Identifying Data

Patient is a 2 year old male,

born full-term to a 28 year
old G1P1 (1001) via NSD,
born to Roman Catholic
parents, residing in Quezon
City, admitted for the first
time on Feb. 1, 2011 to
Pedia Ward.
Chief Complaint
Fever of 6 days duration

Source and Reliability

Patient’s mother with good reliability
 History of Present Illness
6 days PTA
 sudden onset of intermittent fever (Tmax= 39oC)
temporarily relieved by intake of Paracetamol 120mg/5mL, 5mL TID
 associated with productive cough & colds with greenish nasal discharge
slightly relieved by Carbocisteine 100mg/5mL, 5mL every 6 hours
(+) decrease in appetite and activity

Symptoms persisted until…

 History of Present Illness
4 days PTA
 consultation with a private physician at Delgado
Memorial Hospital
 patient was prescribed with the ff. medications:

Paracetamol 250mg/5mL, 2.5mL every 4 hours

Salbutamol 2mg/5mL plain, 3mL TID
Clarithromycin 125mg/5mL, 3.5mL BID x 7 days

Symptoms persisted despite compliance.

 History of Present Illness
2 days PTA
 one vomiting episode after giving of medication amounting to
½ cup; mucoid, non-bloody
(+) loss of appetite, good fluid intake
(+) body weakness and irritability

Symptoms persisted despite compliance to medications, which

prompted the mother to seek consult at the ER, hence
admission.
 Personal History
Prenatal
The mother had regular pre-natal check-
ups. She had cough and colds during the 2nd
trimester which was resolved by increased
oral fluid intake alone. She did not develop
UTI or any major illnesses during the course
of pregnancy. She took multivitamins every
day until she gave birth.
 Personal History
Birth
The patient was born full term to a 28 year
old G1P1 (1001) via normal spontaneous
delivery at home, midwife-assisted. Patient
cried immediately and was noted to have
good color and vigorous activity, with birth
weight of 7 lbs. No complications were noted.
 Personal History
Neonatal
The patient had no other known diseases
during the first month of life. He has no
history of jaundice, pallor, hemorrhage or
dyspnea. No abnormalities in urination and
defecation were noted.
 Personal History
Feeding
The patient was breastfed from birth until
2 years. He was mixed fed with Nestogen
formulated milk (1:1 dilution) at 6 months,
but it was discontinued after 3 weeks of
intake due to diarrhea.
 Personal History
Feeding
Patient preferred breast milk only. At 2
years of age, he was mix fed with Bear
Brand milk (April 2010), then was single fed
with Lactum 1-2-3 after 5 months
(September 2010) when the mother was
already on her 5th month of 2nd pregnancy.
 Personal History
Feeding
He consumes 1 8-oz bottle per feeding,
3-4 bottles/day with good appetite. He was
started on soft diet (Cerelac and “lugaw”) at
6 months and solid diet (rice with meat &
vegetables) at 1 year.
 Personal History
Feeding
Patient doesn’t have milk allergies and
eating problems. He took Tiki-Tiki
multivitamins from 1 month up to 1 year, and
is currently taking Immune-C vitamins.
 Personal History
Behavior
The patient enjoys riding the bicycle,
building blocks and watching television
shows on Animal Planet and National
Geographic. His favorite TV show is Dora
the Explorer. He is very energetic and rarely
throws tantrums.
 Personal History
Behavior
He helps around the house (e.g. sweeps
the floor) and likes to eat without assistance.
He usually sleeps at 9PM and wakes up at
7:30AM.
 Personal History
Developmental
At 5 months, the patient…
GROSS: has good head control
FINE: reaches for objects
LANGUAGE: babbles
SOCIAL: turns to sound
 Personal History
Developmental
At 6 months, the patient…
GROSS: sits with support
FINE: chews
PERSONAL/SOCIAL: recognizes familiar
faces
 Personal History
Developmental
At 8 months, the patient…
GROSS: sits up without support
FINE: transfers objects from hand to hand
LANGUAGE: “mama” and “dada”

At 10 months, the patient stands alone

 Personal History
Developmental
At 1 year, the patient walks alone

At 1 ½ year, the patient…

GROSS: runs well
FINE: drinks from cup
LANGUAGE: indicates needs
PERSONAL/SOCIAL: uses spoon
 Personal History
Developmental
At 2 years, the patient…
GROSS: jumps, walks up and down the stairs, rides tricycle
FINE: imitates a circular stroke
LANGUAGE: points to one body part, follows 2 or 3
directions, names one picture, tells stories about experience
PERSONAL/SOCIAL: removes garment, toilet trained by day
 Personal History
Developmental
At 2 ½ years, the patient…
GROSS: stands momentarily in one foot, walks upstairs one
foot per step and down two feet per step, hops on two feet
FINE: imitates a circle
LANGUAGE: points to multiple body parts, follows multiple
directions, names multiple pictures, gives full name and age,
recognizes multiple colors, counts 1 to 5
PERSONAL/SOCIAL: helps in simple house tasks, dry by
night, washes and dries hands
 Personal History
Immunization
The patient has complete EPI vaccinations

Past Illness
(+) diarrhea – 6 months of age
No previous hospitalizations
No history of trauma or seizures

Family History
There are no hereditary illnesses that run in the family
 Social and Environmental
The patient’s family lives in a bungalow type of house
with 4 rooms and 2 bathrooms, which are shared by 5
occupants. Their house is located far from the main
road, dumpsite and factories. Garbage is collected
twice every week. Household water is provided by
NAWASA. They have their own purifying system for
the drinking water. They own 3 dogs. His mother is a
plain housewife while his father works as a security
guard and provides financial support for the family.
 Attack Rates
 Overall annual rate of pneumonia 12/1000 pop per yr.
 Highest at 0-4 yr age group 12-15/1000 pop per yr.
Etiology Frequency

0-3 mo. 4 mo.- 5 yr 6 – 16 yr

-virus

RSV +++ ++++ +

Hmpneumovirus + ++ ?

