We conducted a retrospective study to analyze the level of concordance between clinical and autopsy diagnosis of pneumonia in children. A secondary objective of the study was to assess if known risk factors associated with mortality due to pneumonia were mentioned in their clinical case records.

Over a 3-year period (January, 2012 to December, 2014), 88 children were confirmed to have pneumonia on autopsy study. Their median (IQR) age was 10.5 (45) months (49 males). Detailed histopathological examination identified etiology of the pneumonia as viral in 42 (47.7%), bacterial in 27 (30.7%), bacterial and viral in 18 (20.4%), and fungal in one (1.1%) child.

Utilizing the Goldman classification [1], our analyses revealed that in only 33 (37.5%) cases the ante mortem diagnosis of pneumonia (including its etiology) was also confirmed on autopsy to be directly related to death (Class V). In only one child the discrepancy was major (Class I) wherein had the correct diagnosis been made clinically, it would have changed patient management and might have resulted in cure or prolonged survival. This case was a 1-year-old girl with severe acute malnutrition admitted with history of fever for 21 days. Her chest radiograph revealed a bronchopneumonia which was treated with broad-spectrum antibiotics. She died after a 7.5 day stay in hospital in spite of intensive care and mechanical ventilator support. Her post-mortem examination revealed fungal (Aspergillus) bronchopneumonia.

In 21 (23.9%) cases, the discrepancy was major (Class II) but the missed diagnosis of pneumonia would not have altered treatment or survival. Of these 21 cases, in 18 (20.4%) cases the patient had already been empirically started on oral antibiotics by a private practitioner (with or without oseltamivir) for a few days before being referred to our institute. The remaining 3 (3.4%) cases had been brought directly to our emergency department. All 21 cases were critically ill and received appropriate resuscitative management, but had succumbed before a chest radiograph could be done.

In 31 (35.2%) cases, the discrepancy was minor (Class III) and the missed diagnosis of pneumonia was not directly related to death but related to the terminal disease process (e.g. septicemia, meningitis, congenital heart disease). In two (2.3%) cases, the discrepancy was minor (Class IV) and the missed diagnosis of pneumonia was not directly related to death nor to the terminal disease process (e.g. fulminant hepatitis, leukemia, encephalitis).

Known risk factors associated with fatal outcomes of childhood pneumonia observed in majority of our cases included: age less than 1 year in 49 (55.7%) [2-4], moderate and severe acute malnutrition in 55 (62.5%) [3-5], belonging to lower socioeconomic status in 70 (79.5%) [5-6], and prior complaints before hospitalization of inability to feed in 58 (65.9%) [2], and altered sensorium in 55 (62.5%) [4]. Small sample size precluded subgroup analysis of the data.

Our study reaffirms the importance of autopsy in hospital practice. Risk factors observed may help identify cases of pneumonia with a predilection for a poor outcome.

Contributors: SK, PV, PS: involved in study design and implementation; LK, PS: collected data; SK, PV, LK, PS: discussed core ideas and interpretation of data; SK: searched the literature and drafted the manuscript; PV, LK, PS: critically reviewed the manuscript; SK: will act as guarantor for this paper. All authors have approved the final manuscript.

Funding: None; Competing interest: None stated.

REFERENCES

1. Goldman L, Sayson R, Robbins S, Cohn LH, Bettmann M, Weisberg M. The value of the autopsy in three medical eras. N Engl J Med. 1983;308:1000-5.

2. Sehgal V, Sethi GR, Sachdev HP, Satyanarayana L. Predictors of mortality in subjects hospitalized with acute lower respiratory tract infections. Indian Pediatr. 1997;34:213-9.

3 Lupisan SP, Ruutu P, Erma Abucejo-Ladesma P, Quiambao BP, Gozum L, Sombrero LT, et al. Predictors of death from severe pneumonia among children 2-59 months old hospitalized in Bohol, Philippines: Implications for referral criteria at a first-level health facility. Trop Med Int Health. 2007;12:962-71.

4. Dembele BPP, Kamigaki T, Dapat C, Tamaki R, Saito M, Saito M, et al. Aetiology and risks factors associated with the fatal outcomes of childhood pneumonia among hospitalised children in the Philippines from 2008 to 2016: A case series study. BMJ Open. 2019;9:e026895.

5. Tomczyk S, McCracken JP, Contreras CL, Lopez MR, Bernart C, Moir JC, et al. Factors associated with fatal cases of acute respiratory infection (ARI) among hospitalized patients in Guatemala. BMC Public Health. 2019;19:499.

6. Sharma R. Revised Kuppuswamy’s socioeconomic status scale: Explained and updated. Indian Pediatr. 2017;54: 867-70.