Pneumonia in normal and immunocompromised children: an overview and update

Human immunoglobulin in combination with antimicrobial agents enhances the treatment efficacy and reduces inflammatory response in children with severe pneumonia

OBJECTIVE

To investigate the efficacy of human immunoglobulin combined with antibiotics in treating severe pediatric pneumonia.

METHODS

A retrospective analysis was performed on 210 pediatric patients with severe pneumonia admitted to the Department of Neonatology of Cangzhou Central Hospital from April 2019 to October 2022. Patients were divided into two groups (the observation group and the control group) based on the administration of human immunoglobulin. Clinical indexes of both groups before and after treatment were analyzed to determine the therapeutic effect of different treatment methods on pediatric severe pneumonia.

RESULTS

The durations of cough, fever, pulmonary rales, and lung shadow, and hospitalization time in the observation group were significantly shorter than those in the control group (all P<0.05). The total clinical effective rate in the observation group was significantly higher than that in the control group (P<0.05). Levels of inflammatory factors (IL-6, IL-8 and hsCRP) were decreased in both groups after treatment (all P<0.05), and were lower in the observation group compared with the control group after treatment (all P<0.05). The serum levels of IgA, IgG and IgM after five days of intervention were obviously higher than those before intervention in the observation group (all P<0.05), but the serum levels of IL-4, INF-γ and INF-γ/IL-4 were obviously lower (all P<0.05). The total incidence of adverse reactions between two groups after intervention was not statistically different (P<0.05).

CONCLUSION

The combination of human immunoglobulin and antibiotics for the treatment of pediatric severe pneumonia is beneficial, because it improves efficacy, boosts the immune system, and reduces inflammation.

Imaging of Acute Complications of Community-Acquired Pneumonia in the Paediatric Population-From Chest Radiography to MRI

The most common acute infection and leading cause of death in children worldwide is pneumonia. Clinical and laboratory tests essentially diagnose community-acquired pneumonia (CAP). CAP can be caused by bacteria, viruses, or atypical microorganisms. Imaging is usually reserved for children who do not respond to treatment, need hospitalisation, or have hospital-acquired pneumonia. This review discusses the imaging findings for acute CAP complications and the diagnostic role of each imaging modality. Pleural effusion, empyema, necrotizing pneumonia, abscess, pneumatocele, pleural fistulas, and paediatric acute respiratory distress syndrome (PARDS) are acute CAP complications. When evaluating complicated CAP patients, chest radiography, lung ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) can be used, with each having their own pros and cons. Imaging is usually not needed for CAP diagnosis, but it is essential for complicated cases and follow-ups. Lung ultrasound can supplement chest radiography (CR), which starts the diagnostic algorithm. Contrast-enhanced computed tomography (CECT) is used for complex cases. Advances in MRI protocols make it a viable alternative for diagnosing CAP and its complications.

Three-dimensional ultrashort echo time magnetic resonance imaging in pediatric patients with pneumonia: a comparative study

BACKGROUND

UTE has been used to depict lung parenchyma. However, the insufficient discussion of its performance in pediatric pneumonia compared with conventional sequences is a gap in the existing literature. The objective of this study was to compare the diagnostic value of 3D-UTE with that of 3D T1-GRE and T2-FSE sequences in young children diagnosed with pneumonia.

METHODS

Seventy-seven eligible pediatric patients diagnosed with pneumonia at our hospital, ranging in age from one day to thirty-five months, were enrolled in this study from March 2021 to August 2021. All patients underwent imaging using a 3 T pediatric MR scanner, which included three sequences: 3D-UTE, 3D-T1 GRE, and T2-FSE. Subjective analyses were performed by two experienced pediatric radiologists based on a 5-point scale according to six pathological findings (patchy shadows/ground-glass opacity (GGO), consolidation, nodule, bulla/cyst, linear opacity, and pleural effusion/thickening). Additionally, they assessed image quality, including the presence of artifacts, and evaluated the lung parenchyma. Interrater agreement was assessed using intraclass correlation coefficients (ICCs). Differences among the three sequences were evaluated using the Wilcoxon signed-rank test.

RESULTS

The visualization of pathologies in most parameters (patchy shadows/GGO, consolidation, nodule, and bulla/cyst) was superior with UTE compared to T2-FSE and T1 GRE. The visualization scores for linear opacity were similar between UTE and T2-FSE, and both were better than T1-GRE. In the case of pleural effusion/thickening, T2-FSE outperformed the other sequences. However, statistically significant differences between UTE and other sequences were only observed for patchy shadows/GGO and consolidation. The overall image quality was superior or at least comparable with UTE compared to T2-FSE and T1-GRE. Interobserver agreements for all visual assessments were significant and rated "substantial" or "excellent."

