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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 5  |  Page : 255-259

A retrospective study of etiology, clinical features, management, and outcomes in children with necrotizing pneumonia


Department of Pediatric Medicine, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India

Date of Submission19-May-2020
Date of Decision09-Jul-2020
Date of Acceptance23-Jul-2020
Date of Web Publication14-Sep-2020

Correspondence Address:
Dr. G V Basavaraja
Professor and Incharge, Pediatric Intensive Care Unit, Department of Pediatric Medicine, Indira Gandhi Institute of Child Health, 1st Block, Siddapura, Jayanagar, Bengaluru - 560 029, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JPCC.JPCC_82_20

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  Abstract 


Introduction: Necrotizing pneumonia (NP) is a severe and emerging complication in children with community-acquired pneumonia (CAP). The study was conducted to analyze the etiology, clinical features, treatment strategies, and outcome of NP in children admitted in a single pediatric tertiary referral care center.
Materials and Methods: The study is a retrospective chart review which included children above 1 month and below 18 years who were admitted at Indira Gandhi Institute of Child Health, from January 2015 to December 2018, with community-acquired NP.
Results: During the study period, 1393 cases of CAP were admitted in our institute. Three hundred and fifty-two cases (25.2%) of complicated pneumonia were admitted which include cases of NP, lung abscess, and empyema. Children who were diagnosed with NP were 3.3% (n = 46) of all CAP cases. All the cases with NP were immunocompetent, with the most common organism isolated being Staphylococcus aureus followed by Streptococcus pneumoniae. NP is associated with complications such as empyema, pneumothorax, and bronchopleural fistula. All the children in the study group survived except for mortality in one case.
Conclusion: NP can be well managed with conservative approaches such as prolonged antibiotic therapy and pleural drainage. Although there are commonly associated with local complications, in general the clinical outcome is good.

Keywords: Bronchopleural fistula, community-acquired pneumonia, necrotizing pneumonia, Staphylococcus aureus


How to cite this article:
Ahmed M, Sanjay K S, Keshavamurthy M L, Basavaraja G V. A retrospective study of etiology, clinical features, management, and outcomes in children with necrotizing pneumonia. J Pediatr Crit Care 2020;7:255-9

How to cite this URL:
Ahmed M, Sanjay K S, Keshavamurthy M L, Basavaraja G V. A retrospective study of etiology, clinical features, management, and outcomes in children with necrotizing pneumonia. J Pediatr Crit Care [serial online] 2020 [cited 2020 Dec 2];7:255-9. Available from: http://www.jpcc.org.in/text.asp?2020/7/5/255/295025




  Introduction Top


Necrotizing pneumonia (NP) is a rare but emerging and most severe complication of community-acquired pneumonia (CAP).[1],[2],[3] NP is due to the destruction of normal architecture of lung parenchyma leading to multiple, thin-walled, small cavitary lesions within areas of lung consolidation.[4] NP or cavitary pneumonia is frequently associated with empyema and bronchopleural fistula (BPF). NP is a part of spectrum between lung abscess and pulmonary gangrene.[4],[5] The cause of lung necrosis is due to the direct cytotoxic effect of toxins of invasive bacteria. Secondary changes in microvasculature of lung-like intravascular thrombosis have also been noted. Such changes lead to reduced concentration of antibiotics in the diseased area of the lung parenchymal tissue. As a result, there is persistence of infection which consequently leads to destruction parenchyma of the lung, transforming the area into a cavity. The cavity is either filled with gas or pus due to discontinuity with bronchial tree.[2],[4],[6],[7]

NP is usually seen in previously healthy children with progressive pneumonia even while on appropriate antibiotics and generally has a prolonged clinical course.[4] As there are less number of studies on children with NP.[1] Hence, the aim of the study is to analyze the etiology, clinical characteristics, management, and outcome of NP in children admitted in a single pediatric tertiary referral care center.


  Materials and Methods Top


The study included children above 1 month and below 18 years admitted at Indira Gandhi Institute of Child Health, a tertiary care referral center, from January 2015 to December 2018, with community-acquired NP. It is a retrospective chart review.

To identify the study group, initially all cases of CAP were segregated from the electronic database of our institute. The children with suspected NP as complication of CAP were included in the study group. The diagnosis of NP was established after reviewing the chest X-ray and contrast-enhanced computed tomography (CECT) thorax by two radiologists who were blinded to the clinical features. The case definition of NP is, a child with signs and symptoms of pneumonia with a specific radiological pattern. The specific radiological pattern includes either multiple airfilled spaces observed as lucencies (areas of low attenuation) or air and fluid spaces, within the areas of consolidation of lung parenchyma. There can also be numerous thinwalled cavities (non-enhancing necrotic lung tissue) encircled by lung parenchyma.

The details of children such as demographics, past medical history, etiology (based on the culture results of blood and pleural fluid culture), clinical data (symptoms and examination findings), and laboratory and radiological data were documented. The data on specifics of treatment strategies, complications, and outcome were also recorded in a standard data collection form. After the case selection, the electronic data were collected from patients' electronic records, and wherever necessary, the medical records were used to complete the data.

