On the nature of pleural involvement in necrotizing pneumonia: A report of two cases of life threatening late complications

Abstract

Suppurative complications of pneumonia such as empyema, lung abscess, pyopneumothorax, and necrotizing pneumonia (NP) are uncommon in children. Over the last decade an increasing incidence of NP has been reported. Streptococcus pneumoniae continues to be the predominant causative organism of NP, and while sporadic cases were reported prior to routine administration of heptavalent pneumococcal vaccine, a marked increase in NP appears to relate to replacement pneumococcal strains. Pleural involvement is almost universal in NP, and the course of pleural disease often determines its duration and outcome, particularly as it relates to complication of bronchopleural fistula. Cavities are formed in NP within the lung parenchyma and in the pleural space as the fibrosing pleural process organizes. The similarity of the radiologic appearance of parenchymal and pleural space cavities often makes the differentiation of pneumatocele versus residua of loculated pneumothorax challenging. The prevailing perception from most reports on childhood NP is of a favorable outcome with conservative approach. We report two pediatric cases with pneumonia who presented with prolonged fever despite antibiotic treatment, eventually diagnosed with NP. After stabilization on prolonged IV antibiotics, and weeks after discharge, they presented with unexpected acute respiratory failure due to a life-threatening tension air collection. In this article we discuss the nature of NP, its typical presentation, benign course and outcome, albeit its potential to cause serious late complications in the light of our recent experiences. Increasing awareness of such complications will result in more careful follow-up and in providing appropriate recommendations to parents of patients recovering from NP.

The value of chest magnetic resonance imaging compared to chest radiographs with and without additional lung ultrasound in children with complicated pneumonia

“…The abscess wall typically appears hypointense compared to the fluid-isointense center of the abscess formation and can be clearly identified on T2-weighted images. In the clinical context the diagnosis of lung abscess formation is important, since it seems to be associated with a higher admission rate to the intensive care unit, while also bearing the risk of bronchopleural fistulas that typically require surgical intervention [35][36][37]. Besides detection it is also important to reliably evaluate treatment response in conservative therapy.…”

Necrotizing pneumonia: an emerging problem in children?

“…Cases of NP in children occur globally and have been reported from North America [4,7,9,10,19,20,26,28,29], Latin America [26,38], UK [22,35], Europe [5,6,14,16,30,33,40], Middle East [3,12,27,31,37], Asia [8,11,17,21,24,25,32,36,39], and Australia [23]. Tables 1 and 2 show that the typical child with either NP or PNP is aged between 2 and 5 years and, except for studies from Taiwan [32,39], is equally likely to be male or female.…”

“…Additional complications worth highlighting include HUS that may emerge during the course of PNP, particularly in Taiwanese children [25,32], and the early or late-onset of life-threatening tension pneumatoceles and tension pneumothorax [4,26]. Tension pneumatoceles arise from ball-valve mechanisms, trapping gas within the cavity, while a late tension pneumothorax may occur from an unrecognized small BPF leading to a low-grade leak and gradual accumulation of gas within the pleural cavity under pressure [26]. Both complications need urgent surgical intervention and thus experts advise that children with residual cavities should have repeat chest radiograph 2 weeks following discharge, or sooner if they develop signs of respiratory distress.…”

“…First reported in adults with severe pneumonia in the 1940s, NP was not described in children until 1994 when a small case series of four patients was published [3]. Since then, descriptions of NP have included individual case reports [4][5][6][7][8][9][10][11][12] and small retrospective series of 2-18 cases [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] with few publications involving larger numbers of affected children. Although still regarded as uncommon, the incidence of NP (as with other more common forms of complicated pneumonia, parapneumonic effusion [PPE] and empyema) may be increasing [18,22,[28][29][30][31][32].…”

Conservative Therapy with Intrapleural Urokinase Avoids Primary Thoracotomy in Childhood Necrotizing Pneumonia: A Case Series

“…Necrotizing pneumonia is a rare and severe complication of bacterial community-acquired pneumonia [1,2] where pleural involvement is almost universal [3]. It only represents 0.8% of community-acquired pneumonia but may be seen upto 6% of hospitalized communityacquired pneumonia [4].…”