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Education & Practice Online First, published on May 12, 2014 as 10.1136/archdischild-2014-306343 EPILOGUE
A pneumonia that does not improve Samuele Naviglio,1 Matteo Chinello,1 Alessandro Ventura1,2 A 2-year-old, previously healthy child was admitted for fever, cough and tachypnoea with intercostal and suprasternal retractions. Crackles and diminished breath sounds were noted on the left hemithorax. Peripheral oxygen saturation (SpO2) was 85% while breathing ambient air. Antibiotic therapy and oxygen supplementation were started for presumed bacterial pneumonia. Despite prompt resolution of fever and improvement of general conditions, after 5 days SpO2 remained 90%, rising to 99% with oxygen supplementation. Physical examination demonstrated markedly diminished breath sounds on the left hemithorax. A chest radiography was performed (figure 1).
QUESTIONS 1. What conditions should be considered when a child with suspected community-acquired pneumonia does not improve as expected with antibiotic therapy? 2. What does the chest X-ray show?
Figure 1 Chest radiograph.
3. Which diagnosis does the X-ray coupled with history and physical examination suggest? 4. What should be the next steps?
Naviglio S, et al. Arch Dis Child Educ Pract Ed 2014;0:1–2. doi:10.1136/archdischild-2014-306343 1 Copyright Article author (or their employer) 2014. Produced by BMJ Publishing Group Ltd under licence.
Downloaded from ep.bmj.com on July 11, 2014 - Published by group.bmj.com
Epilogue ANSWERS 1. Children with community-acquired bacterial pneumonia usually improve within 48–72 h from the start of appropriate antibiotic therapy. When improvement is not apparent, several conditions should be considered (box 1). In our patient, respiratory symptoms persisted well beyond the improvement of fever and general conditions, therefore prompting further investigations, the first of which should always be a chest radiography. 2. Chest radiography showed right deviation of the trachea and hyperlucency of the left lung, suggesting the presence of air trapping in the left lung. While the opposite interpretation (ie, a hypolucent right lung, with the left one being considered ‘normal’) may be mistakenly considered, it should be remembered that breath sounds were markedly diminished on the left hemithorax and normal on the right one. 3. The occurrence of air trapping and pneumonia in a previously healthy toddler should strongly suggest the possibility of an inhaled foreign body in the bronchus. Air trapping occurs because the inhaled foreign body causes a ‘ball-valve’ effect, allowing the air to flow in on inspiration, but not to flow out on expiration. This results in hyperaeration of the involved lung or lobe, which is most evident on a radiography taken at full expiration. Foreign body inhalation most frequently occurs in children between 1 and 3 years of age, but up to 10% of cases may occur under 1 year of age.1 Most commonly inhaled objects include nuts (a third of cases, especially peanuts), pieces of fruits or vegetables, seeds, and small toys. A preceding choking event is the most important factor to be considered in history, and its occurrence should always be specifically asked: even simply eating or playing with nuts should be considered as a positive history. However, a negative history does not exclude the diagnosis. After the initial choking event, the child may become asymptomatic, yet unilateral wheezing and/or a reduction of breath sounds may sometimes be apparent. Nevertheless, children are often not diagnosed until complications occur, such as chronic cough, unexplained fever, pneumonia, haemoptysis or atelectasis.2 While more than 75% of inhaled foreign bodies are not radiopaque, indirect radiological signs may guide the diagnosis.3 However, chest radiography may be normal in 15%–30% of cases; therefore, a high index of suspicion should be maintained. 4. The most appropriate first line procedure is prompt removal by rigid bronchoscopy.
