How Common are Latent and Active Tuberculosis Cases Identified Among Contacts?

Patient Presentation
A 4-year-old female came to clinic for her health supervision visit. The mother had no concerns about the child but wanted to know if there was anything else she needed to do for the child as she was finishing her own treatment for tuberculosis.
The mother was a legal immigrant in the United States from South East Asia, who had visited her relatives and returned to the United States. After the visit she found out she was pregnant and as part of her routine obstetrical care and history, she had a Mantoux skin test placed that was positive.
She had no symptoms of active disease and a normal chest radiograph. At 16 weeks gestation she was placed on isoniazid and pyridoxine for 9 months. The public health department had investigated for potential contacts in the United States and all were negative on physical examination and for skin testing.
The relatives were also contacted by the mother. The mother’s cousin began receiving some treatment but the mother was unsure about what it was.
The pertinent physical exam showed a happy, smiling infant with normal development and growth parameters.
The diagnosis of a healthy infant with a mother who was finishing treatment for latent tuberculosis infection was made. The mother was counseled that there was no other treatment or other evaluations that needed to be made for the child. Follow-up with her own health care provider was encouraged. The mother was also encouraged to contact the public health department about potential visits to her home country or visits from relatives to the United States.

Discussion
In children and adolescents, most tuberculosis infections caused by Mycobacterium tuberculosis or Mycobacterium bovis are asymptomatic.

Definitions:

  • Tuberculin skin test (TST) – a positive TST indicates possible infection with Mycobacterium tuberculosis or Mycobacterium bovis. Reactivity usually occurs 2-12 weeks after initial infection with a median interval of 3-4 weeks.
    In general, TST should be interpreted the same whether a child has received BCG vaccine or not. Specific recommendations for interpretation of TST can be found in the AAP’s Red Book. (see To Learn More below).
    The Mantoux skin testing method of intradermally injecting 5 tuberculin units or purified protein derivative into the volar aspect of the forearm is recommended. Multiple puncture tests are not recommended because of poor sensitivity and specificity.

  • Exposed person – a person with recent contact to another person with suspected or confirmed contagious pulmonary tuberculosis, who has a negative TST, normal physical examination, and chest radiograph.
  • Latent tuberculosis infection – a person with a positive TST with normal physical examination and chest radiograph.
  • Tuberculosis or active disease – a person with symptomatic disease which may be pulmonary, extrapulmonary or both.

Children, especially those < 5 years, have a high likelihood of progression from latent to active disease. They are also more likely to develop disseminated and serious forms of tuberculosis.
Increased risk of dissemination also occurs in children with impaired immune systems especially HIV infected children, and those with chronic disease such as diabetes, renal failure, malnutrition and recent measles.

Clinically, patients with active disease can present with fever, weight loss, poor weight gain, growth delay, cough, night sweats and chills.
Pulmonary tuberculosis from Mycobacterium tuberculosis will show radiographic findings that range from normal to abnormal radiographs showing lymphadenopathy, atelectasis, segmental or lobar infiltration, pleural effusion, and cavitary or miliary lesions.
Extrapulmonary symptoms from Mycobacterium tuberculosis include meningitis, granulomas of lymph nodes, bones, joints, skin, the middle ear and mastoid. Renal tuberculosis also occurs.
Another manifestations from Mycobacterium bovis is intermittent partial intestinal obstruction with chronic abdominal pain.

Treatment for active disease depends on a number of factors including the actual active disease manifestations, organism isolation and sensitivities to anti-infective agents, and previous treatment with anti-infective agents. Drugs used must be used in combination to decrease drug resistance. Drugs commonly recommended include isoniazid, rifampin, pyrazinamide, ethambutol and streptomycin.
Treatment for latent tuberculosis infection is isoniazid for adults. Infants, children and adolescents with latent tuberculosis who have never received anti-tuberculosis therapy should receive isoniazid therapy, unless the known source has isoniazid-resistant tuberculosis or another specific contraindication exists.
Specific recommendations for treatment can be found in the AAP’s Red Book. (see To Learn More below). Women who are pregnant with latent infection should receive isoniazid and pyridoxine for 9 months beginning after the first trimester.