The lung abscess has a single cavity with rim of enhancement. It differs from NP in having different underlying causes and treatment and hence has been excluded from the study. The study was conducted after the approval of the Institutional Ethics Committee.

Statistical analysis

The variables in the results of the study were summarized by standard descriptive statistics. The comparison between different groups based on clinical presentations, various interventions, and complications of NP was done using nonparametric, Fisher's exact test, or Mann–Whitney U-test. P < 0.05 was considered as statistically significant.


  Results Top


Demographic and clinical data

During the 3-year study period, 1393 cases of CAP were admitted in our institute. There were 352 cases (25.2%) of complicated pneumonia which included 46 (3.3%) cases of NP, 7 cases of lung abscess, and 299 cases of empyema.

The median age in the study group was 4.7 years (1 year 6 months–16 years). The study group included 26 males and 20 females. The past medical history (to look for underlying diseases and comorbidities), of the children with NP revealed four cases that had recurrent history of upper respiratory tract infection and two cases suffered viral infection prior to presentation with NP. Type I diabetes mellitus and oculocutaneous albinism were present in one case each. None had prior history of asthma or congenital heart disease. No immunodeficiency was noted in any of the cases in the study group.

The most common symptoms at presentation were fever (95%), cough (88%), and hurried breathing (63%). Chest pain and abdominal pain were also a part of presenting complaints in one patient each. The median range of number of days of fever before admission was 7 days (interquartile range [IQR]: 5–10 days). Examinations findings at admission include dullness on percussion and decreased breath sounds on auscultation in 69%. Crackles on auscultation were heard in 48% of the patients with NP. Three cases were initially treated as tuberculosis with antitubercular therapy for 2 weeks. These three children had persistent fever and clinical deterioration despite antitubercular therapy; hence, CECT thorax was done which was suggestive of NP. The treatment was reviewed, and appropriate antibiotics were initiated for which the children responded.

Laboratory data

The significant laboratory parameters included acute phase reactants such as C-reactive protein (CRP) with mean of 78.9 mg/dl (range: 6–100 mg/dl), white blood cells of 15,900 cells/mm3 (range: 2200–42,100), neutrophils of 73% (IQR: 66–79), anemia (mean hemoglobin: 8.8 g/dl), and hypoalbuminemia (mean serum albumin: 2.9 mg/dl). Pleural fluid analysis was done in 35 cases, with a median high cell count of 28,000 cells (IQR: 15,000–50,000 cells) with polymorphic predominance, high pleural fluid protein of 3.7 g/L (IQR: 3–4.2 g/L), high pleural fluid lactate dehydrogenase of 9800 U/l (IQR: 5270–14,098 U/l), and low pleural fluid glucose of 26 mg/dl (IQR: 17–34 mg/dl).

Radiological data

All the cases underwent chest X-ray and CECT scan of lungs [Figure 1]. The chest radiographs of 39 children revealed unilateral consolidation with 22 cases involving the right lung and 17 cases involving the left lung and 7 cases had bilateral consolidation. At admission, chest X-ray revealed 9 cases with pneumothorax and 27 cases with empyema. In the CECT thorax of 46 children, there was consolidation with cavities, loss of architecture, and decreased parenchymal enhancement. Cavitary necrosis with low attenuation varying from homogeneous to patchy was seen in single lobe in 6 cases, multiple lobes but unilateral in 33 cases, and in bilateral lungs in 7 cases. Parapneumonic effusion/empyema was seen in 39 cases, of which 1 case had bilateral empyema. Thirteen cases had pneumothorax and eight cases had BPF.
Figure 1: Contrast-enhanced computed tomography chest of a 5-year-old child with air space within the areas of consolidation of lung parenchyma suggestive of necrotizing pneumonia

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Microbiological data

Blood cultures were sent in all cases. Thirteen blood cultures were positive, of which six cases grew Streptococcus pneumoniae, four cases were methicillin-sensitive Staphylococcus aureus, and three cases grew methicillin-resistant S. aureus (MRSA). S. aureus was seen in four cases of pleural fluid. Bronchoalveolar lavage was done in five cases where only one showed culture positive for MRSA.

Management and outcome

The median duration of hospital stay and antibiotic therapy for the children with NP was 25 days (IQR: 19.5–33) and 30 days (IQR: 24–34), respectively. The most common first-line antibiotics prescribed were amoxicillin with clavulanic acid and cefuroxime. The most common second-line antibiotics include ceftriaxone, vancomycin, and meropenem. A combination of two drugs was given for all patients.

Bronchoscopy was done in five patients, wherein thick pus was seen in one case. Three children required noninvasive ventilation (NIV) for 3 days each. One child responded to NIV as first-line therapy and the other two children were given NIV support while weaning from mechanical ventilation. Seventeen children required mechanical ventilation support for a median duration of 7 days (IQR: 5–11).

Video-assisted thoracoscopic surgery (VATS) was done in eight children, of which one case required bilateral VATS. Twelve cases underwent thoracotomy and decortication. Only one case received fibrinolytic therapy with urokinase. Chest drain was inserted in 39 cases. All the eight cases who had BPF underwent thoracotomy except for one who underwent VATS. All cases with BPF had chest drain inserted during the course of treatment for more than 7 days. All the cases of NP survived except for mortality in one case.