CONCLUSIONS

In conclusion, UTE MRI is a useful and promising method for evaluating pediatric pneumonia, as it provided better or similar visualization of most imaging findings compared with T2-FSE and T1-GRE. We suggest that the UTE MRI is well-suited for pediatric population, especially in younger children with pneumonia who require longitudinal and repeated imaging for clinical care or research and are susceptible to ionizing radiation.

Mechanisms of Lung and Intestinal Microbiota and Innate Immune Changes Caused by Pathogenic Enterococcus Faecalis Promoting the Development of Pediatric Pneumonia

Bacterial pneumonia is the main cause of illness and death in children under 5 years old. We isolated and cultured pathogenic bacteria LE from the intestines of children with pneumonia and replicated the pediatric pneumonia model using an oral gavage bacterial animal model. Interestingly, based on 16srRNA sequencing, we found that the gut and lung microbiota showed the same imbalance trend, which weakened the natural resistance of this area. Further exploration of its mechanism revealed that the disruption of the intestinal mechanical barrier led to the activation of inflammatory factors IL-6 and IL-17, which promoted the recruitment of ILC-3 and the release of IL-17 and IL-22, leading to lung inflammation. The focus of this study is on the premise that the gut and lung microbiota exhibit similar destructive changes, mediating the innate immune response to promote the occurrence of pneumonia and providing a basis for the development and treatment of new drugs for pediatric pneumonia.

Utilizing metagenomic next-generation sequencing for diagnosis and lung microbiome probing of pediatric pneumonia through bronchoalveolar lavage fluid in pediatric intensive care unit: results from a large real-world cohort

Background

Metagenomic next-generation sequencing (mNGS) is a powerful method for pathogen detection in various infections. In this study, we assessed the value of mNGS in the pathogen diagnosis and microbiome analysis of pneumonia in pediatric intensive care units (PICU) using bronchoalveolar lavage fluid (BALF) samples.

Methods

A total of 104 pediatric patients with pneumonia who were admitted into PICU between June 2018 and February 2020 were retrospectively enrolled. Among them, 101 subjects who had intact clinical information were subject to parallel comparison of mNGS and conventional microbiological tests (CMTs) for pathogen detection. The performance was also evaluated and compared between BALF-mNGS and BALF-culture methods. Moreover, the diversity and structure of all 104 patients' lung BALF microbiomes were explored using the mNGS data.

Results

Combining the findings of mNGS and CMTs, 94.06% (95/101) pneumonia cases showed evidence of causative pathogenic infections, including 79.21% (80/101) mixed and 14.85% (15/101) single infections. Regarding the pathogenesis of pneumonia in the PICU, the fungal detection rates were significantly higher in patients with immunodeficiency (55.56% vs. 25.30%, P =0.025) and comorbidities (40.30% vs. 11.76%, P=0.007). There were no significant differences in the α-diversity either between patients with CAP and HAP or between patients with and without immunodeficiency. Regarding the diagnostic performance, the detection rate of DNA-based BALF-mNGS was slightly higher than that of the BALF-culture although statistically insignificant (81.82% vs.77.92%, P=0.677) and was comparable to CMTs (81.82% vs. 89.61%, P=0.211). The overall sensitivity of DNA-based mNGS was 85.14% (95% confidence interval [CI]: 74.96%-92.34%). The detection rate of RNA-based BALF-mNGS was the same with CMTs (80.00% vs 80.00%, P>0.999) and higher than BALF-culture (80.00% vs 52.00%, P=0.045), with a sensitivity of 90.91% (95%CI: 70.84%-98.88%).

Conclusions

mNGS is valuable in the etiological diagnosis of pneumonia, especially in fungal infections, and can reveal pulmonary microecological characteristics. For pneumonia patients in PICU, the mNGS should be implemented early and complementary to CMTs.

Enhancing thoracic disease detection using chest X-rays from PubMed Central Open Access