Learning Point
In low incidence countries such as the United States, for 1 active tuberculosis case, 5-10 contacts are identified. Among these contacts 30% are found to have latent tuberculosis infections and another 1-4% are found to have an active tuberculosis infection.
In high prevlance countries among the contacts 50% are found to have latent tuberculosis infections and another 10-20% are found to have active tuberculosis infection.

Questions for Further Discussion
1. Where are the high-prevelance regions of tuberculosis in the world?
2. What are the recommendations for isolation of potential source patients?
3. What are some of the manifestations of non-tuberculosis Mycobacterium?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for this topic: Tuberculosis
and at Pediatric Common Questions, Quick Answers for this topic: Tuberculosis

To view current news articles on this topic check Google News.

American Academy of Pediatrics. Tuberculosis In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2006;678-698.

Hopewell PC, Pai M, Maher D, Uplekar M, Raviglione MC. International Standards for Tuberculosis Care. Lancet Infect Dis. 2006;6:710-25.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    November 27, 2006

  • How Do I Treat Asthma According to the NIH Guidelines?

    Patient Presentation
    A 7-year-old male came to clinic because the last 3 nights he has been having a cough that has been interfering with sleep.
    During the day he is also having some problems running on the playground and in gym class, but no problems during rest.
    He has had mild clear rhinorrhea for 4 days with no sore throat, or emesis. He has complained of feeling “warm” but his temperature was 99.0 degrees Fahrenheit.
    The family is out of his albuterol metered-dose inhaler.
    The past medical history reveals 1-2 asthma exacerbations a year for the last 5 years that occur with upper respiratory infections. He has never been hospitalized nor been to the emergency room. He has used oral corticosteroids for some exacerbations and in between exacerbations is well. . He had atopic dermatitis as an infant and has some dry skin in the wintertime.
    He has no symptoms of allergies and there is no tobacco smoking around him.
    The family history shows hayfever in both parents. His brother also had atopic dermatitis as an infant.
    The review of systems is otherwise negative.
    The pertinent physical exam shows an alert male in no acute distress. Respiratory rate is 26 and he is afebrile. He easily converses but coughs several times during the examination.
    He has clear rhinorrhea in the nose and posterior pharynx. His lung examination shows a mildly prolonged end-expiratory phase with intermittent mild, end-expiratory wheezing.
    The diagnosis of an acute exacerbation of his mild intermittent asthma is made. He is given another prescription for albuterol metered-dose inhalers with a spacer to be given 2 puffs for increased work of breathing, before bedtime, and before exercise. More than one inhaler was given so the patient would have an inhaler available at home and school.
    A prescription for oral corticosteroids is given to be used if symptoms are increasing such as needing to use the albuterol more than every 4 hours. The family was again instructed on the role of the medication, how to use the medication and spacer properly, and when to call a physician or go to the emergency room for an exacerbation.
    The patient’s clinical course over the next several days showed him using the inhaler ~ 4 times/day initially and then decreasing over the next 5 days. Oral corticosteroids were not begun.

    Discussion
    Asthma is a chronic inflammatory process of the airways where episodic, reversible airway obstruction occurs and alternative diagnoses are excluded.
    In children it is commonly associated with atopy. Wheezing with viral infections, a family history of allergy are strongly associated with continued asthma during childhood
    Various factors can make asthma difficult to control and should be screened for in each patient. If the factors are present patient and their families should be appropriately counseled and treatment recommendations made. Examples include:

    • Allergens – indoor and outdoor
    • Irritants – including tobacco smoke or occupational or recreational exposure
    • Foods and medications – e.g. sulfites, beta-blockers, aspirin
    • Gastroesophageal reflux
    • Rhinitis and sinusitis
    • Upper respiratory tract infections

    Learning Point
    According to the National Institutes of Health’s Expert Panel Report entitled “Guidelines for Asthma Diagnosis and Management,” asthma is classified by severity and treatment recommendations are made based upon those classifications. More recently, studies are beginning to look at classifications based upon how well the asthma symptoms are controlled.