Parainfluenzae

Type + ++ +

+ + +

++ +++ ++
 Etiology Frequency

0 -3 mo. 4 mo.- 5 yr 6 – 16 yr
virus
Influenzae
Type A ++ +++ +++
Type B ++ ++ +
Adenovirus + ++ ++
Rhinovirus + + +
HIV + ++ +
VZV + + +
CMV +++ + +
Mycoplasma - + ++++

Ch.pneumonia - + +++

Ch.trachomatis ++++ - -
P.carinii + ++ +
 30

25

20

15 Incidence(cases/100,000
inhabitants)

10

0
1-2 2-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79

Age(years)
Incidence(cases/100,0000) of pneumococcal disease by age
group,Goteborg,Sweden,1970-1980.
250

200

150

Number/1000
Children/Year
100

50

0
<1 1 2 3 4 5 6-8 9-11 12-14 >15

Age(Years)
Incidence of lower respiratory disease by age group,chapel Hill Corolina.
 Leading Etiologic Agents of Pneumonia Infants and Children

Age Bacterial pathogens Viral Pathogens Other

-Neonate Group B Streptocaccus RSV

Gram-negative Herpes simplex
bacilli( E.coli,K.pneumoni virus
ae,Proteus spp.,others) CMV
S.aureus Adenovirus

1-3 mo. S.pneumoniae RSV C.trachomatis

H.Infuenzae type b
4 mo.-5 yrs S.pneumoniae Parainflenza virus1
H.Influenzae type b and 3,
Adenovirus
Influenza viruses A
and B

5 yrs and older S.pneumoniae M.pneumoniae

C.pneumoniae
 Clues to The Etiology of Pneumonia Obtained Through
History - Taking

Type of Contact or Prodrome Disease or Organism

- Contact with an individual with a lung Tuberculosis

infection M.pneumoniae
RSV
S.pneumoniae

- Infant/young child in day care H.Influenzae type B

N.meningitis
Respiratory viruses
 Clues to The Etiology of Pneumonia Obtained Through
History – Taking

Type of Contact or Disease or Organism

Prodrome
-Animal contact Psittacosis
Tularemia
Plaque, Q fever
Geographic regions Histoplasmosis
Coccidioidomycosis
Rickettsial infections

Building construction Aspergillus spp.

Air conditioning cooling towers Legionaires’ disease

 Clues to The Etiology of Pneumonia Obtained Through
History – Taking ( con’t)

Type of Contact or Disease or Organism

Prodrome
-Outbreak/epidemic Group A Streptococcus
Influenza
RSV

- Smoker,smoking in household,wood- Increase in all lower respiratory

burning stove infections

- Short prodrome Bacterial agents such as

S.pneumoniae,H.influenzae type b,
Group A Streptococcus
 Clues to The Etiology of Pneumonia Obtained Through
History – Taking ( con’t)

Type of Contact or Disease or Organism

Prodrome

- Long prodrome M.pneumoniae

C.pneumoniae or C.trachomitis
RSV

- Preceding rash Measles

N.meningitidis
M.pneumoniae
S.aureus
Preceding focal abscess;intra-or S.aureus
extrapulmonary
 Pneumonia:
-- Epidemiology
-- Diagnosis
-- Treatment
-- Prevention

Diagnosis
-- Signs and symptoms -- CXR
-- Physical Examination -- Culture
-- Lab -- Antigen Detection

Diagnosis Practice for Acute Lower Respiratory Tract Infection

-P.E. -- Transtracheal Aspirate
-CXR -- Lung tape
-Sputum -- Thoracocentesis
-CBC -- Antigen Detection
-Blood CIS

Gold standard for Diagnosis of Pneumonia is to Obtain:

1. Etiology agent from lung tissue
2. Blood culture
3. Detection of antigen from pleural fluid
Respiratory Rates (Breaths/minute) of Normal
children
Age Normal Rate- sleeping Normal Rate-Awake

Mean Range Mean Range

6-12 mo. 27 22-31 64 58-75

1-2 yr. 19 17-23 35 30-40

2-4 yr. 19 16-25 31 23-42

4-6 yr. 18 14-23 26 19-36

6-8 yr. 17 13-23 23 15-30

Diagnostic Tools for pneumonia
 CXR
 Sputum culture
 Blood culture
 Urine antigen test – CIE or latex
agglutination
 Lung tap
 Pleural fluid culture
 Three Types of Pediatric Pneumonia

 The pediatrician can see when looking at

the film.
 The pediatrician can not see when looking
at the film until pointed out by radiologist.
 The pediatrician can not see when looking
at the film even after being pointed out by
radiologist
 Epidemiology,Clinical,and Laboratory Features of
Acute Pneumonia in Normal Infants and Children
According to Etiologic Agents