In our case, before endoscopic evaluation could be arranged, the child coughed-up a piece of nut, with
2
Box 1 Conditions to be considered when pneumonia does not improve ▸ Complications of pneumonia: empyema, pulmonary abscess ▸ Bacterial resistance to antibiotic therapy (resistant bacterial strains or other bacteria like Mycoplasma, Chlamydophila, Mycobacteria—eg, M tuberculosis) ▸ Non-bacterial infectious aetiology (viral, fungi) ▸ Bronchial obstruction (foreign body inhalation, mucous plug, external compression—eg, from lymphadenopathy) ▸ Pre-existing predisposing disease (immune deficiencies, cystic fibrosis, ciliary dyskinesia, pulmonary sequestration, cystic adenomatoid malformations) ▸ Aspiration pneumonia (usually in children with predisposing comorbidities) ▸ Other, non-infectious causes (hypersensitivity pneumonia, eosinophilic pneumonia, bronchiolitis obliterans, vasculitis—eg, granulomatosis with polyangiitis)
prompt normalisation of SpO2. On further questioning, there was no history of choking. Samuele Naviglio,1 Matteo Chinello,1 Alessandro Ventura1,2 1
University of Trieste, Trieste, Italy Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, Trieste, Italy
2
Correspondence to Dr Samuele Naviglio, University of Trieste, via dell’Istria 65/1, Trieste 34137, Italy; [email protected]
Contributors SN and MC cared for the patient and wrote the manuscript. AV cared for the patient and critically revised the manuscript. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed. To cite Naviglio S, Chinello M, Ventura A. Arch Dis Child Educ Pract Ed Published Online First: [ please include Day Month Year] doi:10.1136/ archdischild-2014-306343 Received 5 March 2014 Accepted 16 April 2014
REFERENCES 1 Wang K, Harnden A, Thomson A. Foreign body inhalation in children. BMJ 2010;341:c3924. 2 Mortellaro VE, Iqbal C, Fu R, et al. Predictors of radiolucent foreign body aspiration. J Pediatr Surg 2013;48:1867–70. 3 Sersar SI, Rizk WH, Bilal M, et al. Inhaled foreign bodies: presentation, management and value of history and plain chest radiography in delayed presentation. Otolaryngol Head Neck Surg 2006;134:92–9.
Naviglio S, et al. Arch Dis Child Educ Pract Ed 2014;0:1–2. doi:10.1136/archdischild-2014-306343
Downloaded from ep.bmj.com on July 11, 2014 - Published by group.bmj.com
A pneumonia that does not improve Samuele Naviglio, Matteo Chinello and Alessandro Ventura Arch Dis Child Educ Pract Ed published online May 12, 2014
doi: 10.1136/archdischild-2014-306343
Updated information and services can be found at: http://ep.bmj.com/content/early/2014/05/12/archdischild-2014-306343.full.html
These include:
References
This article cites 3 articles, 2 of which can be accessed free at: http://ep.bmj.com/content/early/2014/05/12/archdischild-2014-306343.full.html#ref-list-1
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Education & Practice Online First, published on May 12, 2014 as 10.1136/archdischild-2014-306343 EPILOGUE
A pneumonia that does not improve Samuele Naviglio,1 Matteo Chinello,1 Alessandro Ventura1,2 A 2-year-old, previously healthy child was admitted for fever, cough and tachypnoea with intercostal and suprasternal retractions. Crackles and diminished breath sounds were noted on the left hemithorax. Peripheral oxygen saturation (SpO2) was 85% while breathing ambient air. Antibiotic therapy and oxygen supplementation were started for presumed bacterial pneumonia. Despite prompt resolution of fever and improvement of general conditions, after 5 days SpO2 remained 90%, rising to 99% with oxygen supplementation. Physical examination demonstrated markedly diminished breath sounds on the left hemithorax. A chest radiography was performed (figure 1).
QUESTIONS 1. What conditions should be considered when a child with suspected community-acquired pneumonia does not improve as expected with antibiotic therapy? 2. What does the chest X-ray show?
Figure 1 Chest radiograph.
3. Which diagnosis does the X-ray coupled with history and physical examination suggest? 4. What should be the next steps?
Naviglio S, et al. Arch Dis Child Educ Pract Ed 2014;0:1–2. doi:10.1136/archdischild-2014-306343 1 Copyright Article author (or their employer) 2014. Produced by BMJ Publishing Group Ltd under licence.