Large chest X-rays (CXR) datasets have been collected to train deep learning models to detect thorax pathology on CXR. However, most CXR datasets are from single-center studies and the collected pathologies are often imbalanced. The aim of this study was to automatically construct a public, weakly-labeled CXR database from articles in PubMed Central Open Access (PMC-OA) and to assess model performance on CXR pathology classification by using this database as additional training data. Our framework includes text extraction, CXR pathology verification, subfigure separation, and image modality classification. We have extensively validated the utility of the automatically generated image database on thoracic disease detection tasks, including Hernia, Lung Lesion, Pneumonia, and pneumothorax. We pick these diseases due to their historically poor performance in existing datasets: the NIH-CXR dataset (112,120 CXR) and the MIMIC-CXR dataset (243,324 CXR). We find that classifiers fine-tuned with additional PMC-CXR extracted by the proposed framework consistently and significantly achieved better performance than those without (e.g., Hernia: 0.9335 vs 0.9154; Lung Lesion: 0.7394 vs. 0.7207; Pneumonia: 0.7074 vs. 0.6709; Pneumothorax 0.8185 vs. 0.7517, all in AUC with p< 0.0001) for CXR pathology detection. In contrast to previous approaches that manually submit the medical images to the repository, our framework can automatically collect figures and their accompanied figure legends. Compared to previous studies, the proposed framework improved subfigure segmentation and incorporates our advanced self-developed NLP technique for CXR pathology verification. We hope it complements existing resources and improves our ability to make biomedical image data findable, accessible, interoperable, and reusable.

DNA methyltransferase inhibition induces dynamic gene expression changes in lung CD4+ T cells of neonatal mice with E. coli pneumonia

Bacterial pulmonary infections are a major cause of morbidity and mortality in neonates, with less severity in older children. Previous studies demonstrated that the DNA of CD4+ T cells in the mouse lung, whose primary responsibility is to coordinate the immune response to foreign pathogens, is differentially methylated in neonates compared with juveniles. Nevertheless, the effect of this differential DNA methylation on CD4+ T cell gene expression and response to infection remains unclear. Here we treated E. coli-infected neonatal (4-day-old) and juvenile (13-day-old) mice with decitabine (DAC), a DNA methyltransferase inhibitor with broad-spectrum DNA demethylating activity, and performed simultaneous genome-wide DNA methylation and transcriptional profiling on lung CD4+ T cells. We show that juvenile and neonatal mice experienced differential demethylation in response to DAC treatment, with larger methylation differences observed in neonates. By cross-filtering differentially expressed genes between juveniles and neonates with those sites that were demethylated in neonates, we find that interferon-responsive genes such as Ifit1 are the most down-regulated methylation-sensitive genes in neonatal mice. DAC treatment shifted neonatal lung CD4+ T cells toward a gene expression program similar to that of juveniles. Following lung infection with E. coli, lung CD4+ T cells in neonatal mice exhibit epigenetic repression of important host defense pathways, which are activated by inhibition of DNA methyltransferase activity to resemble a more mature profile.

Diagnosis of asthmatic pneumonia in children by lung ultrasound vs. chest X-ray: an updated systematic review and meta-analysis

Introduction

Chest X-ray (CXR) is used as the standard diagnostic method in lung diseases, especially in pneumonia, but unfortunately, despite the high risk of receiving radiation, it also has a high false negative rate. Therefore, some researchers recommend ultrasound to diagnose pneumonia.

Aim

To investigate the accuracy of lung ultrasound compared to CXR for the diagnosis of pneumonia children by meta-analysis method.

Material and methods

Original articles which evaluated accuracy of lung ultrasound compared to chest X-ray for the diagnosis of pneumonia in children, published between 1 January 2010 and 20 March 2021, were identified in the PubMed, Web of Science, Embase, Scopus and Cochrane Library databases. Data synthesis and statistical analysis were carried out using STATA software. Odds ratios with 95% confidence interval (CI), fixed effect model and mean difference with 95% CI, random effect model (REM) were calculated.

Results

At the first step, 1016 potentially important research abstracts and titles were discovered in our electronic searches, 8 papers were in agreement with our inclusion criteria. The statistical analysis showed sensitivity of 95.5% (95% CI: 93.6-97.1%) and specificity of 96.3% (95% CI: 92.1-98.4%) for the lung ultrasound, and CXR sensitivity and specificity were 87.4% (95% CI: 84.3-90.0%) and 98.6% (95% CI: 95.8-99.6%), respectively.

Conclusions

The present study showed that ultrasound can be useful in diagnosing pneumonia in children, and due to the lack of risk of receiving radiation, this method is even more preferred.

Silencing of Long Non-coding RNA H19 Alleviates Lipopolysaccharide (LPS)-induced Apoptosis and Inflammation Injury by Regulating miR-140-5p/TLR4 Axis in Cell Models of Pneumonia

OBJECTIVE

Mounting studies have clarified the link between long non-coding RNAs (lncRNAs) and pneumonia. This research aims to probe the function and regulatory mechanism of lncRNA H19 in lipopolysaccharide (LPS)-induced cell models of pneumonia.