Bacteria Virus Mycoplasma

Historical clues
- Age Any,esp.infant Any School
age,adolescent

- Temp. Majority ≥ 39° C < 39° C Majority < 39° C

- Onset Abrupt Gradually Gradually worsening

worsening URI cough
- Others in home ill Infrequent Frequent Frequent,wk.apart

- Ass. Signs, Meningitis,otitis,arMyalgia,rash,conjuHeadache,sorethroat,

symptom thritis nctivitis myalgia
- Cough Productive Nonproductive Hacking

- Pleuritic chest pain Frequent Infrequent Infrequent

 Epidemiology,Clinical,and Laboratory Features of
Acute Pneumonia in Normal Infants and Children
According to Etiologic Agents (con’t)
Bacteria Virus Mycoplasm
a
Physical Findings Confined Diffuse,bilat. Unilateral rales in
- Auscultatory rales,no Rales.Wheezes most
rales.Occasional in young infant
dullness to
percussion,dimini
shed tubular
sounds

-Toxicity Degree illness > Degree illness ≤ Degree illness <

findings findings findings
 Epidemiology,Clinical,and Laboratory features of
Acute Pneumonia in Normal Infants and Children
According to Etiologic Agents (con’t)
Bacteria virus mycoplasma

Radiographic Hyperaeration ± Hyperaeration Alveolar-

Findings alveolar infiltrate ± interstitial interstitial patchy
- Initial infiltrate infiltration
examination
- Progression Frequent,rapid Infrequent May be migratory

- Pleural fuild May be Infrequent,small,n Infrequent,small,n

large,rapidly ot progressive ot progressive
progressive
 Epidemiology,Clinical,and Laboratory Features of
Acute Pneumonia in Normal Infants and Children
According to Etiologic Agents (con’t)
Bacteria Virus Mycoplasma

Laboratory Majority> Majority<15,000.L Majority normal or

Findings 15,000.Granulocy ymphocytes less than 15,000
- Peripheral tes predominate predominate
WBC/cu.mm
- C-reactive Majority Infrequent Infrequent
protein

- Sed rate ≥ 30 Majority Majority Majority

mm/hr
 Etiology of Pneumonia in infants and
Children
Viral Winter S.Pneumonia
Agents
Para 1,2,3
Influenza
A,B Etc. Mycoplasma
Summer

RSV
C.Trachomatis
CMV 1°
Strep. 2°Staph.
Gr.B Staph.
C. pneumoniae
E.coli
H.Inf.B.

1 mo. 3 mo. 6 mo. 1 yr. 3 yrs. 5 yrs. 10 yrs.

 Prospective Studies of Perinatal
Chlamydia Infection
Infants
City Mother Conjunctivitis(%) Pneumonia (%)
San
Francisco 5 18 16
Seattle 13 44 --
Denver 9 44 22
Boston 2 33 17
Seattle 12 33 8
Lund 9 22 --
Nairobi 22 37 12
 Clinical Features of C. Trachomatis Pneumonia

 Onset at 3 to 11 wks of age

 Cough greater than one week in duration
 Prior conjunctivitis
 Afebrile tachypnea with diffuse rales
 Hyperinflation and interstitial infiltrates on chest
film
 Eosinophilia
 Increased IgM
 Increased IgA and IgG
 9

6
Number of patients

5
Erythromycin
4 Sulfisoxazole

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14

Treatment day
Treatment day when improvement first noted
 25

20

15
Staphylococcal
Haemophilus
Pneumococcal
10
Steptococcal

5
• Pleural effusion

0
<3 mo. 3-6 mo. 6-12 mo. 1-3 yr. >3 yr.

Age distribution of 107 hospitalized children with identified bacterial pneumonia

 Annual Rate of Bacteremia by
Organism
6

4
Strep.pneumoniae
3 H.influenzae
N.Meningitidis
2

0
82 83 84 85 86 87 88 89 90 91 92 93

Pedriatic Infect Dis J.1994;13:1143-44

 Pneumococcal pneumonia

Most common in late winter or early spring during

the peak of viral infection

 Abrupt onset of fever

 Restlessness
 Respiratory distress following URI
 Physical exam & Labs
 Diminished B. S or fine, crackling rales
 Neck rigidity without meningitis may occur
(RUL)
 WBC 15,000 - 40,000
 Blood C/S positive only 30%
 Lobar consolidation (less common in
infants)
 Para-pneumonic effusion is relatively
common
 Characteristics of 65 Patients with Pneumonia due
to Haemophilus influenzae Type b
Characteristic No.(%)
Physical Examination
Temp. > 39°C 58( 89% )
Decreased breath sounds over af- 53 ( 82%)
fected area
cough 49 (75%)
Ass. Conditions
Otitis media 28 (43%)
Meningitis 10 (15%)
Pericarditis 3 (5%)
Bacterial Cultures
Bl. 49/65(75%)
Pleural fluid 36/46(78%)
CSF 10/40(25%)
 Characteristics of 65 Patients with Pneumonia due
to Haemophilus influenzae Type b (con’t)
Characteristic No. (%)
Bacterial Cultures(con’t)
Middle ear fluid 8/9 (89%)
Lung aspirate ½ (50%)
Roentgenographic Examination
49 Patients with consolidation
Unilateral disease 28 (57%)
Bilateral disease 11 (22%)
Pleural fluid 37 (76%)
16 Patients with bronchopneumonia
Unilateral disease 11 (69%)
Bilateral disease 5 (31%)
Pleural fluid 12 (75%)
25