    Overall, the goals of asthma treatment include:

    • No or minimal chronic symptoms
    • No or minimal exacerbations
    • No activities of daily living and school/work limitations
    • Maintain normal or near normal pulmonary function
    • Minimal use of short-acting inhaled beta-2 agonists
    • No or minimal medication side-effects

    Review treatment and step down every 1-6 months if possible. Step up if control is not maintained.

    NIH’s asthma severity and long-term control treatment recommendations include:

  • Step 1. Mild Intermittent
    • Definition
      • Symptoms < or = 2 times/week
      • Nocturnal symptoms < or = 2 times/month
      • Symptom free in-between exacerbations
    • Long-term control for patients < 5 years
      • No daily medication needed
    • Long-term control for patients > 5 years
      • No daily medication needed
  • Step 2. Mild Persistent
    • Definition
      • Symptoms > 2 times/week but < 1 time/day
      • Activities may be affected by exacerbations
      • Nocturnal symptoms > 2 times/month
    • Long-term control for patients < 5 years
      • Preferred: low-dose inhaled corticosteroid
      • Alternative: cromolyn or leukotriene receptor antagonist
    • Long-term control for patients > 5 years
      • Preferred: low-dose inhaled corticosteroid
      • Alternative: cromolyn, leukotriene modifier, nedocromil OR sustained-release theophylline
  • Step 3. Moderate Persistent
    • Definition
      • Symptoms daily
      • Nocturnal symptoms > 1 time/week
    • Long-term control for patients < 5 years
      • Preferred: low-dose inhaled corticosteroids along with a long-active inhaled beta-2 agonist, OR medium-dose inhaled corticosteroids alone
      • Alternative: low-dose inhaled corticosteroids along with either a leukotriene receptor antagonist or theophylline
      • If needed for specific patients, alternative recommendations are made by the expert group, see “To Learn More” below
    • Long-term control for patients > 5 years
      • Preferred: low-medium dose inhaled corticosteroids along with long-active inhaled beta-2 agonists
      • Alternative: increase inhaled corticosteroids within medium-dose range, OR low-medium dose inhaled corticosteroids along with either a leukotriene modifier or theophylline
  • Step 4. Severe Persistent
    • Definition
      • Symptoms continuous
      • Nocturnal symptoms frequently
    • Long-term control for patients < 5 years
      • Preferred: high-dose inhaled corticosteroids along with long-acting beta-2 agonist, AND if needed systemic corticosteroids
    • Long-term control for patients > 5 years
      • Preferred: high-dose inhaled corticosteroids along with long-acting beta-2 agonist, AND if needed systemic corticosteroids

    Short-term asthma relief includes:

    • Short-acting bronchodilators
    • Treatment intensity depends on severity of the exacerbations. Up to 3 treatments at 20-minute intervals or a single nebulizer treatment as needed.
    • Systemic corticosteroids may be needed.
    • Using short-acting beta-2 agonists > 2 times/week in intermittent asthma or daily and increasing use in persistent asthma may indicate the need to increase or initiate long-term control treatment

    Guidelines for specific medication dosing can be found in the executive summary of the guidelines listed below in To Learn More

    Questions for Further Discussion
    1. How many medication doses are there in a metered-dose inhaler?
    2. How should a peak flow meter be used?
    3. What are the potential side-effects of inhaled and systemic corticosteroid use?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Asthma in Children and
    at Pediatric Common Questions, Quick Answers for this topic: Asthma

    To view current news articles on this topic check Google News.

    Yawn BP, Brenneman SK, Allen-Ramey FC, Cabana MD, Markson LE. Assessment of asthma severity and asthma control in children.
    Pediatrics. 2006 Jul;118(1):322-9.

