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Brief Reports Indian Pediatrics 2003; 40:967-970 |
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Persistent Pneumonia in Children |
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Rakesh Lodha, Madhavi Puranik, Uma Chandra Mouli Natchu and S. K. Kabra From the Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India. Correspondence to: Dr. S.K. Kabra, Additional Professor, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India. E-mail: [email protected]
While acute lower respiratory tract infections remain the most important cause of mortality and morbidity in under fives in the developing countries, persistent pneumonia is uncommon. The incidence rate for pneumonia in developing countries may go upto 10 per 100 children per year(1,2). A subgroup of these children has persistence of pneumonia. As there is no universally accepted definition of persistent pneumonia, the true incidence of persistent pneumonia in children is not known. There is limited data on the under-lying illness predisposing to persistence of pneumonia. The purpose of this study is to describe the underlying causes of persistent pneumonia in children. Subjects and Methods All the patient records of Pediatric Chest Clinic of the hospital between 1996 and 2000 were screened to identify children with persis-tent pneumonia. Persistent pneumonia was defined as persistence of symptoms and radiographic abnormalities for more than one month(3). Children with cystic fibrosis, congenital heart disease and tuberculosis were not included in the analysis. A standardized data extraction form was used to obtain the demographic data, details of the illness, and the results of the investigations including chest radiograph, computed tomo-graphy of the chest, sweat chloride esti-mation, pulmonary function tests, and bron-choscopy. Gastroesophageal reflux was documented by a radionuclide scan. Immuno-globulin profile and ELISA for antibody against HIV were performed in a subgroup of patients. Underlying illness was identified on the basis of the available clinical and laboratory data. A child was considered to be suffering from recurrent aspirations when history of choking/coughing during feedings or restless-ness after feeding were present. Presence of gastroesophageal reflux on technetium scan with absence of abnormalities on CT of chest and barium swallow, led to a diagnosis of significant gastroesophageal reflux (GER). Diagnoses of esophageal stricture, H-type tracheoesophageal fistula and pharyngeal incoordination were based on barium swallow study. A diagnostic label of post tubercular bronchiectasis was given when there was a definitive past history of pulmonary tuber-culosis (the patient was carrying a suggestive chest radiograph, documented positive Mantoux test at that time, with or without history of contact with tubercular patient), that had been treated, followed by persistent pneumonia and computed tomography showed bronchiectatic changes. Asthma was considered as the underlying cause when the child had documented reversible airway obstruction, other investi-gations were normal and there was a response to anti-asthma treatment on follow-up. Ciliary dyskinesia was considered when situs inversus along with sinusitis was present. In absence of situs inversus, a possibility of ciliary dyskinesia was considered if the child had chronic sinusitis, and delayed saccharine clearance (>30 minutes) and other investi-gations were normal. Persistent pneumonia was attributed to a foreign body when a history of foreign body inhalation was elicited, and a foreign body was documented on rigid bronchoscopy, and other investigations were normal. Results During the 5-year period, nearly 2200 children attended the Pediatric Chest Clinic at our institute; the common disorders were bronchial asthma, cystic fibrosis, bronchiec-tasis, and interstitial lung disease. Nineteen children (<1%) satisfied the criteria for persistent pneumonia. Of these, 16 (84.2%) were boys. The median age at presentation to our clinic was 96 (95% confidence interval 35- 144) months. Two (10.5%) children had onset of symptoms before 3 months of age, 6 (31.5%) between 3 and 12 months, 5 (26.3%) between 1 and 3 years and 3 (15.8%) children after the age of 5 years. All children had cough at presentation. The other complaints at presentation were fever (78.9%), breathlessness (52.6 %), and wheezing (36.8%). Nine children had a past history of tuberculosis, 2 had measles; one child had a history of a foreign body inhalation. Three children were tachypneic on examination; auscultation of chest revealed abnormalities in 14 children. The chest radiograph showed abnormalities in all the children. The common radiological findings included persistent infiltrates in all. Additional features of collapse and consolidation were present in one and two patients respectively. Computed tomography of the chest was performed in 13 children. Ten scans showed bronchiectatic changes, one suggested a foreign body in right lower lobe bronchus, one showed lingular and left upper lobe collapse and multiple areas of consolidation and one had features of fibrotic bands, and sub segmental atelectasis in right lower lobe. Bronchoalveolar lavage, performed in two children, did not reveal any microorganism responsible for the ongoing infection. The radionuclide scan for GER was positive in 1 of the 16 (6.25%) children in whom it was performed. ELISA for HIV was positive in one child. Immunoglobulin profile was done in one child, in whom it was normal. Based on the clinical features and the results of the investigations, underlying illness could be identified in 16 (84.2%) children (Table I). Three children, in whom a cause could not be found, had bronchiectasis and 2 had a past history suggestive of measles. TABLE I Underlying Illness in Children with Recurrent Pneumonia
(Figures in parentheses are the percentages) Discussion The most frequent underlying causes for persistent pneumonia in children were post tubercular bronchiectasis and asthma. Persistent pneumonia implies a chronic, non-resolving pneumonia. It is defined as persistence of symptoms and radiographic abnormalities for more than one month(3); however some authors prefer to use the cut off of 3 months, Recurrent and persistent pneumonias usually result from deficiencies in the local pulmonary or systemic host defenses or from underlying disorders that modify the lung defenss(4). The causes of recurrent and persistent pneumonias overlap considerably. The underlying disorders associated with these infections can be due to congenital malformations of upper or the lower respiratory tract, and cardiovascular system, recurrent aspirations, defects in the clearance of airway secretions especially cystic fibrosis, ciliary abnormalities, or disorders of systemic / local immunity(4). There are few reports on the underlying causes of persistent pneumonia in children. Most of the reports are on recurrent pneumonia(5-8); others have discussed recurrent and persistent pneumonia together. Adam reported 18 Saudi children with recurrent/persistent pneumonia(5). Of these, 3 children had persistent pneumonia; one each had pulmonary candidiasis, benign cystic teratoma, and opsonization immune deficiency. Eigen, et al.(6) could identify a definite etiology in only 20 of 81 children evaluated for recurrent/persistent pneumonia; 8 of these 20 had significant neuromuscular dysfunction or mental retardation or both. The data for recurrent and persistent pneumonias are not given separately. In 61 children without any apparent cause, 18% were wheezing during initial visit, 31% had a history of wheezing and 49% had a history of allergy or family history of asthma. This data suggests that asthma is an important cause of persistent/recurrent pneumonia in children and that pneumonia may occur as the initial symptom even in the absence of wheezing. Our data also suggests that asthma could be an important cause. Our data is limited to children evaluated in our specialty clinic. It is likely that these children had relatively mild illness; complete information would require inclusion of patients admitted with persistent pneumonia. The exact contribution of conditions like tuberculosis and cystic fibrosis cannot be commented upon in our series. Our center acts as a referral center for cystic fibrosis and inclusion could have lead to a false impression about its frequency. The retrospective nature of our study is also a limitation, All children were not subjected to a uniform set of investigations. A detailed immunological work up could not be performed because of lack of such facilities. Contributors: RL, SKK collected and analyzed the data and prepared the manuscript. MP, UCMN participated in the collection of data. SKK will act as the guarantor. Funding: None stated. Competing interests: None.
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