20

15

Number of patients
10

0
0-6 7-12 13-24 25-48 >48

Months of age
Ages of 65 patients with H.influenzae b pneumonia
 25

20

15

Number of patients
10

0
5-10 11-15 16-20 21-25 26-30 >30

WBC x 10³
The peripheral leukocyte count at the time of hospital admission in 65 patients with H.influenzae b pneumonia
 Factors Influencing the Case Fatality Rates in 79 Infants and
Children with staphylococcal pneumonia

Factor No. died/total P

1.Primary pneumonia 14/61 (23)
Secondary pneumonia 6/18 (33) 0.35
2.1965-1971 15/40 (37.5)
1972-1978 5/39 (12.5) <0.05
3.≥ 12 mos. Of age 14/45 (31)
> 12 mos. Of age 6/34 (18) <0.5
4.Unilateral pneumonia 5/42 (11.9)
Bilateral and/or multilobe
pneumonia
5.Initial WBC ≥10,000/cu mm 14/20 (70)
Initial WBC >10,000/cu mm 6/59 (11.8) <0.001
6.Appropiate ATB 4/54 (7)
Inappropiate 12/21 (57) <0.001
7.Empyema:drainage 8/50 (16)
No drainage 3/10 (300) 0.19
  Age 6 yrs and older
 Febrile pneumonia
■ Mycoplasma pneumoniae
■ C. pneumoniae
■ S. pneumoniae
- Treatment:
▲Erythromycin
▲Clarithromycin
▲Azithromycin
 Mycoplasma pneumoniae in the United
States
Syndrome Incidence/year Total cases

Pneumonia 2/1.000 500,000

Tracheobronchitis 46/1,000 11,500,000

Asymptomatic 12/1,000 3,000,000

Infections

All infections 15,000,000

 Incubation Clinical illness Convalescence

Wks.-2 -1 0 1 2 3 4 5 6

Symptoms:
Headache,malaise
Fever
Sore throat
Cough
Signs:
Sputum

Dullness

Rales
Laboratory:
Positive culture

x-ray
 M.pneumoniae Infections
 Asymptomatic
 Respiratory diseases with or without
pneumonia
 Responsible for 35% of out patient
pneumonias
 3-18%(median 7%) of community acquired
pneumonias necessitating hospitalization
 Diagnostic of Mycoplasma
Pneumonia Diseases
 Consider in all cases of pneumonia.
 “Flu-like” Febrile illness of gradual onset.
 Symptom of acute tracheobronchitis.
 Paucity of physical findings.
 CXR.
 Exclude bacterial disease.
 Cold hemagglutinin test.
 Mycoplasma culture.
 Mycoplasma serology.
 BEDSIDE COLD
HEMAGGLUTININ
0.2 ml. patient blood is mixed with and
equal volume of sodium citrate solution in
a small tube which is iced for 15 sec.The
tube is then tipped and rotated for
inspection of the blood film.A positive is
indicated by agglutination which
disappears when the tube is warmed to
37°C.A positive test indicates a standard
method titer ≥ 1: 64
 Diagnostic Tests for Mycoplasma pneumoniae
Test Specimen Sensitivity(%) Specificity(%) Comments
Culture Throat or NP swab, > 90 50-90 Not routinely available;
sputum, bronchial slow-growing organism
washing
tissue
PCR Throat or NP swab, 95 95-99 Not commercially available
sputum, potencially useful for rapid
broncial washings, diagnosis test
tissue
Serology cold agglutinins 50 < 50 Nonspecific;takes several
wks to develop
Serum 75-80 80-90 Paired acute-convalescent
Complement sera preferred;takes 4-9wks
fixation for seroconversion
Elisa Diagnostic criteria
Definite: 4-fold increase in
titer
 Respiratory and Nonrespiratory Complications of Mycoplasma Pneumoniae
Infections
General Hematologic
Skin rashes Anemia (including hemolytic)
Erythema multiforme DIC
Maculopapular eruptions Throboembolism
Vesicular eruption Cardiac
Toxic epidermolysis Pericarditis
Erythema nodosum Myocarditis
Arthritis Neurologic
Glomerulitis Encephalitis
Pulmonary Meningitis
ARDS Poliomyelitis-like syndrome
Broncial asthma exacerbation GB syndrome
Bronchiectasis Brain-stem syndrome
celabellar ataxia
Bronchiolitis obliterans Psychosis
Hyperlucent lung syndrome
Interstitial fibrosis
Lung abscess
Pleuritis,pulmonary embolism
Pneumatocele,pneumothorax
File Timetal:ID clinic NA vol.12,No.3,Sept 1998
Chlamydia pneumoniae ( TWAR )

This organism cause pneumonia,

bronchitis,sinusitis and pharyngitis
and is a common cause of infection
in children from the age 5 – 15 years.
Of the three Chlamydia species,
Chlamydia pneumonia is by far the
most common cause of human infection
 Clinical Finding in Pneumonia Associated with
M.Pneumoniae,TWAR and Viral Respiratory Agents

