Evaluation of Persistent Pneumonia and Percutaneous Needle Aspiration of Lung as a Tool in the Etiological Evaluation of Children with Persistent Pneumonia

Srinivasan, G (2006) Evaluation of Persistent Pneumonia and Percutaneous Needle Aspiration of Lung as a Tool in the Etiological Evaluation of Children with Persistent Pneumonia. Masters thesis, Madras Medical College, Chennai.

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Abstract

INTRODUCTION: Parenchymal lung diseases are a significant cause of morbidity and mortality, both in the devoloping as well as the devoloped world,especially in children.World wide pneumonia is estimated to cause the death of four million children under five years of age annually1.While acute lower respiratory tract infections remain the most important cause of morbidity and mortality in the under fives in the devoloping countries, persistent and recurrent pneumonias are not uncommon. The incidence of all respiratory tract infections in devoloping countries varies from 4.2-8.7 per child per year2,3. However the incidence rates of pneumonia are much lower about 10 per 1000 children per year2,3.Though only a small fraction of these turn out to be persistent pneumonia,still they contribute to a significant proportion of morbidity and mortality. No community studies have reported the incidence of persistent or recurrent pneumonia4. Persistent pneumonia implies a chronic non resolving pneumonia.They often manifest as acute lower respiratory tract infections and continue to persist for a varying period of time, irrespective of the treatment.Sporadic reports reveal various aspects of this important disease which often baffles the peadiatricians,patients and parents. Many different entities are known to either influence or to cause pneumonia that is persistent. Commonly encountered conditions like asthma,tuberculosis and foreign bodies can give rise to persistent lung infiltrates5.Swallowing abnormalities and gastroesophageal reflux can give rise to recurrent aspiration, leading on to persistent pneumonia.Some children experience persistent pneumonia as a result of deficiencies in the local pulmonary or systemic host defences or from underlying lung disorders that modify the lung defences5.Congenital malformations of the airways may predispose the child to recurrent aspirations leading on to pneumonia. Congenital anomalies of the lung like sequestration,hypoplasia and cystadenomatoid malformations may also act as the underlying cause of persistent lung infiltrates5.Anomalies of the cardiovascular system, especially left to right shunts increase the risk of recurrent and persistent pneumonia5.Non infectious disorders like hypersensitivity pneumonitis, pulmonary haemosiderosis and sickle cell disease may be responsible for persistent lung infiltrates in a small fraction of cases5.Persistent lung infiltrates pose a significant challenge to the paediatricians.Persistent pneumonia is a diagnostic challenge rather than a therapeutic dilemma. In view of the changing pattern of the etiological agents responsible for pneumonia in childhood, it is essential to identify the etiological agent.The etiological diagnosis is essential in a overwhelming majority of clinical conditions that require specific therapy. Various techniques have been used to study these infections but none seems to be ideal.Moreover paediatricians are limited in their ability to make a specific etiologic diagnosis because sputum is not usually available,results of throat cultures may be unrevealing and results of nasopharngeal cultures are frequently misleading because of high carrier rates of respiratory pathogen in this age group6.Though lung aspiration is a simple and the most direct way to obtain a specimen from lung parenchyma without risk of any contamination to identify the etiologic agent, it is hardly practiced. Compared to other invasive procedures like transbronchial lung biopsy, thoracoscopic lung biopsy and open lung biopsy, percutaneous needle aspiration is a minimally invasive procedure with good safety records that can provide adequate tissue sample for microbiological and cytological studies7.Percutaneous needle aspiration is a useful tool in the identification of the etiological agent in persistent pneumonia 7. Frequent occurrence of persistent pneumonia in children required further studies to enlighten the various aspects of this disease that remain a diagnostic challenge to the paediatricians throughout the world. AIM OF THE STUDY: 1. Diagnostic work up of children with persistent pneumonia 2. Percutaneous transthoracic needle aspiration of the lung as a tool in the etiological evaluation of children with persistent pneumonia where no underlying causes or contributory factors are found by other investigations. DISCUSSION: Persistent pneumonia implies a chronic non resolving pneumonia. Though there is no universal consensus on when to label pneumonia as persistent, the presence of symptoms and radiographic abnormalities beyond a period of one month, should raise the possibility of an abnormal predisposing condition. The correct identification of the predisposing cause and its appropriate treatment is the cornerstone in the management of these children. The underlying disorder associated with these infections can be due to congenital malformations of the upper or lower respiratory tract, cardiovascular system, recurrent aspirations, defects in the clearance of the airway secretions, ciliary abnormalities and disorders of systemic or local immunity which may be congenital or acquired. There are few reports on the underlying causes of persistent pneumonia in children. Most of the reports are on recurrent pneumonia. Some authors have discussed about recurrent and persistent pneumonia together. There are no recent reports regarding lung aspiration in children with persistent pneumonia. The study done by Kumar et al27 in AIIMS was on children with malignancy on chemotherapy with persistent lung infiltrates. In this study, children presenting within the first year of life accounted for around 50% of the patients while another 33% presented between 1-5 years age group. Only 17% of the children were above 5 years of age. In the study conducted by Lodha et al28 in children with persistent pneumonia, the reported age distribution was similar. Male children contributed to 56.5% of the cases in our study. Lodha et al reported an even greater disproportion in sex distribution, male children comprising nearly 80%. Tuberculous etiology was identified in one case as the cause of persistent pneumonia(2.94%).It was interesting to note that this child was negative for tuberculosis in all the other preliminary tuberculosis related investigations carried out. No organisms were isolated in 64.70% of the cases after lung aspiration. This may be due to the non infectious causes of pulmonary infiltrates, viral causes or other fastidious organisms which requires special media. It has to be remembered that even after a procedure as invasive as open lung biopsy the diagnosis may not be possible in upto 20% of the cases. CONCLUSION: Persistent pneumonia occurs predominantly in the under-five age group and more so in infancy. Male children were affected slightly more frequently than their female counterparts. The male female ratio was 1.3:1. The common complaints in the children were cough, fever, breathlessness, irritability, poor feeding and failure to thrive. The common clinical features were fever, tachpnea, dyspnea and the presence of crackes on auscultation. Malnutrition was found to be a common accompaniment. Bad child rearing practice was a possible contributory factor, especially in children below one year, leading on to lipoid pneumonia which presented as persistent lung infiltrates. Foreign body, congenital airway anomalies and anatomical lung abnormalities commonly presented as consolidation on x-ray chest whereas immunodeficiencies and lipoid pneumonia presented as diffuse infiltrates. As tuberculosis still accounted for around 20% of the total cases presenting as persistent lung infiltrates, we may be justified in starting emperical anti tuberculous drugs when the etiology remains clueless. Foreign body aspiration, congenital heart diseases, gastroesophageal reflux, swallowing abnormalities, anatomical lung abnormalities etc. should all be kept in mind while evaluating a case of persistent lung infiltrates. HIV screening should be done in all cases.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Evaluation ; Persistent Pneumonia ; Percutaneous Needle Aspiration ; Lung ; a Tool ; Etiological Evaluation ; Children ; Persistent Pneumonia
Subjects: MEDICAL > Orthopaedics
Depositing User: Ravindran C
Date Deposited: 12 Jul 2017 05:23
Last Modified: 20 Apr 2018 06:45
URI: http://repository-tnmgrmu.ac.in/id/eprint/1494

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