Recurrent or persistent pneumonia: A case series with discussion

Manoj Madhusudan

Consultant – Pediatric Interventional Pulmonology, Maa Kauvery, Trichy

Introduction

Recurrent pneumonia is defined as two episodes of pneumonia in 12 months / three or more episodes of pneumonia in a lifetime. With the characteristics of clinical/radiological persistence >6 weeks despite appropriate therapy, with radiological clearance in-between.

Definition: Pneumonia

As per WHO, any child who presents with fast breathing is technically classified as having pneumonia. Clinically, the X-ray shows fluffy alveolar consolidation involving a lobe or the whole lung +/—air bronchogram and/or effusion on the lateral pleural space. This was developed specifically for children with Pneumococcus and Hib.

Is it necessary to document resolution?

  1. In a first episode of uncomplicated pneumonia, in an otherwise healthy child no need.
  2. Resolution X-ray is recommended when
  • 2nd Episode of pneumonia
  • Clinical pointers to immunodeficiency
  • Focal changes during clinical examination
  • Complicated pneumonia- sometimes

Case Presentation

Case-1

Question 1: Is it a pulmonary lesion?

A 15-year-old asymptomatic girl, with an incidental shadow on an X-ray and no clearance with antibiotics.

Fig Arrow: Mediastinal Mass

Extrapulmonary Lesions

  • Thymus
  • Lymph Node
  • Bronchogenic Cyst
  • Mediastinal mass

Case-II

Question 2: Is it a Pneumonia?

A 5-year-old boy was previously admitted four times with a mild fever, cough, and fast breathing andimproved with nebulization.

H/O Eczema and allergic rhinitis

Fig: Right middle lobe syndrome

Recurrent Pulmonary Infiltrates

  • Asthma
  • Hypersensitive Pneumonitis
  • Pulmonary Hemosiderosis
  • ILD

Case- III

Question 3: Is there clinical improvement?

A 15-month-old, diagnosed with TB Empyema of the left side then started ATT; fever settled, weight improved. Follow up at 2 months, air entry still reduced

Delayed Radiological Clearance

  • TB
  • Adenovirus
  • Mycoplasma

Case-IV

Question 4: Is it Unilobar/Multilobar?

A 7-year-old boy was admitted twice, both for right lower lobe pneumonia.

CT After resolution of the second episode

Fig: Congenital Pulmonary Airway Malformation

Case – V

A 3-year-old girl with persisting consolidation in left lower lobe then was treated with antibiotics.

Results: No fever, but wet cough persistent.

Recurrent Unilobar Pneumonia

Narrowed Airways

Extrinsic compressionBronchial wallEndo bronchial
• Lymph node

• Vascular Ring

• Mediastinal tumor
• Bronchomalacia

• Stricture/Stenosis
• Endobronchial TB

• Foreign Body

• Tumor

Investigations: Unilobar

  • HRCT Chest +/- Contrast
  • Bronchoscopy

Case – VI

A 3-year-old boy had a previous history of psoas abscess at 6 months.

Left lower lobe Pneumonia 1.5 years back, now came with severe bilateral pneumonia but poor response to antibiotics. History of a sibling death at 3 years- recurrent infection

Discussion

  • Very early onset
  • Sibling death
  • Multiple sites of infection
  • Deep seated abscess

Investigations

TC35,000;
N90
CRP115
Blood CultureBurkholderia
NBT < 10% dye accumulation
ExomeChronic granulomatous disease

Primary Immunodeficiency

  • T cell defects – very early
  • CVID/B Cell – Sinopulmonary
  • CGD – Deep seated abscess
  • Hyperactive IgE – Eczema

Case – VII

A patient with multiple admissions for respiratory illness and chronic nasal stuffiness along CSOM.

Persisting shadows on the X-ray

Impression

  • Collapse Lingula and Right Middle Lobe,
  • Bronchiectasis
  • BAL – Pneumococcus
  • Clinical Exome – Primary Ciliary Dyskinesia

Primary Ciliary Dyskinesia

  • Bronchiectasis
  • CSOM
  • Chronic Rhinorrhea
  • Situs inversus (50%)

Case – VIII

A 6-year-old boy, apparently normal till 5 years. History of recurrent respiratory illness with fever for the past 1 year, then improved with antibiotics  but recurred

X-ray revealing infiltrates in various lobes during various admissions. Grade 2 clubbing, bilateral fine crepitations

Clinical Presentation

Impression

  • ACTH- >1000, Cortisol low
  • Barium swallow – Achalasia
  • Schirmer’s Test – Alacrimia
  • AAA Syndrome- recurrent aspiration pneumonia
  • Started on replacement steroids, underwent hellers myotomy

Multilobar Pneumonia

Discussion

Multilobar Pneumonia

  • PID (Pelvic Inflammatory Disease) Workup: Ig Profile, T/B cell markers, GGD workup (NBT/DHR)
  • HIV
  • Tests for aspiration – Barium swallow, Milk Scan, Bronchoscopy/OGD scopy
  • Echocardiogram
  • Sweat chloride/ Clinical exome sequencing

Cystic fibrosis and Primary Ciliary Dyskinesia

  • Echogenic Bowel Focus
  • Raised IRT
  • Delayed passage of meconium/ Oily Stools
  • Cholestasis/ Hepatits
  • Unexplained anemia
  • Rec Respiratory infections
  • Pseudo- Barter Syndrome
  • Recurrent Respiratory Infections/ Bronchiectasis
  • CSOM
  • Nasal Polyposis

Kauverian Bookshelf

Applied Medical Statistics

Journals

Kauvery Hospital
Find Doctor
Book Appointment