suspected; an aortogram will be helpful to

confirm the diagnosis of sequestered lobe.

Evaluation of recurrent persistent pneumonia involving multiple lobes:

The diagnostic considerations for multilobar-infiltrates are broadly

classified into aspiration syndromes, asthma, immunodeficiency states,

mucociliary dysfunction, structural abnormalities, alpha-1 antitrypsin

deficiency, hypersensitivity pneumonitis and pulmonary hemosideoris

should be considered. When aspiration is suspected, a barium study or

cineesophagogram is performed to study any defect in swallowing

disorders or esophageal pathology. If gastro esophageal reflux is

present, it is further confirmed by esophageal pH monitor, technetium

milk scan, esophagoscopy and biopsy. If Gastro-Esophageal reflux is

absent, FFBS is performed and the Broncho alveolar lavage (BAL) may

yield lipid laden alveolar macrophages, which is suggestive of lipoid

aspiration. A child presenting with wheeze and mutilobar pulmonary

infiltrates often pose problem in the management. If there is PEFR

variation of more than 20% with good response to the bronchodilator

therapy - asthma is confirmed. The pulmonary infiltrates are secondary

to the multiple atelectasis from mucus plugging. If there is a poor

response to bronchodilator therapy, the other underlying conditions

can be considered based on the following factors. To detect the

structural abnormalities of tracheo-bronchial tree, a CT Scan and

bronchogram will be done. A careful cardiac evaluation with an

echocardiography can identify a congenital heart disease. Evaluation

of immunodeficiency state includes quantitative estimation of

immunoglobulins and for phagocyte disorder- total and differential

white blood cell count are performed in addition to nitroblue

tetrazolim (NBT), to evaluate mechanism of intracellular killing.

Cystic fibrosis can be diagnosed by sweat chloride estimation be

quantitative pilocarpineiontophoresis method. The ciliary dyskinesia

can be identified by saccharin clearance, a simple test to assess the

ciliary beat frequency. The simplest screening test to study ciliary

defects is the measurement of the ciliary beat frequency by studying

under electron microscopy the nasal brush biopsy or scrapping the

nasal mucosa. By doing serum electrophoresis the absence of alpha

globulin can be detected and further confirmation by gene analysis to

confirm alpha-1 antitipsin deficiency.

The hypersensitivity pneumonitis can be diagnosed by doing lung

biopsy. The patients will show gradual improvement in hospital

atmosphere and relapse on return to home when exposed to the offending

antigens in the environment. BAL is performed when a child presents

with anemia and recurrent pneumonia, which may show alveolar

macrophages filled with hemosiderin pigments which is suggestive of

pulmonary hemosiderosis.

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