///////////////// TWAR M.pneumoniae Viruses

( N=26 ) ( N=35 ) ( N=86 )
Cough 100% 97% 89%

Sore throat 50% 48% 50%

Horesness 48% 32% 37%

WBC>10,000 25% 21% 37%

Fever>106°F 67% 94% 93%

Hospitalized 4% 3% 5%
 Diagnostic Tests For Chlamydia Pneumoniae
Test Specimen Sentivity (%) Specificity(%) Comments

Culture NP swab,sputum.broncial 50-90 ? Requires tiss. Culture

washings,pleural fluid requires several days
incubation
PCR Sputum,broncial washings 80-90 >85 potential for rapid
pleural fluid,tiss.,throat or diagnosis
NP swab
Serology Serum microimmunofluo- 50-90 ? Paired
IgG and IgM Acute and
convalescent
Diagnostic criteria
Definite: 4 fold rise
microimmunofluorescence
Ab Possible IgG≥1:512
IgM ≥ 1:32
 Minimal Inhibitory Concentration(MIC) of Selected
Antibiotics Against C.pneumoniae
Drug MIC Utility Activity
Rifampin 0.005 - 0.25 not used very high
Tetracyclines
tetracycline 0.05 - 0.1 drug of high
doxycycline 0.03 - 0.05 choice high
Erythomycin 0.1 - 1.0 alternative high
Sulfamethoxazole 0.5 – 4.0 alternative moderate
Fluoroquinolones
ofloxacin 0.5 - 1.0 may prove moderate
ciprofloxacin 1.0 - 4.0 useful moderate
enoxacin 2.0 – 8.0 low
norfloxacin 4.0 - 16.0 not reliable
Penicillins
ampicillin 0.5 – 10.0 low
penicillin 1.0 – 10.0
Cephalosporins
ceftriazone 10-100 none none
moxalactam 100 none none
Gentamicin 500 none none
Vancomicin 1000 none none
 SARS Outbreak in Humans

Dates and Location Total Cases Deaths Comments

November 16, 2002-June 15, 2003 8,096 774 (9.6%) Global spread began February 21, 2003;
Guangdong Province, China, then WHO declares epidemic contained on July 5,
worldwide 2003

August 26, 2003-October 1, 2004 1 0(0.0%) 27-year-old postgraduate medical student

Singapore, Malaysia working in a virology laboratory

December 5-30, 2004 1 0(0.0%) 44-year-old military research scientist working

Taipei, Taiwan in a virology laboratory

December 16, 2003-January 17, 2004 1 0(0.0%) 32-year-old television producer, source of
Guangzho, Guangdong Province, China infection unknown

December 25, 2003-January 17, 2004 1 0(0.0%) 20-year-old waitress who worked in a
Guangzho, Guangdong Province, China restaurant serving wild game and civet cats;
source of infection unknown
 SARS Outbreaks (continued)
Dates and Location
December 31, 2003-January 21,2004
Shenzen, Guangdong Province, China
January 7-30, 2004
Guangzho, Guangdong Province, China
March, 2004-April 19, 2004
Beijing, and Anhui Province, China
have
TOTAL
Total Cases Deaths Comments
1 0(0.0%) 35-year-old businessman, source of
infection unknow
1 0(0.0%) 40-year-old hospital director and physician;
source of infection unknown
9 1(11.1%) First reported April 22, 2004. Declared
contained by WHO on May 18, 2004. Index
case worked at the National Institute of Beijing
and infected her mother in Anhui Province.
The mother died. The index case traveled by
train from Beijing to Anhui twice, but no other
infected contacts were found. A nurse who
treated the index case in Beijing spread it to her
family and to another patient and the patient’s
daughter. Another ill researcher at the National
Institute of Virology also was confirmed to
SARS-CoV.
8,111 775 (9.6%)
 Severe Acute Respiratory Syndrome (SARS)
CDC continues to recommend consideration of testing for SARS-
CoV in patients who require hospitalization for radiographically
confirmed pneumonia or ARDS without identifiable etiology
AND who have one of the following risk factors in the 10 days
before the onset of illness:
 Travel to mainland China, Hong Kong, or Taiwan, or close contact with an
ill person with a history of recent travel to one of these areas, OR
 Employment in an occupation associated with a risk for SARS-CoV
exposure (e.g., health care worker with direct patient contact; worker in a
laboratory that contains live SARS-CoV), OR
 Part of a cluster of cases of atypical pneumonia without an alternative
diagnosis.
 Avian Influenza Outbreaks in Humans
(through November 2004)

Dates and Location Subtype Total Cases Deaths Comments

May-December 1997 H5N1 18 6(33.3%) First confirmed avian influenza outbreak

Hong Kong in humans

March 1999 H9N2 2 0(0.0%) Two children with mild influenza-like

Hong Kong symptoms

April 2002 H7N2 1 0(0.0%) First probable case in US; had mild
Virginia, USA influenza-like symptoms; diagnosis made
by serology only

February 2003 H5N1 2-3 1-2 (50.0-66.7%) Family had visited China, one child’s cause
Hong Kong of death is unknown

February 2003 H7N7 84 1(1.2%) Most presented with conjunctivitis; one

Netherlands veterinarian died
 Avian Outbreaks (continued)