METHODS

WI-38 cells were exposed to LPS for 12 h to mimic cell models of pneumonia. The relative expression of H19, miR-140-5p, and toll-like receptor 4 (TLR4) were detected by quantitative real-time polymerase chain reaction (qRT-PCR). The cell viability was detected by MTT assay. The protein expression of apoptosis-associated proteins (Bax and Bcl-2) and TLR4 were determined by western blot. Moreover, the content of interleukin (IL)-6, IL-1β, and tumor necrosis factor (TNF)-α were measured by enzyme-linked immunosorbent assay (ELISA). The target relationship between miR- 140-5p and H19/ TLR4 was confirmed by Dual luciferase reporter (DLR) assay.

RESULTS

LncRNA H19 and TLR4 were up-regulated, while miR-140-5p was downregulated in peripheral blood of patients with pneumonia and LPS-treated WI-38 cells compared with their controls. Silencing of H19 or miR-140-5p mimics facilitated cell viability, whereas repressed apoptosis and reduced content of TNF-α, IL-6, and IL-1β in LPS-induced WI-38 cells. H19 targeted miR-140-5p and it inversely regulated miR-140- 5p expression. MiR-140-5p targeted TLR4 and it inversely regulated TLR4 expression. H19 positively regulated TLR4 expression. Moreover, inhibition of miR-140-5p or overexpression of TLR4 reversed the effects of H19 silencing on cell viability, inflammation, and apoptosis in LPS-induced WI-38 cells.

CONCLUSION

Silencing of H19 inhibited apoptosis and inflammation by miR-140- 5p/TLR4 pathway in LPS-induced WI-38 cells.

A Broad Learning System to Predict the 28-Day Mortality of Patients Hospitalized with Community-Acquired Pneumonia: A Case-Control Study

This study was to conduct a model based on the broad learning system (BLS) for predicting the 28-day mortality of patients hospitalized with community-acquired pneumonia (CAP). A total of 1,210 eligible CAP cases from Chifeng Municipal Hospital were finally included in this retrospective case-control study. Random forest (RF) and an eXtreme Gradient Boosting (XGB) models were used to develop the prediction models. The data features extracted from BLS are utilized in RF and XGB models to predict the 28-day mortality of CAP patients, which established two integrated models BLS-RF and BLS-XGB. Our results showed the integrated model BLS-XGB as an efficient broad learning system (BLS) for predicting the death risk of patients, which not only performed better than the two basic models but also performed better than the integrated model BLS-RF and two well-known deep learning systems-deep neural network (DNN) and convolutional neural network (CNN). In conclusion, BLS-XGB may be recommended as an efficient model for predicting the 28-day mortality of CAP patients after hospital admission.

Imaging findings in acute pediatric coronavirus disease 2019 (COVID-19) pneumonia and multisystem inflammatory syndrome in children (MIS-C)

The two primary manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in children are acute coronavirus disease 2019 (COVID-19) pneumonia and multisystem inflammatory syndrome (MIS-C). While most pediatric cases of acute COVID-19 disease are mild or asymptomatic, some children are at risk for developing severe pneumonia. In MIS-C, children present a few weeks after SARS-CoV-2 exposure with a febrile illness that can rapidly progress to shock and multiorgan dysfunction. In both diseases, the clinical and laboratory findings can be nonspecific and present a diagnostic challenge. Thoracic imaging is commonly obtained to assist with initial workup, assessment of disease progression, and guidance of therapy. This paper reviews the radiologic findings of acute COVID-19 pneumonia and MIS-C, highlights the key distinctions between the entities, and summarizes our understanding of the role of imaging in managing SARS-CoV-2-related illness in children.

Pediatric Lower Respiratory Tract Infections: Imaging Guidelines and Recommendations

Lower respiratory tract infection (LRTI) remains a major cause of morbidity and mortality in children. Various organisms cause LRTI, including viruses, bacteria, fungi, and parasites, among others. Infections caused by 2 or more organisms also occur, sometimes enhancing the severity of the infection. Medical imaging helps confirm a diagnosis but also plays a role in the evaluation of acute and chronic sequelae. Medical imaging tests help evaluate underlying pathology in pediatric patients with recurrent or long-standing symptoms as well as the immunocompromised.

Evaluation of illness severity of neonate infectious pneumonia and neurobehavioral development through ultrasonography under adaption algorithm

Objectives:

To explore the diagnostic effect of ultrasound imaging on the illness severity, and to analyze neurobehavioral development of neonates with Infectious Pneumonia (IPN), Self- Adaptation (SD), and Spatial Smoothing (SS) technologies were adopted to build SDSS. Then, the WFFSF algorithm based on Wiener Filtering (WF) and Feature Space Fusion (FSF) and the SNRP-FSF algorithm based on Signal-to-noise ratio post-filtering (SNRP) and FSF were introduced for comparison.