    National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Available from the Internet at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (rev. July 1997, cited 10/30/06).

    National Asthma Education and Prevention Program Expert Panel Report Guidelines for the Diagnosis and Management of Asthma – Update on Selected Topics 2002. Available from the Internet at:
    http://www.nhlbi.nih.gov/guidelines/asthma/execsumm.pdf (rev. 2002, cited 10/30/06).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    November 20, 2006

  • What is the Most Reliable Indicator of Acute Otitis Media?

    Patient Presentation
    A 9-month-old male came to clinic after 2 days of clear rhinorrhea. He woke in the night crying and was difficult to console. He had a fever to 38.7 degrees Celsius and responded to an appropriate dose of acetaminophen. He then returned to sleep.
    In the morning he was cranky and again had some relief with acetaminophen. He breastfed but seemed uncomfortable with it.
    The past medical history revealed no previous ear infections, but a couple of upper respiratory infections.
    The review of systems wss negative including rash, cough, emesis or diarrhea.
    The pertinent physical exam showed a tired-appearing male with a temperature of 38.3 degree Celsius, respiratory rate = 32, and heart rate = 124. His growth parameters were 10-50%.
    HEENT revealed copious clear rhinorrhea, normal pharynx, and s right tympanic membrane that was red, bulging and normal landmarks were not visible. Pneumatic otoscopy showed no movement of the right tympanic membrane.
    The left tympanic membrane was grey with clear fluid and an air-fluid level visible approximately 50% of the way to the top of the tympanic membrane. There was decreased mobility of the left tympanic membrane. He had shoddy anterior cervical nodes.
    The rest of his examination was normal.
    The diagnosis of right acute otitis media was made and he was begun on Amoxicillin 80-90 mg/kg/day for 10 days. He was to follow-up in ~ 6 weeks to re-check his ear and receive an influenza vaccination.

    Discussion
    Acute otitis media (AOM) is one of the most common infectious diseases in childhood.
    It significantly impacts the health of children and causes a social burden due to indirect costs in lost time in school and work.
    Costs in 1995 in the United States were estimated at $1.96 billion directly and $1.02 billion indirectly.

    AOM is an inflammatory process that affects the mucosa of the middle ear and is characterized by fever and otalgia.
    The inflammatory process may continue with build-up of pus in the middle ear leading to rupture of the tympanic membrane and otorrhea.
    It is caused by both viruses and bacteria. Common viral pathogens are adenovirus, Influenza type A and Respiratory Syncytial Virus.
    Common bacteria include Streptoccus pneumoniae, Moraxella catarrhalis, and Haemophilus influenza type B.
    Some locations are seeing a decrease in Haemophilus influenza type B, presumably due to vaccination.

    AOM should be treated with pain control, and watchful waiting and/or antibiotics depending on the age and severity of symptoms.
    The American Academy of Pediatrics Clinical Practice Guideline published in 2004 has specific recommendations (see To Learn More below).

    Learning Point
    AOM can be diagnosed when the following 3 elements are present:

    • History of recent, usually abrupt onset of acute signs and symptoms,
      e.g. otalgia, fussiness, crying, fever

    • Middle ear effusion documented by any of the following:
      • Tympanic membrane bulging
      • Mobility that is limited or absent
        often documented by pneumatic otoscopy, sometimes tympanometry is used, tympanocentesis is sometimes used

      • Air-fluid level presence behind the middle ear
      • Otorrhea
    • Middle ear effusion signs and symptoms documented by any of the following
      • Tympanic membrane erythema
      • Otalgia that is referable to the ears and that interferes with activities or sleep

    The most reliable diagnostic criteria are bulging of the tympanic membrane, otalgia, and otorrhea.
    Most children present without otorrhea, so for those without otorrhea, bulging of the tympanic membrane is the best predictor of AOM especially when combined with color and mobility.

    AOM is distinctly different from otitis media with effusion and recurrent AOM.
    Otitis media with effusion is defined as fluid in the middle ear without signs of symptoms of acute ear infections.
    Recurrent acute otitis media is defined as 3 or more AOM infections in 6 months or more than 4 episodes in a year. Patients must be disease free in between these AOM episodes.