Dates and Location Subtype Total Cases Deaths Comments

November 2003 H7N2 1 0(0.0%) No known avian contacts; source

New York, USA remains unknown

December 2003 H9N2 1 0(0.0%) 5-year-old; hospitalized with

Hong Kong influenza-like symptoms

December 2003-present H5N1 44 to date 32 to date (72.7%) No cases from April-June 2004;
Thailand and Vietnam epidemic is ongoing, with possible
17 in Thailand 12 in Thailand human-human transmission
27 in Vietnam 20 in Vietnam

February-April 2004 H7N3 2 0(0.0%) Both had conjunctivitis and mild

British Columbia, Canada influenza-like symptoms

Bold indicates highly pathogenic avian influenza. Overall mortality in human beings from all avian influenza or all HPAI strains
combined is about 19%, whereas it is >60% of H5N1 is the infecting subtype.
 Cambo
dia
Aug
2005
4
cases
4
deaths
Indone
sia
Thaila Aug
nd 2005
Aug 1
2005 cases
17 1
cases Vietna deaths
12 m
deaths Aug
2005
90
cases
 Clinical manifestation of Avian Flu
 Respiratory symptoms - Flu like illness
- ARDS
 GI symptoms : Acute diarrhea, vomiting,
abdominal pain
 CNS : Encephalitis
 Multiple organ dysfunction
 Sepsis / septic shock

Not all cases have respiratory symptoms

 Influenza A(H5N1) Virus Infections (Avian Flu)

I. Testing for influenza A(H5N1) is indicated for hospitalized

patients with:

a. Radiographically confirmed pneumonia, acute respiratory

distress syndrome (ARDS), or other severe respiratory illness
for which an alternate diagnosis has not been established, AND

b. History of travel within 10 days of symptom onset to a country

with documented H5N1 avian influenza in poultry and/or humans
(for a listing of H5N1-affected countries, see the OIE Web site at
www.oie.int/eng/en_index.htm and the WHO Web site at
www.who.int/en).
II. Testing for influenza A(H5N1) should be considered on a case-
by-case basis in consultation with state and local health depart-
ments for hospitalized or ambulatory patients with:

a. documented temperature of >38ºC (>100.4ºF), AND

b. one or more of the following: cough, sore throat, shortness of
breath, AND
c. history of contact with domestic poultry (e.g., visited a poultry
farm, household raising poultry, or bird market) or a known or
suspected human case of influenza A(H5N1) in an H5N1-
affected country within 10 days of symptom onset.
 Interim Recommendations: Infection Control
Precautions for Influenza A(H5N1)
 Standard Precautions
Pay careful attention to hand hygiene before and after all patient contact
 Contact Precautions
Use gloves and gown for all patient contact
 Eye protection
Wear when within 3 feet of the patient
 Airborne Precautions
Place the patient in an airborne isolation room (i.e.,monitored negative air
pressure in relation to the surrounding areas with 6 to 12 air changes per
hour).

Use a fit-tested respirator, at least as protective as a NIOSH- approved N-95

filtering facepiece respirator, when entering the room.
 Laboratory Testing Procedures

Highly pathogenic avian influenza A(H5N1) is classified as a select

agent and must be worked with under Biosafety Level (BSL) 3+
laboratory conditions. Therefore, respiratory virus cultures should
not be performed in most clinical laboratories and such cultures
should not be ordered for patients suspected of having H5N1
infection.

Clinical specimens from suspect A(H5N1) cases and SARS-CoV cases

may be tested by PCR assays using standard BSL 2 work practices
in a Class II biological safety cabinet. In addition, commercial
antigen detection testing can be conducted under BSL 2 levels to
test for influenza.
Considerations for Inpatient Management of
Children with Pneumonia

Toxic appearance
Respiratory distress
Pleural effusion
Age considerations
<3 months
<3 years, with lobar pneumonia
<5 years, with lobar pneumonia (more than 1 lobe)
Considerations for Inpatient (continued)

Existing chronic disease

Pulmonary (including asthma)
Cardiac
Renal
Diabetes mellitus
Metabolic disorders
Anemia (including sickle cell disease)
Malignancies
Immunocompromised host
Progression of pneumonia during outpatient therapy
 Initial Therapy of Pneumonia
Treatment Principal pathogens
Outpatient Hospitalized
Age

0-4 wks. - Ampicillin and Group B Streptococcus(+

Gentamicin (+/- +)
cefotaxime) Enteric gram negative
bacilli(+)
1-5 mo. Amoxicillin ( or Cefotaxime* Pneumococcus(+
amoxicillin-clavulanate) +);virus(++);S.aureus(+)
6 mo.-6 yr. Amoxicillin ( or Cefotaxime* +/- Pneumococcus(+
amoxicillin-clavulanate) macrolide† +);virus(+
+);S.aureus(+);Group A
Streptococcus(+);Mycopla
sma(+)

6 yr. Macrolide † (+/- Cefotaxime* and Mycoplasma( +

amoxicillin) macrolide † +);pneumococcus(+);S.aur
eus(+);Group A
Streptococcus(+);Chlamyd
ia(+)

Immunocompromised - Cefazidime‡ and Many

Vancomycin +/-
macrolide†
+Occasional cause ++common cause *or ceftriazone or cefuroxime ,†Erythromycin azithromycin or clarithromycin ,‡cefepime
 Outpatient Inpatient
(septic, alveolar infiltrate, large pleural
effusion or all)

