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11/11/2015 Community-acquired pneumonia in children: Clinical features and diagnosis
Section EditorsSheldon L Kaplan, MDGeorge B Mallory, MD
Deputy EditorMary M Torchia, MD
Communityacquired pneumonia in children: Clinical features and diagnosis
All topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through: Oct 2015. | This topic last updated: Oct 07, 2015.
INTRODUCTION — Communityacquired pneumonia (CAP) is defined as signs and symptoms of an acuteinfection of the pulmonary parenchyma in a previously healthy patient who acquired the infection in thecommunity, as distinguished from hospitalacquired (nosocomial) pneumonia [1,2]. CAP is a common andpotentially serious illness with considerable morbidity.
The clinical features and diagnosis of CAP in children will be reviewed here. The epidemiology,pathogenesis, and treatment of pneumonia in children are discussed separately. (See "Pneumonia inchildren: Epidemiology, pathogenesis, and etiology" and "Communityacquired pneumonia in children:Outpatient treatment" and "Pneumonia in children: Inpatient treatment".)
CLINICAL PRESENTATION — The clinical presentation of childhood pneumonia varies depending uponthe responsible pathogen, the particular host, and the severity. The presenting signs and symptoms arenonspecific; no single symptom or sign is pathognomonic for pneumonia in children.
Symptoms and signs of pneumonia may be subtle, particularly in infants and young children. Thecombination of fever and cough is suggestive of pneumonia; other respiratory findings (eg, tachypnea,increased work of breathing) may precede cough. Cough may not be a feature initially since the alveoli havefew cough receptors. Cough begins when the products of infection irritate cough receptors in the airways.The longer fever, cough, and respiratory findings are present, the greater the likelihood of pneumonia [3].
Neonates and young infants may present with difficulty feeding, restlessness, or fussiness [4]. Youngchildren (ie, <5 to 10 years of age) may present with fever and leukocytosis [3,5]. Older children maycomplain of pleuritic chest pain (pain with respiration), but this is an inconsistent finding. Occasionally, thepredominant manifestation may be abdominal pain (because of referred pain from the lower lobes) or nuchalrigidity (because of referred pain from the upper lobes). "Walking pneumonia" is a term that is sometimesused to describe pneumonia in which the respiratory symptoms do not interfere with normal activity.
CLINICAL EVALUATION — The evaluation of the child with cough and potential lower respiratory tractdisease has two goals: the identification of the clinical syndrome (eg, pneumonia, bronchiolitis, asthma) andan assessment of the severity of the illness [4]. The severity of illness determines the need for additionalevaluation.
History — Important aspects of the history for children with possible communityacquire pneumonia arelisted in the table (table 1) [4,6,7]. Historical features can be helpful in determining the etiologic agent, thelikelihood of infection with an organism that is resistant to antibiotics, and the severity of illness. (See"Pneumonia in children: Epidemiology, pathogenesis, and etiology", section on 'Etiologic agents'.)
Examination — Important aspects of the examination are summarized in the table (table 2) and discussedin greater detail below.
General appearance — In the young infant, assessment of general appearance includes the ability toattend to the environment, to feed, to vocalize, and to be consoled. The state of awareness and presence ofcyanosis should be assessed in all children, although children may be hypoxemic without cyanosis [8]. Mostchildren with radiographically confirmed pneumonia appear ill [9].
Fever — Fever is a common manifestation of pneumonia in children [10]. However, it is nonspecific and
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11/11/2015 Community-acquired pneumonia in children: Clinical features and diagnosis
variably present. Young infants may have afebrile pneumonia related to Chlamydia trachomatis or otherpathogens. (See "Chlamydia trachomatis infections in the newborn", section on 'Pneumonia' and"Pneumonia in children: Epidemiology, pathogenesis, and etiology", section on 'In infants'.)