Downloaded from ep.bmj.com on July 11, 2014 - Published by group.bmj.com
Epilogue ANSWERS 1. Children with community-acquired bacterial pneumonia usually improve within 48–72 h from the start of appropriate antibiotic therapy. When improvement is not apparent, several conditions should be considered (box 1). In our patient, respiratory symptoms persisted well beyond the improvement of fever and general conditions, therefore prompting further investigations, the first of which should always be a chest radiography. 2. Chest radiography showed right deviation of the trachea and hyperlucency of the left lung, suggesting the presence of air trapping in the left lung. While the opposite interpretation (ie, a hypolucent right lung, with the left one being considered ‘normal’) may be mistakenly considered, it should be remembered that breath sounds were markedly diminished on the left hemithorax and normal on the right one. 3. The occurrence of air trapping and pneumonia in a previously healthy toddler should strongly suggest the possibility of an inhaled foreign body in the bronchus. Air trapping occurs because the inhaled foreign body causes a ‘ball-valve’ effect, allowing the air to flow in on inspiration, but not to flow out on expiration. This results in hyperaeration of the involved lung or lobe, which is most evident on a radiography taken at full expiration. Foreign body inhalation most frequently occurs in children between 1 and 3 years of age, but up to 10% of cases may occur under 1 year of age.1 Most commonly inhaled objects include nuts (a third of cases, especially peanuts), pieces of fruits or vegetables, seeds, and small toys. A preceding choking event is the most important factor to be considered in history, and its occurrence should always be specifically asked: even simply eating or playing with nuts should be considered as a positive history. However, a negative history does not exclude the diagnosis. After the initial choking event, the child may become asymptomatic, yet unilateral wheezing and/or a reduction of breath sounds may sometimes be apparent. Nevertheless, children are often not diagnosed until complications occur, such as chronic cough, unexplained fever, pneumonia, haemoptysis or atelectasis.2 While more than 75% of inhaled foreign bodies are not radiopaque, indirect radiological signs may guide the diagnosis.3 However, chest radiography may be normal in 15%–30% of cases; therefore, a high index of suspicion should be maintained. 4. The most appropriate first line procedure is prompt removal by rigid bronchoscopy.
In our case, before endoscopic evaluation could be arranged, the child coughed-up a piece of nut, with
2
Box 1 Conditions to be considered when pneumonia does not improve ▸ Complications of pneumonia: empyema, pulmonary abscess ▸ Bacterial resistance to antibiotic therapy (resistant bacterial strains or other bacteria like Mycoplasma, Chlamydophila, Mycobacteria—eg, M tuberculosis) ▸ Non-bacterial infectious aetiology (viral, fungi) ▸ Bronchial obstruction (foreign body inhalation, mucous plug, external compression—eg, from lymphadenopathy) ▸ Pre-existing predisposing disease (immune deficiencies, cystic fibrosis, ciliary dyskinesia, pulmonary sequestration, cystic adenomatoid malformations) ▸ Aspiration pneumonia (usually in children with predisposing comorbidities) ▸ Other, non-infectious causes (hypersensitivity pneumonia, eosinophilic pneumonia, bronchiolitis obliterans, vasculitis—eg, granulomatosis with polyangiitis)
prompt normalisation of SpO2. On further questioning, there was no history of choking. Samuele Naviglio,1 Matteo Chinello,1 Alessandro Ventura1,2 1
University of Trieste, Trieste, Italy Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, Trieste, Italy
2
Correspondence to Dr Samuele Naviglio, University of Trieste, via dell’Istria 65/1, Trieste 34137, Italy; [email protected]
Contributors SN and MC cared for the patient and wrote the manuscript. AV cared for the patient and critically revised the manuscript. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed. To cite Naviglio S, Chinello M, Ventura A. Arch Dis Child Educ Pract Ed Published Online First: [ please include Day Month Year] doi:10.1136/ archdischild-2014-306343 Received 5 March 2014 Accepted 16 April 2014
REFERENCES 1 Wang K, Harnden A, Thomson A. Foreign body inhalation in children. BMJ 2010;341:c3924. 2 Mortellaro VE, Iqbal C, Fu R, et al. Predictors of radiolucent foreign body aspiration. J Pediatr Surg 2013;48:1867–70. 3 Sersar SI, Rizk WH, Bilal M, et al. Inhaled foreign bodies: presentation, management and value of history and plain chest radiography in delayed presentation. Otolaryngol Head Neck Surg 2006;134:92–9.
Naviglio S, et al. Arch Dis Child Educ Pract Ed 2014;0:1–2. doi:10.1136/archdischild-2014-306343
Downloaded from ep.bmj.com on July 11, 2014 - Published by group.bmj.com
A pneumonia that does not improve Samuele Naviglio, Matteo Chinello and Alessandro Ventura Arch Dis Child Educ Pract Ed published online May 12, 2014
doi: 10.1136/archdischild-2014-306343
Updated information and services can be found at: http://ep.bmj.com/content/early/2014/05/12/archdischild-2014-306343.full.html
These include:
References
This article cites 3 articles, 2 of which can be accessed free at: http://ep.bmj.com/content/early/2014/05/12/archdischild-2014-306343.full.html#ref-list-1
P