 0-20 days
 0-20 days
 IV amp/gent with or w/o IV
 Admit pt. cefotaxime
 3wks-3mos  3wks-3mos
 Afebrile;give PO  Give IV cefotaxime or
erythromycin. Admit for ceftriaxone
fever or hypoxia  4mos-4yrs
 4mos-4yrs  IV cefotaxime, ceftriaxone,
 PO amox or azithro. If >8 if pt not well consider IV
yrs, PO doxycycline azithromycin*
(4mg/kg/day, 2 divided
doses)
The end!
 Pleural Empyema In Children
Stages of infection
Exudative (allows needle aspiration)
Fibrinopurulent (may be loculated)
Organizing
Treatment options
Exudative Repeated needle aspiration (1-5 days)
Exudative or Chest tube drainage
fibrinopurulent
Organizing Decortication
If >50% limitation of lung shown by CT scan
After 2-4 weeks of medical management
tachypnea, asymmetry of chest wall
expansion, fever,or leukocytosis remain
 50

40
Percent Incorrectly Classified

30

Transudates
20
Exudates

10

0
LDH>200 LDH PRO LDH>200 PRO PRO PRO
R>0.6 R>0.5 or LDH R>0.5 or R>0.5 or R>0.5 or
R>0.6 LDH R LDH>200 LDH>200
>0.6 or LDH
R>0.6

Annals of Internal Medicine 77:507-513,1972

 Characteristics of Different Types of Pleural Effusions
Clinical Condition Type of Predominate Glucose pH
effusion Cells in Level(mg/dL)
Effusion

Empyema Exudate PMN <30 <7.00

cells>50,000/m
m3
Parapneumonic Exudate PMN >30 <7.20
effusion cells<50,000/m
m3
Tuberculosis Exudate Lymphocytes 30-60 7.00-7.30

Congestive heart Transudate Lymphocytes >60 >7.40

failure
Hypoalbuminemia Transudate Lymphocytes(f <60 >7.40
ew)
Malignancy,SLE Exudate Lymphocytes,mVariable Variable
alignant cells
 Reported frequency of pleral effusion in pneumonia

Etiology Frequency(%)
S.aureus 72-76
Strep.pneumoniae 57
H.Influenzae 49-75
Group A Streptococcus 86-91
Mycoplasma pneumoniae 21
Adenovirus 11-33
 Bacterial Isolates from Pleural Effusions and Empyema in Children and
Adolescents

Percentage of Isolates
Brook,1990(72 cases) Freij et al,1984(227
Bacterial Species cases)

-Strep.pneumoniae 18 22
-Group A 4 1
Streptococcus(Streptococcus
pyogenes)
-Viridans streptococci 7 <1
-Nonhemolytic streptococci 6 -
-Enterococcus faecalis 3 -
-Other streptococcus - 1
-S. aureus 14 29
-H.influenzae 21 18
 Bacterial Isolates from Pleural Effusions and Empyema in
Children and Adolescents(con’t)
Percentage of Isolates
Bacterial Species Brook,1990(72 cases) Freij et al,1984(227
cases)

-E.coli
-Klebsiella pneumoniae
-Pseudomonas aeruginosa
-Proteus mirabilis
-Gram-positive anaerobic
isolates
-Gram-negative rod
anaerobic isolates
-Mixed infections
-sterile
3 -
4 1
3 1
1 -
17 -
29 -
- 4
- 24
 Duration of Antimicrobial Therapy and Hospitalization in
Empyema Survivors

Duration of Antimicrobial Duration of

therapy(Days) Hospitalization(Days)
No. of cases Mean ± SD No. of cases Mean ± SD

S.aureus 40 24.2 ± 10.6 50 26.8 ± 9.5

Strep.pneumoni 41 12.3 ± 6.3 48 12.9 ± 7.9

ae
Haemophilus 34 13.0 ± 4.8 37 16.7 ± 10.4

Sterile 37 11.8 ± 5.9 51 11.7 ± 7

Mixed bacteria 7 21.9 ± 13.6 8 31.4 ± 21.6

 Guidline for Chest Tube Insertion in Patients With
Nonpurulent,Gram-Negative Parapneumonic Effusions

Pleural Fluid Result Management

Light Recommendations*
-pH< 7.00 or glucose<40 mg/dL
-pH 7.00-7.20 or LDH † >1000 IU/L
-pH>7.20 and glucose>40 mg/dL and
LDH<1000 IU/L
Placemant of chest tube for drainage in most
patients
Consider chest tube for drainage ( loculate or
large )
Chest tube not indicated,even for
loculation:reevaluate with repeat
thoracentesis( patient not response or effusion
increases)

*Light RW:Management of parapneumonic effusions.Chest 100:892-893,1991

†LDH,lactate dehydrogenase
 Guidline for Chest Tube Inserttion in Patients With
Nonpurulent,Gram-Negative Parapneumonic Effusions
(con’t)
Pleural Fluid Result Management

Sahn Recommendations ‡
-pH <7.10,usually with glucoe<40 Placement of chest tube for drainage
mg/dL, LDH>1000 IU/L
-pH 7.10-7.29 glucose 40-60 mg/dL, Repeat thoracentesis in 6-8 hr:if pH
LDH 500-1000 IU/L decreases and clinical status
worsens,placement of chest tube
indicated
-pH ≥7.30,pleural fluid to serum glucose No indication for chest tube
ratio >0.5. LDH<1000 IU/L drainage:continue close observation