  Discussion Top


The current study which includes 46 patients with NP is one of the largest case series of pediatric NP analyzed in the subcontinent to best of our knowledge. The cohort of NP has mostly immunocompetent children, with the most common organism isolated being S. aureus. Despite prolonged hospital stay and associated complications such as empyema, pneumothorax, and BPF, the overall outcome is good. [Table 1] enumerates the summary and comparison of the present study with two other large retrospective studies in children with NP by Sawicki et al. and Lemaître et al.[1],[6]
Table 1: Summary and comparison of the present study with two other large retrospective studies in children with necrotizing pneumonia by Sawicki et al. and Lemaître et al.[1],[6]

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The children in the study group had similar features with respect to age and demography as cases in other studies.[1],[8],[9] The most common symptoms were fever and cough for about 7 days before admission to hospital similar to a study by Sawicki et al.[1] The persistence of fever in most of the children could be due to the pyrogens generated as a result of inflammation and parenchymal destruction.[1] Leukocytosis, high CRP, and anemia were found to be associated with children with NP in this study.[1],[2],[4],[10] Hypoalbuminemia was also observed which could be secondary to protein loss in pleural fluid or affected pulmonary tissue.[1]

Thirty-seven percent of the cultures were only positive in our study, whereas other studies have 8%–55% of the patients, which could be due reasons like our use of traditional culture methods. All the children with NP received antibiotics before hospitalization which could have sterilized the blood/pleural fluid.[4] It is also possible that causative organisms could be viruses, anaerobic bacteria, or atypical organisms such as Mycoplasma pneumoniae which were not tested in our study.[1],[2],[6],[11],[12],[13]

S. aureus was isolated in 11 cases (23.9%) as the most common organism in our study, of which three were MRSA. S. aureus was also a common causative organism in 13 cases (61.9%) in a study of 41 cases of NP, all of which were strains encoding genes of Panton–Valentine leukocidin and resistant to methicillin except one.[6] In another retrospective study of eighty cases of NP analyzed by Sawicki et al., eight cases (10%) with S. aureus were identified, of which 3 cases were methicillin resistant.[1] Six cases of S. pneumoniae were seen in our study, but serotyping was not done. S. pneumoniae was the most common causative organism as per the systematic review and in a number of studies where serotype 3 is associated with high risk of NP and complications such as hemolytic uremic syndrome.[1],[2],[4],[10],[14],[15],[16],[17],[18],[19],[20]

NP should be considered in a child with pneumonia who is sick with persistence of fever even after 3–5 days of appropriate antibiotics and significantly raised markers of inflammation in blood for which chest X-ray and CECT thorax play a major role. The CECT thorax is most sensitive in diagnosing cases of NP.[2],[4],[21],[22],[23] With increased use of CECT thorax in cases with complicated pneumonia, there is an increased yield of diagnosis of NP, thereby facilitating better management of children.[1],[2],[4]

NP is commonly associated with local complications in children. Empyema was seen in 39 (85%) cases in our study where the incidence of empyema in other studies has been reported in the range of 63%–97%.[2],[6] Chest drain was placed in 83% (n = 38) of the cases similar to another study where 87.5% of the cases were treated with placement of chest drain.[2] Surgical intervention was done in the form of VATS in 17% of the cases (n = 8) and thoracotomy and decortication in 26% of the cases (n = 12). There are no randomized control trials to compare the efficacy of pleural drainage with or without fibrinolytic versus VATS in cases with NP.[2] The severity of disease and conditions such as adhesions, location, and volume of pleural fluid directly influences the selection of just pleural drainage or VATS or thoracotomy.[24] Pleural drainage is sufficient in most of the cases like in our study, but early VATS is indeed justified.[2],[7]

BPF was seen in eight cases with incidence of 17%, whereas studies have shown an incidence between 15% and 67% of the cases with NP.[1],[2],[25],[26] In our study, all children who had chest drain placement for more than a week developed BPF. This could be due to the pleura becoming friable secondary to inflammation as it is adjacent to the necrotized pulmonary tissue.[1]

The only mortality was a case that had MRSA isolated in culture, but we could not test the strain. Lethal strain of S. aureus ST398 which caused NP has been documented in a case report.[27] A case series of four children reported a high mortality with Panton–Valentine leukocidin-associated S. aureus. Thus, in such cases, an aggressive approach to start early empirical combination antibiotic therapy, which could also include a toxin-suppressing agent, may be crucial to avert mortality.[28] The limitation of the study is that we could not investigate viral etiology and serotyping of isolated bacteria as it is a retrospective study. The study was conducted only at one center also that all children had received antibiotics before admission.


  Conclusion Top


NP can be well managed with conservative approaches such as prolonged antibiotic therapy and pleural drainage though there are commonly associated with short-term local complications, in general the clinical outcome is good.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

We would like to thank the Department of Radiology, Indira Gandhi Institute of Child Health.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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