    Questions for Further Discussion
    1. What are the indications for observation (i.e. watchful waiting) in children with AOM?
    2. What are the indications for treatment with pressure-equalizing tubes (i.e. tympanostomy tubes, grommets)?
    3. What are efficacious treatments for otitis media with effusion?
    4. How does breastfeeding, tobaco exposure and vaccination potentially impact the frequency of AOM?>br>

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Ear Infections

    To view current news articles on this topic check Google News.

    American Academy of Pediatrics. Otitis Media with Effusion. Pediatrics. 2004;113;1412-1429.

    American Academy of Pediatrics. Diagnosis and Management of Acute Otitis Media. Pediatrics. 2004:113;1451-1465.

    Lous J, Burton MJ, Felding JU, Ovesen T, Rovers MM, Williamson I. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. (Protocol)
    The Cochrane Database of Systematic Reviews. 2006 Issue 3

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.

    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    November 13, 2006

  • What Are the Complications of Pneumonia?

    Patient Presentation
    A 4.5-year-old female came to the emergency room with a 2 week history of cough that was increasing in frequency.
    She also had a fever with a maximum of 102 degrees Fahrenheit.
    For the past 3 days she had some increasing shortness of breath and mild abdominal pain.
    She did not want to eat solid food but was drinking.
    The past medical history was negative. She was current on her vaccinations and had some colds and ear infections in the past.
    The review of systems was negative.
    The pertinent physical exam showed a tired-appearing female with respiratory rate of 44, temperature of 38 degrees Celsius, heart rate of 140 and normal blood pressure. Capillary refill was 3 seconds.
    Height and weight were 25-50%. Her oxygen saturation by pulse oximetry was 97% on room air.
    Her HEENT examination was normal except for suprasternal retractions and mild nasal flaring.
    Lung examination showed no breath sounds on the left side and normal sounds on the right.
    Heart examination revealed right-sided heart sounds with no murmurs. Peripheral pulses were normal.
    Abdominal examination showed mild diffuse tenderness with no masses or hepatosplenomegaly or guarding.
    The rest of the examination was normal.
    The radiologic evaluation of a chest radiograph showed complete whiteout of the left hemi-thorax with deviation of the trachea and heart into the right thorax.
    The laboratory evaluation showed a white blood cell count of 18.2 x 1000/mm2 with 12,000 polymorphonuclear cells, and 1400 bands. The platelets were elevated at 840 x 1000/mm2.
    The C-reactive protein was 4.3 mg/dl. Total protein, albumin, amylase, and lipase were normal. A venous blood gas showed pH = 7.4, CO+2 = 37, O+2=48 and bicarbonate = 24.
    The work-up included a chest computed tomography examination which showed a large left-sided pleural effusion. The left lung was completely consolidated and possibly necrotic with deviation of the left lung to the midline and right-sided deviation of the heart.
    The diagnosis of pneumonia with empyema was made.
    The patient’s clinical course included being taken to the operating room where 1.6 liters of frank pus was drained and a drainage tube placed. Culture was positive for Group A, beta-hemolytic streptococcus.
    She was initially treated with intranvenous fluids and ceftriaxone, and later changed to penicillin with clinical improvement; subsequent chest radiographs showed marked decrease in the empyema and expansion of the left lung.
    Treatment duration was to be decided based on clinical improvement.


    Figure 39 – PA and lateral radiographs of the chest demonstrate complete opacification of the left hemithorax with tracheal and mediastinal shift to the right.


    Figure 40 – Axial image from a CT scan of the chest performed with intravenous contrast demonstrates the left hemithorax opacification is due to a large left pleural effusion causing complete atelectasis of the left lung and mediastinal shift to the right. There was concern that a circular area of necrosis may be present within the atelectatic lung.