‡Strange C.Sahn S. Management of parapneumonic pleural effusions and empyema.Infect Dis Clin North
Am 5:539-559,1991
Algorithm for Empyema

Pleural effusion

Thoracentesis

Gram stain-neg Gram stain-pos

Observe Chest tube

Resolution Increasing fluid

Resolution Non-resolution

Open drainage
Decortication
 Common Causes of Community-Acquired
Pneumonia in Otherwise Healthy Children

Viruses Respiratory syncytial virus

Influenza A or B
Parainfluenza viruses 1, 2, and 3
Adenovirus
Measles virus
Mycoplasma Mycoplasma pneumoniae
Chlamydia Chlamydia trachomatis
Chlamydia pneumoniae
Bacteria Streptococcus pneumoniae
Mycobacterium tuberculosis
Staphylococcus aureus
Haemophilus influenzae type b II
Nontypeable H. influenzae
 Uncommon Causes of Community-Acquired
Pneumonia in Otherwise Healthy Children

Virus Varicella zoster virus

Coronaviruses
Enteroviruses (coxackievirus and echovirus)
Epstein-Barra virus
Mumps virus
Herpes simplex virus (in newborns)
Hantavirus
Chlamydia C. psittaci
Coxiella C. burnettii
 Uncommon Causes (continued)

Bacteria S. pyogenes
Anaerobic mouth flora (S. milleri, Peptostreptococcus)
Non-type b (but typeable) Haemophilus influenzae
B. pertussis
K. pneumoniae
E. coli
L. monocytogenes
N. menigitidis (often group Y)
Legionella
Pseudomonas pseudomallei
F. tularensis
B. abortus
Leptospira
 Uncommon Causes (continued)

Fungi C. immitis
H. capsulatum
B. dermatitidis
Which of the following statements regarding
pneumonia in children is true?
A .Specific microbial pathogen usually can be
identified
 B. All children who have pneumonia should be
hospitalized for observation and treatment
 C. Pneumonia is a rare cause of child mortality
worldwide
 D. Radiographs of the chest always should be
obtained to determine the cause
 E. Viral agents are the most common causes of
pneumonia in older infants and children
You are evaluating an 8 year old boy who has 7 day history
of malaise and worsening cough. His mother reports that
he has had low grade fever. PE reveals a well appearing
boy with normal RR and pulse ox. Lung exam reveals
bilateral crackles without wheezing . Chest x-ray show
bilateral interstitial infiltrates without effusion.

 Most likely pathogen is:

 A. Haemophilus influenzae
 B. Mycobacterium tuberculosis
 C. Mycoplasma pneumoniae
 D. Respiratory syncytial virus
 E. Streptococcus pneumonia
 An 8 week old girl presents to ER with increased work of
breathing x 1 day. Temp of 101.1 F, difficulty breastfeeding
due to nasal congestion. RR 70, pulse ox 90% on RA. Lung
exam reveals bilateral wheezes and crackles. CXR shows
increased perihilar markings bilaterally and right middle
lobe opacity.
 Most likely cause of her symptoms is;
 A. Adenovirus
 B. Bordetella pertussis
 C. Chlamydia trachomatis
 D. Group B Streptococcus
 E. Respiratory syncytial virus
 #4
Main Cause of Necrotizing Pneumonia
is:
A. Streptococcal hyaluronidase
B. Teichoic acid
C. Pneumolysin
D. Fibrinolysin
E. Ponton-valentine leukocidine
 #5
The following microorganisms are
frequent causes of pleural effusion
EXCEPT:
A. S. aureus
B. Strep pneumoniae
C. Group A streptococcus
D. Haemophilis influenzae type B
E. Mycoplasma pneumoniae
 #6
Characteristics chlamydial pneumonia
include the following EXCEPT:
A. Afebrile
B. History of conjunctivitis
C. Staccato cough
D. Eosinophilia
E. Present at 4-6 months of age
 #7
Distinguish features of exudate from
transudate are as follows EXCEPT:
A. Pleural fluid: serum protein ratio > 0.5
B. Pleural fluid LDH > 200 IU/ml
C. Pleural fluid: serum LDH > 0.6
D. Pleural fluid protein > 3 gm/ml
E. Leukocyte count > 1,000/CU/mm
Features Differentiating Exudative
& Transudative Pleural Effusion
Transudate Exudate

 WBC <10,000/mm³ >50,000/ mm³

 pH >7.2 <7.2
 Protein <3.0 g/dL >3.0 g/dL
 Protein ratio <0.5 >0.5
 LDH <200 IU/L >200 IU/L
 LDH ratio <0.6 >0.6
 Glucose ≥60 mg/dL <60 mg/dL
TIME TO WAKE UP!!!
 Atypical Pneumonia Clues to Traditional
Causes(con’t)
Pathogens Clinical Clues
Legionella pneumophila a. Acute onset,multiple shaking chills,high
fever,pleurisy
b.Associated CNS,GI,GU abnormalities
c. Underlying smoking history or lung
disease
d. Sporadic or epidemic cases
Geographic fungi (e.g.,Histoplasma)a. Regional diseases – importance of travel
history
b. Outdoor exposures
c. Mimics tuberculosis
d. Skin,bone,lymph node extrapulmonary
manifestations
e. May occur in epidermics