Methods:

One hundred and thirty-two neonates were divided into group without respiratory failure (S1) and respiratory failure group (S2). The study was conducted from March 2018 to July 2020. According to scoring systems for neonatal critically illness, they were divided into non-severe group (W1), severe group (W2), and extremely-severe group (W3). According to the Scale of Child Development Center of China (CDCC), they were divided into a normal neurobehavioral developmental group (P1) and an abnormal neurobehavioral developmental group (P2).

Results:

The normalized mean square distance l and normalized mean absolute distance f of SDSS algorithm were significantly lower than that of WFFSF algorithm and SNRP-FSF algorithm, and the peak signal-to-noise ratio (PSNR) was significantly higher than that of WFFSF algorithm and SNRP-FSF algorithm (P<0.05). The lung ultrasound score (40.62±7.22%) of S1 was greatly higher than S2 group (28.47±6.29%) (P<0.05); the lung ultrasound score (39.13±8.25) in W1 was greatly higher than W2 (27.28±6.39) and W3 groups (14.33±7.03); neonates in group W2 had higher lung ultrasound scores than W3 (P<0.05), and lung ultrasound scores in P1 (42.57±8.58) was greatly higher than that the P2 group (26.49±6.09).

Conclusion:

In contrast with traditional algorithms, the SDSS algorithm based on AD has a better reconstruction effect on neonatal IPN ultrasound images. The lung ultrasound score can clearly indicate the severity of the disease and neurobehavioral development of neonate IPN, and the lung ultrasound score is negatively correlated with the severity of the child’s disease and the abnormality of neurobehavioral development.

Clinical Impact of Metagenomic Next-Generation Sequencing of Bronchoalveolar Lavage in the Diagnosis and Management of Pneumonia: A Multicenter Prospective Observational Study

Rapid and accurate pathogen identification is necessary for appropriate treatment of pneumonia. Here, we describe the use of shotgun metagenomic next-generation sequencing (mNGS) of bronchoalveolar lavage for pathogen identification in pneumonia in a large-scale multicenter prospective study with 159 patients enrolled. We compared the results of mNGS with standard methods including culture, staining, and targeted PCR, and evaluated the clinical impact of mNGS. A positive impact was defined by a definitive diagnosis made using the mNGS results, or change of management because of the mNGS results, leading to a favorable clinical outcome. Overall, mNGS identified more organisms than standard methods (117 versus 72), detected 17 pathogens that consistently were missed in all cases by standard methods, and had an overall positive clinical impact in 40.3% (64 of 159) of cases. mNGS was especially useful in identification of fastidious and atypical organisms causing pneumonia, contributing to detection of definitive pathogens in 45 (28.3%) cases in which standard results were either negative or insufficient. mNGS also helped reassure antibiotic de-escalation in 19 (11.9%) cases. Overall, mNGS led to a change of treatment in 59 (37.1%) cases, including antibiotic de-escalation in 40 (25.2%) cases. This study showed the significant value of mNGS of bronchoalveolar lavage for improving the diagnosis of pneumonia and contributing to better patient care.

Imaging of Acute Pulmonary and Airway Diseases in Children

소아의 다양한 응급질환 중 급성 폐질환 또는 급성 기도질환은 영상의학과 의사가 자주 대하게 되는 임상 상황이며, 일차적으로 시행되는 영상검사는 흉부 방사선사진이다. 따라서 다양한 임상 상황에서의 감별진단과 영상 소견을 숙지하는 것이 중요하다. 본 종설에서는 급성 폐질환의 다양한 원인과 폐렴을 알아보고, 폐렴과 감별해야 하는 급성 폐질환을 생각해보았다. 급성 기도질환으로는 크룹, 급성 후두염, 기관연화증, 천식, 감염 후 폐쇄세기관지염, 그리고 이물 흡인을 검토하였다. 이렇게 소아에서 고려해야 할 질환들의 영상 소견을 검토하여 진단과 치료에 도움을 줄 수 있길 바란다.

Pediatric oncologic emergencies: Clinical and imaging review for pediatricians

Children with cancer are at increased risk of life-threatening emergencies, either from the cancer itself or related to the cancer treatment. These conditions need to be assessed and treated as early as possible to minimize morbidity and mortality. Cardiothoracic emergencies encompass a variety of pathologies, including pericardial effusion and cardiac tamponade, massive hemoptysis, superior vena cava syndrome, pulmonary embolism, and pneumonia. Abdominal emergencies include bowel obstruction, intussusception, perforation, tumor rupture, intestinal graft-versus-host disease, acute pancreatitis, neutropenic colitis, and obstructive uropathy. Radiology plays a vital role in the diagnosis of these emergencies. We here review the clinical features and imaging in pediatric patients with oncologic emergencies, including a review of recently published studies. Key radiological images are presented to highlight the radiological approach to diagnosis. Pediatricians, pediatric surgeons, and pediatric radiologists need to work together to arrive at the correct diagnosis and to ensure prompt and appropriate treatment strategies.