    Discussion
    Pneumonia is a common infection world-wide. As the lung’s lobes or segments become consolidated in acute bacterial pneumonias, lung compliance and vital capacity diminishes and increased work of breathing occurs.
    On physical examination the child may have tachypnea, retractions, nasal flaring, grunting, rales and tubular breather sounds are often heard. There may also be no adventitial breath sounds.
    With increasing lung involvement, especially if complicated by concomitant pain or fatigue, the child’s oxygenation saturation may begin to fall often with increased CO+2 retention and possibly respiratory failure. Evaluation by pulse oximetry and/or blood gases can be helpful for monitoring pulmonary status.
    Patients are often treated outpatient with 10-14 days of a second or third generation cephalosporin to cover common organisms. Radiographs will remain abnormal for 6-8 weeks despite clinical improvement.

    Group A Streptococcus usually occurs after exanthems but can also occur in previously healthy children. Chest radiographs may show peribronchial thickening, lobar or segmental involvement and/or effusion. The most common complications are abscesses and empyema.
    Children usually are treated for 10-14 days with oral penicillin but seriously ill children may need longer treatment.

    Many different organisms can cause pneumonia. Most commonly in the United States these include:

    • Viruses – including coronaviruses, adenovirus, influenza, parainfluenza, respiratory syncytial virus, rhinovirus, varicella, etc.
    • Streptococcus, Group A
    • Streptococcus pneumoniae
    • Staphylococcus aureus – including methicillin-resistant types
    • Mycoplasma pneumoniae
    • Haemophilus influenzae, non-typable – H. influenza type b is less common due to vaccination
    • Anaerobic bacteria
    • Klebsiella pneumoniae

    Nosocomial and immunocompromised hosts may also have:

    • Pseudomonas aeruginosa
    • Enterobacteriaceae species
    • Serratia
    • Escherichia coli
    • Acinetobacteriaceae species
    • Fungi

    Learning Point
    Complications of pneumonia include:

    • Abscess
    • Apnea or respiratory failure
    • Bacteremia and/or sepsis
    • Death
    • Pleural effusion
    • Empyema
    • Hilar adenopathy
    • Pneumatocoeles
    • Recurrent pneumonia

    In the US and other developed countries, pneumonia is usually promptly treated without complications.
    But world-wide, pneumonia causes 19% of all deaths in children under the age of 5 or about 2 million children/year.
    This does not include neonatal deaths caused by pneumonia. If these were added, it is estimated that more than 3 million children/year would die of pneumonia.
    Pneumonia is the number one cause of deaths in children under 5 years of age. It is estimated that 600,000 children’s lives could be saved with universal antibiotic treatment.
    Prevention with immunizations for S. pneumococcus, H. flu type b and measles vaccine would also dramatically decrease the mortality and morbidity.

    World-wide, cause-specific mortality rates in children under 5 years of age are:

    • Miscellaneous neonatal deaths = 27%
    • Pneumonia = 19%
    • Diarrheal illnesses = 17%
    • Neonatal severe infections (mainly pneumonia and sepsis) = 10%
    • Malaria = 8%
    • Measles = 4%
    • Injuries = 3%
    • HIV/AIDS = 3%
    • Others = 10%

    Questions for Further Discussion
    1. What are the indications for hospitalization for pneumonia?
    2. What are the indications for an immunology work-up in a patient with a recurrent pneumonia?
    3. What are the indications for surgical intervention in a patient with complicated pneumonia?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Pneumonia and Streptococcal Infections
    and at Pediatric Common Questions, Quick Answers for this topic: Pneumonia

    To view current news articles on this topic check Google News.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1980-1983.

    Wardlaw T, Salama P. White Johansson E. Mason. Pneumonia: The Leading Killer of Children. Lancet. Lancet. 2006;368:1048-50.

    Bradley JS, Nelson JD. Nelson’s Pocket Book of Pediatric Antimicrobial Therapy. 16th edit. Allianace for World Wide Editing. Buenos Aires, Argentina. 2006;37-44.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    November 6, 2006