Fever may be the only sign of occult pneumonia in highly febrile young children. In one report, 26 percent of146 children (<5 years) with fever ≥39ºC (102.2°F), no clinical evidence of pneumonia or other localizingsigns, and peripheral white blood cell count ≥20,000/microL had radiographic evidence of pneumonia [5].
Tachypnea — Tachypnea is the most sensitive and specific sign of radiographically confirmedpneumonia in children [4,1113]. In a systematic review of studies evaluating the correlation between clinicalexamination findings and radiographic pneumonia, tachypnea was twice as frequent in children with thanwithout radiographic pneumonia, and the absence of tachypnea was the single most valuable sign forexcluding pneumonia [4]. Tachypnea in infants with pneumonia (respiratory rate >70 breaths/min) also hasbeen associated with hypoxemia [14]. Tachypnea may be less useful early in the course of illness (eg, lessthan three days) [11].
The World Health Organization agerelated definitions of tachypnea are as follows [15,16]:
The respiratory rate varies with activity in infants and young children, and in these patients is best assessedby counting for a full 60 seconds [4,1719]. Observation of chest wall movements is preferable toauscultation because auscultation may stimulate the child, falsely elevating the rate [4]. The respiratory ratemay increase by as many as 10 breaths per minute per degree (Celsius) of fever in children withoutpneumonia [20]; the effect of fever on respiratory rate in children with pneumonia has not been investigated[4].
Respiratory distress — Signs of respiratory distress include tachypnea, hypoxemia (peripheral arterialoxygen saturation [SpO ] <90 percent on room air at sea level), increased work of breathing (intercostal,subcostal, or suprasternal retractions; nasal flaring; grunting; use of accessory muscles), apnea, and alteredmental status [1].
Oxygen saturation should be measured in any child with increased work of breathing, particularly if he or shehas a decreased level of activity or agitation [1,2,21]. Infants and children with hypoxemia may not appearcyanotic [8]. Hypoxemia is a sign of severe disease and an indication for admission [1,2].
Signs of respiratory distress are more specific than fever or cough for lower respiratory tract infection. In areview of 192 febrile infants younger than three months of age, the specificity of at least one sign ofrespiratory distress for radiographic pneumonia (respiratory rate >60 breaths/min, retractions, flaring,crackles, grunting, apnea, or cyanosis) was 93 percent, but the sensitivity was only 59 percent [22].
Signs of respiratory distress that are predictive of pneumonia include hypoxemia (defined differently indifferent studies, usually oxygen saturation <94 to 96 percent in room air), retractions, head bobbing, andnasal flaring [7,9,12,23]. Unlike tachypnea, the absence of these findings does not exclude a diagnosis ofpneumonia.
Younger than two months: >60 breaths/minTwo to 12 months: >50 breaths/minOne to 5 years: >40 breaths/min≥5 years: >20 breaths/min
2
In a review of children 2 to 59 months of age, oxygen saturation ≤96 percent in room air was 2.8 timesmore frequent among children with pneumonia than without [12]
In a systematic review, retractions were 2.5 times more frequent in infants with pneumonia than without[4]
Nasal flaring is approximately three times more frequent in children <5 years with pneumonia thanwithout [4], and five times more frequent in infants 2 to 12 months with pneumonia than without [12]
11/11/2015 Community-acquired pneumonia in children: Clinical features and diagnosis
Lung examination — Examination of the lungs may provide clues to the diagnosis of pneumonia and/orpotential complications.
Auscultation is an important component of the examination of the child who presents with findings indicativeof pneumonia. However, auscultatory findings have less interobserver agreement than observable findings,such as retractions [4]. Auscultation of all lung fields should be performed.
Examination findings consistent with radiographically confirmed pneumonia include [13]:
Severity assessment — An assessment of pneumonia severity is necessary to determine the need forlaboratory and imaging studies and the appropriate treatment setting. The severity of pneumonia isassessed by the child's overall clinical appearance and behavior, including an assessment of his or herdegree of awareness and willingness to eat or drink (table 3) [7].