Prospective observational study of point-of-care ultrasound for diagnosing pneumonia

OBJECTIVES

The clinical diagnosis of pneumonia lacks specificity and may lead to antibiotic overuse, whereas radiological diagnoses can lack sensitivity. Point-of-care lung ultrasound is an emerging diagnostic tool. There are limited prospective data, however, on the accuracy of sonologists in the paediatric emergency department setting. We aimed to test the diagnostic accuracy of lung ultrasound for pneumonia using chest radiograph (CR) as the reference standard.

METHODS

This prospective observational cohort study in a paediatric emergency department enrolled children aged 1 month to <18 years, who had a CR ordered for possible pneumonia. Lung ultrasounds were performed by two blinded sonologists with focused training. Sonographic pneumonia was defined as lung consolidation with air bronchograms. Radiograph and ultrasound results both required agreement between two readers, with final results determined by an arbiter in cases of disagreement. Patient management was decided by treating clinicians who were blinded to lung ultrasound results. Follow-up was performed by phone and medical record review to obtain final diagnosis and antibiotic use.

RESULTS

Of 97 included patients, CR was positive for pneumonia in 44/97 (45%) and lung ultrasound was positive in 57/97 (59%). Ultrasound sensitivity was 91% (95% CI 78% to 98%) and specificity was 68% (95% CI 54% to 80%). Ultrasound results displayed greater consistency with CR and patient outcomes when sonographic consolidation exceeded 1 cm. Thirteen of 57 patients with sonographic consolidation improved without antibiotics.

CONCLUSION

Lung ultrasound may have a role as first-line imaging in patients with possible pneumonia, with higher specificity for consolidations exceeding 1 cm.

TRIAL REGISTRATION NUMBER

ACTRN12616000361404, http://www.ANZCTR.org.au/ACTRN12616000361404.aspx.

Lung magnetic resonance imaging for pneumonia in children

Technical factors have historically limited the role of MRI in the evaluation of pneumonia in children in routine clinical practice. As imaging technology has advanced, recent studies utilizing practical MR imaging protocols have shown MRI to be an accurate potential alternative to CT for the evaluation of pneumonia and its complications. This article provides up-to-date MR imaging techniques that can be implemented in most radiology departments to evaluate pneumonia in children. Imaging findings in pneumonia on MRI are also reviewed. In addition, the current literature describing the diagnostic performance of MRI for pneumonia is discussed. Furthermore, potential risks and limitations of MRI for the evaluation of pneumonia in children are described.

Computed tomography in children with community-acquired pneumonia

Diagnostic imaging plays a significant role in both the diagnosis and treatment of complications of pneumonia in children and chest radiography is the imaging modality of choice. Computed tomography (CT) on the other hand, is not currently a first-line imaging tool for children with suspected uncomplicated community-acquired pneumonia and is largely reserved for when complications of pneumonia are suspected or there is difficulty in differentiating pneumonia from other pathology. This review outlines the situations where CT needs to be considered in children with pneumonia, describes the imaging features of the parenchymal and pleural complications of pneumonia, discusses how CT may have a wider role in developing countries where human immunodeficiency virus (HIV) and tuberculosis are prevalent, makes note of the role of CT scanning for identifying missed foreign body aspiration and, lastly, addresses radiation concerns.

Clinical and epidemiological characteristics in children with community-acquired mycoplasma pneumonia in Taiwan: A nationwide surveillance

BACKGROUND

Community-acquired pneumonia (CAP) is the leading cause of hospitalization of children. Mycoplasma pneumoniae is one of the most common pathogens. The disease severity is diverse, and the diagnosis remains a challenge to clinical pediatricians. The aims of this study are to provide a nationwide surveillance of the epidemiology and clinical manifestations of community-acquired mycoplasma pneumonia (CAMP) in children in Taiwan.

METHODS

The medical records of children enrolled by the Taiwan Pediatric Infectious Disease Alliance (TPIDA) project during 2010-2011 were reviewed. Hospitalized children with segmental or lobar pneumonia were included. The demographic, clinical, laboratory and radiographic data were analyzed. Nasopharyngeal swabs, pleural effusion, and serum were collected for multiplex viral and bacterial polymerase chain reaction (PCR), mycoplasma immunoglobulin M (IgM), or paired immunoglobulin G (IgG) titer.

