CME article
Necrotising pneumonia in children

https://doi.org/10.1016/j.prrv.2013.10.001Get rights and content

Summary

Necrotising pneumonia remains an uncommon complication of pneumonia in children but its incidence is increasing. Pneumococcal infection is the predominant cause in children but Methicillin resistant Staphylococcus aureus (MRSA) and Panton-Valentine leukocidin (PVL) staphylococcal infection are also important causes of severe necrotising pneumonia. Clinical features of necrotic pneumonia are similar to those of an uncomplicated pneumonia except that the patient is clinically much more unwell and has usually failed to respond adequately to what would normally be considered as appropriate antibiotics. Pleural involvement is frequent. Initial management is similar to that for non-complicated pneumonia with careful attention to fluid balance and adequate analgesia required. Some patients will need intensive care support, particularly those with PVL-positive staphylococcal infection. Broad-spectrum antibiotics should be given intravenously, with the exact choice of agent informed by local resistance patterns. Pleural drainage is often required. Despite the severity of the illness, outcomes remain excellent with the majority of children making a full recovery.

Introduction

Necrotizing pneumonia is a severe form of lung disease associated with the formation of abscesses and cavitation within the lung parenchyma, and usually, but not always significant pleural involvement.

Section snippets

Aetiology

Many insults can cause acute lung necrosis, but the great majority of cases in children are related to infection. Bacterial infection is the most common, especially Streptococcus pneumoniae and Staphylococcus aureus, a list of causative organisms is given in Table 1. Other organisms including Mycoplasma pneumoniae and adenovirus can cause serious disease with chronic and even fatal consequences. It should be remembered that infection is frequently culture negative and modern culture negative

Epidemiology

Necrotising pneumonia is an ancient condition, and previously a major cause of death in both adults and children. The clinical features may well have first been described by Hippocrates and later in some detail by Laennec in 1826.1

The complications of bacterial pneumonia were major killers of all age groups prior to the era of antibiotics and modern surgical techniques. A high proportion of those dying in the great pandemics of influenza such as that in 1919 will have died from complications

Pathophysiology

The term necrotising refers to the death of cells or groups of cells and implies permanent cessation of their integrated function, although this does not mean that significant clinical and structural recovery may not occur. Most necrosis in the context of the lung parenchyma is of the liquifactive or colliquative form. Necrosis by organisms causing putrefaction results in the production of foul-smelling gas and brown, green or black discolouration of the tissues is referred to as gangrene. The

Clinical features of necrosting pneumonia

The overall features of necrotising pneumonia are similar to those of an uncomplicated pneumonia, usually with pleural involvement. The main distinction is that the patient is clinically much sicker and has usually failed to respond adequately to appropriate antibiotics by the time that the diagnosis is considered. The child may well have persisting fever, tachycardia, hypoxia and tachypnoea with poor peripheral perfusion. Chest signs may include bronchial breathing, the stony dullness of a

Investigations

All patients should have routine blood count and serum biochemistry along with blood culture if pyrexial. An antistreptolysin titre and acute viral and mycoplasmal serology should also be sent. Anaemia is common, as are thrombocytosis and thrombocytopenia. Frank renal failure is unusual, but hyponatraemia is not uncommon.

It is unusual for paediatric patients to be able to expectorate sputum, but if produced this should be sent for bacterial and viral studies. Nasopharygeal aspirates can

Radiology

All patients will have a routine chest radiograph performed. As well as demonstrating pneumonic changes, this may indicate the presence and approximate volume of pleural fluid along with an indication of any mediastinal shift due to pleural involvement. The plain chest radiograph will reveal the presence of larger cavities and abscesses, although significant changes visible only on CT can easily be missed (Figure 1, Figure 2). The plain radiograph can also not tell the nature of any pleural

Management

General initial management should be similar to that for non-complicated pneumonia. Patients should be given supplemental oxygen if they are hypoxic. Adequate analgesia is imperative, especially as the intensely sharp discomfort of pleuritic pain may result in shallow breathing and a reluctance of the patient to cough adequately.

Particular care should be made in the assessment and management of circulating blood volume. It has previously been suggested that patients with pneumonia are prone to

Prognosis

Necrotising pneumonia is associated with significant morbidity and mortality, but in a previously well child death is now remarkably uncommon in children managed in specialised units with access to modern intensive care and paediatric thoracic surgical facilities. Recovery can be prolonged with persisting respiratory symptoms, reduced lung function and limited energy levels for many months after the acute illness, but the great majority of patients do recover fully. Cavities previously visible

Conflict of interest

The authors declare no conflict of interest.

Role of Funder

Commissioned review without external funding.

Practice points

  • Necrotising pneumonia in children appears to be increasing.

  • Pneumococcal infection remains the predominant cause but PVL-positive staphylococcal infection is associated with a severe necrotic pneumonia.

  • High quality supportive care is crucial and particular attention should be paid to analgesia and fluid balance in these patients.

  • Conservative management of lung necrosis remains preferential but aggressive management of pleural involvement is often required.

Educational aims

  • To describe the pathophysiology of lung necrosis

  • To highlight recent changes in pneumococcal and staphylococcal disease and their implications for therapy

  • To discuss recent changes in the aetiology and epidemiology of necrotic pneumonia in children

  • To provide a practical guide to the management of children with necrotising pneumonia

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