CME articleNecrotising pneumonia in children
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
CME Section
This article has been accredited for CME learning by the European Board for Accreditation in Pneumology (EBAP). You can receive 1 CME credit by successfully answering these questions online.
- (A)
Visit the journal CME site at http://www.prrjournal.com.
- (B)
Complete the answers online, and receive your final score upon completion of the test.
- (C)
Should you successfully complete the test, you may download your accreditation certificate (subject to an administrative charge).
References (37)
- et al.
Increase in incidence of childhood empyema in West Midlands, UK
Lancet
(1997) - et al.
Epidemiological differences among pneumococcal serotypes
Lancet Infect Dis
(2005) - et al.
Pneumococcal disease manifestation in children before and after vaccination: What's new?
Vaccine
(2011) - et al.
Decline in pneumonia admissions after routine childhood immunisation with pneumococcal conjugate vaccine in the USA: a time-series analysis
Lancet
(2007) - et al.
Herd immunity and serotype replacement 4 years after seven-valent pneumococcal conjugate vaccination in England and Wales: an observational cohort study
Lancet Infect Dis
(2011) - et al.
Association between Staphylococcus aureus strains carrying gene for Panton-Valentine leukocidin and highly lethal necrotising pneumonia in young immunocompetent patients
Lancet
(2002) Traite de l’auscultation mediate et des maladies des poumons et du coeur
(1826)- et al.
Necrotising pneumonia is an increasingly detected complication of pneumonia in children
Eur Respir J
(2008) - et al.
Necrotizing pneumococcal pneumonia in children: the role of pulmonary gangrene
Pediatr Pulmonol
(2006) - et al.
Clinical manifestations and molecular epidemiology of necrotizing pneumonia and empyema caused by Streptococcus pneumoniae in children in Taiwan
Clin Infect Dis
(2004)
Trends in pneumonia and empyema in Scottish children in the past 25 years
Arch Dis Child
Prevalence and risk factors of suppurative complications in children with pneumonia
Acta Pædiatr
An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: Risk factors and microbiological associations
Clin Infect Dis
Empyema: an increasing concern in Canada
Can Respir J
Assessment of the burden of paediatric empyema in Australia
J Paediatr Child Health
BTS guidelines for the management of pleural infection in children
Thorax
Empyema: the use of broad range 16S rDNA PCR for pathogen detection
Arch Dis Child
Cited by (42)
[Translated article] Use of an Endobronchial Valve for Management of a Persistent Air-leak in a Child with Necrotizing Pneumonia
2022, Archivos de BronconeumologiaLong-term outcomes of necrotizing pneumonia
2021, Anales de PediatriaPaediatric pneumonia in high-income countries: Defining and recognising cases at increased risk of severe disease
2021, Paediatric Respiratory ReviewsNecrotizing pneumonia with bronchopleural fistula as an uncommon complication of pneumonia in children: a case report
2021, Radiology Case ReportsCitation Excerpt :Necrosis of the lung parenchyma occurs due to thrombotic occlusion of the alveolar capillaries because of inflammation that leads to ischemia [5]. This condition is rarely seen in children [6,7]. Pediatric patients with pneumonia symptoms, such as persistent fever and dyspnea, that do not improve despite administration of adequate antibiotic treatment need to be evaluated for the diagnosis of NP [8].
Pleural Effusion, Necrotizing Pneumonia and Long-Term Morbidity of Respiratory Infection in Childhood
2021, Encyclopedia of Respiratory Medicine, Second EditionSevere necrotizing pneumonia complicated by empyema in a neonate
2020, Respiratory Medicine Case ReportsCitation Excerpt :The most common causes of NP include Streptococcus pneumonia and SA [3,5]. NP complicates between 0.8 and 7% of community-acquired pneumonia and 20% of those with empyema end up admitted to tertiary pediatric hospitals [5]. In a study of 47 children with empyema, half of those had concomitant NP.