RESULTS

There were overall 127 children with CAMP. Among them, 16 (12.6%) children had PCR and IgM positivity, 74 (58.3%) children had a positive serologic study, 34 (27.8%) children had positive PCR detection, and three (2.4%) children had paired IgG above a four-fold increase. Enrolled patients were divided into two groups before and after the age of 5 years. Children younger than 5 years or younger had a significantly longer hospitalization, higher intensive care unit (ICU) admission rates, and more complications. They were more frequent to receive oxygen supplementation and even surgical intervention. The white blood cell counts and C-reactive protein levels were higher in children 5 years old or younger.

CONCLUSION

Mycoplasma pneumoniae is an important etiology of CAP in children 5 years or younger. They had a longer length of hospitalization, higher inflammatory responses, and more complications, compared to children older than 5 years.

Cystic lung lesions in newborns and young children: differential considerations and imaging

Numerous diverse entities produce cystic lung changes in neonates and young children. This review provides an evidence-based, age-appropriate, differential diagnostic framework to use when confronted with pulmonary cystic changes. The categories of diseases that have been discussed include congenital cystic bronchopulmonary malformations, neoplastic conditions, infections, collagen or soft tissue abnormalities, and mimics of cystic lung disease. An understanding of the pathophysiology, imaging appearance, and demographics of these entities is essential in guiding optimal care. Important educational points include differentiating bronchopulmonary malformations from neoplasms and the management and surveillance of lung cysts in young children.

Comparative effectiveness of ceftriaxone in combination with a macrolide compared with ceftriaxone alone for pediatric patients hospitalized with community-acquired pneumonia

BACKGROUND

Guidelines for management of community-acquired pneumonia recommend empiric therapy with a macrolide and beta-lactam when infection with Mycoplasma pneumoniae is a significant consideration. Evidence to support this recommendation is limited. We sought to determine the effectiveness of ceftriaxone alone compared with ceftriaxone combined with a macrolide with respect to length of stay and total hospital costs.

METHODS

We conducted a retrospective cohort study of children 1-17 years with pneumonia, using Poisson regression and propensity score analyses to assess associations between antibiotic and length of stay. Multivariable linear regression and propensity score analyses were used to assess log-treatment costs, adjusting for patient and hospital characteristics and initial tests and therapies.

RESULTS

A total of 4701 children received combination therapy and 8892 received ceftriaxone alone. Among children 1-4 years of age, adjusted models revealed no significant difference in length of stay, with significantly higher costs in the combination therapy group [cost ratio: 1.08 (95% confidence interval: 1.05-1.11)]. Among children 5-17 years of age, children receiving combination therapy had a shorter length of stay [relative risk: 0.95 (95% confidence interval: 0.92-0.98)], with no significant difference in costs [cost ratio: 1.01 (95% confidence interval: 0.98-1.04)].

CONCLUSIONS

Combination therapy did not appear to benefit preschool children but was associated with higher costs. Among school-aged children, combination therapy was associated with a shorter length of stay without a significant impact on cost. Development of sensitive point-of-care diagnostic tests to identify children with M. pneumoniae infection may allow for more focused prescription of macrolides and enable comparative effectiveness studies of targeted provision of combination therapy.

Acute Chest Diseases: Infection and Trauma

Acute chest diseases include clinical situations with infectious and traumatic etiology. Pulmonary infection is the most common indication for performing chest radiography. Radiological imaging often confirms the diagnosis and allows the evaluation of the location and extent of infection. Chest radiography is the primary imaging procedure and the starting point for the evaluation of all children with acute chest disease. Accurate interpretation of pediatric chest films also requires a basic understanding of the physiologic and anatomic differences among adults, neonates, and infants and their most important differences will be referred. Characterization of pulmonary infiltrates is important, because patterns of abnormality suggest specific organisms and aetiologies. Although providing evidence suggestive of the causative agent, the chest radiograph cannot confirm viral infection, confirm or exclude bacterial etiology. In fact, in infancy, pneumonia usually produces a combination of alterations of the airspace and interstitium. However, some aspects may be useful in distinguishing between viral and bacterial pneumonia. Close attention to CT technique is crucial for imaging evaluation of pneumonia in pediatric patients, namely those with persistent symptoms and/or progressive symptoms despite medical or surgical therapy, or in immunocompromised patients. CT with low radiation dose technique should be carefully performed in these cases. CT examination with IV contrast is very useful for the evaluation of complications of chest infection. Thoracic trauma in children is rare, only 4–6 % of children are hospitalized following severe trauma. Only a small number of children with trauma have thoracic injury (14 %), but the injuries tend to be of serious nature. About 25–50 % of thoracic trauma cases occur in combination with other trauma locations. Pulmonary contusion and lacerations, tracheobronchial injuries, pneumothorax, and esophageal rupture are referred as the main consequences of trauma. The decision for the appropriate use of imaging techniques must consider the specific case under review. Chest radiography should be the initial screening method. The decision to use CT is determined by the nature of the trauma, the clinical circumstances, and the prediction of future revaluation, always taking into account the radiation dose applied to the child.

Infections

Lower respiratory tract infection is a very common illness in children and is a significant cause of morbidity and mortality. Clinical signs and symptoms are nonspecific especially in infants and younger children and some even present with nonrespiratory complaints. Infectious agents causing pneumonia is not limited to viruses and bacteria, but it could also be due to Mycoplasma, Mycobacteria, fungi, protozoa, and parasites. Coinfection with two or more microbial agents can also occur. The etiologic agent of lower respiratory infection in a child is often difficult to obtain, but the patient’s age can help narrow the possible cause. Microbiological tests are important but could be difficult to obtain especially in younger children. Various medical imaging modalities not only play an important role as an aid in diagnosis but can also help during and after therapy. Imaging can also help evaluate complications to pneumonia and exclude other causes of respiratory distress including underlying developmental anomalies, foreign body, gastroesophageal reflux disease, and aspiration. In this chapter, the imaging modalities utilized in the detection of pulmonary infections will be discussed. The spectrum of typical imaging findings for various etiologic agents in both immunocompetent and immunocompromised children will be presented.

The value of radiographic findings for the progression of pandemic 2009 influenza A/H1N1 virus infection

Background

Most illnesses caused by pandemic influenza A (H1N1) pdm09 virus (A/H1N1) infection are acute and self-limiting among children. However, in some children, disease progression is rapid and may require hospitalization and transfer to a pediatric intensive care unit (PICU). We investigated factors associated with rapid disease progression among children admitted to hospital for A/H1N1 infection, particularly findings on initial chest radiographs.

Methods

In this retrospective study, we investigated the records of children who had received a laboratory or clinical diagnosis of A/H1N1 infection and were admitted to the largest children’s hospital in Japan between May 2009 and March 2010. The medical records were reviewed for age, underlying diseases, vital signs on admission, initial chest radiographic findings, and clinical outcomes. According to chest radiographic findings, patients were classified into 4 groups, as follows: [1] normal (n = 46), [2] hilar and/or peribronchial markings alone (n = 64), [3] consolidation (n = 64), and [4] other findings (n = 29). Factors associated with clinical outcomes were analyzed using logistic regression.

Results

Two hundreds and three patients (median 6.8 years) were enrolled in this study. Fifteen percent (31/203) of patients were admitted to PICU. Among 31 patients, 39% (12/31) of patients required mechanical ventilation (MV). When the initial chest radiographic findings were compared between patients with consolidation (n = 64) and those without consolidation (n = 139), a higher percentage of patients with consolidation were admitted to PICU (29.7% vs.8.6%, P < 0.001) and required MV (17.2% vs. 0.7%, P < 0.001). These findings remain significant when the data were analyzed with the logistic regression (P < 0.001, P < 0.001, respectively).

Conclusions

Consolidation on initial chest radiographs was the most significant factor to predict clinical course of hospitalized children with the 2009 A/H1N1 infection.

A case study of pediatric pneumonia with empyema

This case study provides a discussion of the diagnosis, management and comprehensive plan of care for empyema in children for the advanced practice registered nurse (APRN) working in primary care. The incidence of complicated pneumonias including those progressing to empyema is on the rise among pediatric patients. The ambiguous signs and symptoms of complicated pneumonias create a challenge for the provider when developing an accurate diagnosis and plan of care. Pediatric nurse practitioners must be cognizant of the increased incidence of complicated pneumonias and manage their patients accordingly. If left untreated, empyema may result in severe pulmonary complications.

Fatal respiratory distress syndrome due to coronavirus infection in a child with severe combined immunodeficiency

Please cite this paper as: Szczawinska‐Poplonyk et al. (2012) Fatal respiratory distress syndrome due to coronavirus infection in a child with severe combined immunodeficiency. Influenza and Other Respiratory Viruses DOI: 10.1111/irv.12059.

Coronaviruses have been demonstrated to contribute substantially to respiratory tract infections among the child population. Though infected children commonly present mild upper airway symptoms, in high‐risk patients with underlying conditions, particularly in immunocompromised children these pathogens may lead to severe lung infection and extrapulmonary disorders. In this paper, we provide the first report of the case of a 15‐month‐old child with severe combined immunodeficiency and coronavirus HKU1‐related pneumonia with fatal respiratory distress syndrome.