Clues to etiology — Clinical features classically taught to be characteristic of bacterial pneumonia, atypicalbacterial pneumonia, or viral pneumonia are summarized in the table (table 4). However, the featuresfrequently overlap and cannot be used reliably to distinguish between the various etiologies [26,27]. Inaddition, as many as 50 percent of infections may be mixed bacterial/viral infections. (See "Pneumonia inchildren: Epidemiology, pathogenesis, and etiology", section on 'Communityacquired pneumonia'.)
Grunting, when present, is a sign of severe disease and impending respiratory failure [24]
Crackles, also called rales or crepitations; in a systematic review, crackles were 3.5 times morefrequent in infants with radiographic pneumonia than without [4]
Findings consistent with consolidated lung parenchyma, including:
Decreased breath sounds•
Bronchial breath sounds (louder than normal, with short inspiratory and long expiratory phases,and higherpitched during expiration), egophony (E to A change)
•
Bronchophony (the distinct transmission of sounds such as the syllables of “ninetynine”)•
Whispered pectoriloquy (transmission of whispered syllables)•
Tactile fremitus (eg, when the patient says “ninetynine”)•
Dullness to percussion•
Wheezing is more common in pneumonia caused by atypical bacteria and viruses [25] than bacteria(see 'Clues to etiology' below)
Findings suggestive of pleural effusion include chest pain with splinting, dullness to percussion, distantbreath sounds, and a pleural friction rub (see "Epidemiology; clinical presentation; and evaluation ofparapneumonic effusion and empyema in children", section on 'Clinical presentation')
Bacterial – Classically, bacterial ("typical") pneumonia, usually resulting from Streptococcuspneumoniae and less commonly from Staphylococcus aureus and group A Streptococcus, which mayfollow days of upper respiratory tract infection symptoms, is considered abrupt in onset, with the febrilepatient appearing ill and sometimes toxic. Respiratory distress is moderate to severe; auscultatoryfindings may be few and focal, limited to the involved anatomic segment. Signs and symptoms ofsepsis and localized chest pain (signifying pleural irritation) are more suggestive of bacterial etiology[10], as they are rarely present in nonbacterial pneumonia. Complications, discussed below, also aremore suggestive of bacterial etiology (see 'Complications' below) On the other hand, primary bacterialpneumonia is unlikely in children older than five years if wheezing is present [28].
Pneumococcal pneumonia is the most common typical bacterial pneumonia in children of all ages. Inone retrospective review of 254 children and young adults (age <1 month to 26 years) with
11/11/2015 Community-acquired pneumonia in children: Clinical features and diagnosis
Atypical bacterial – "Atypical" bacterial pneumonia resulting from Mycoplasma pneumoniae orChlamydia pneumoniae usually presents abruptly with constitutional findings of fever, malaise andmyalgia, headache, photophobia, sore throat, and gradually worsening nonproductive cough despiteimprovement of other symptoms [25,28]. Although hoarseness may be seen in disease caused by bothagents, it is more frequently seen with C. pneumoniae infection. Wheezing is a frequent finding inatypical bacterial and viral pneumonias [10]. (See "Pneumonia caused by Chlamydia species inchildren" and "Mycoplasma pneumoniae infection in children", section on 'Clinical features'.)
M. pneumoniae may be associated with a variety of extrapulmonary manifestations. Dermatologicmanifestations may range from a mild erythematous maculopapular rash or urticaria to the StevensJohnson syndrome. Other extrapulmonary manifestations include hemolytic anemia, polyarthritis,pancreatitis, hepatitis, pericarditis, myocarditis, and neurologic complications [30]. (See "Mycoplasmapneumoniae infection in children", section on 'Clinical features'.)
Infants younger than one year of age may develop "afebrile pneumonia of infancy". Afebrile pneumoniaof infancy is a syndrome generally seen between two weeks and three to four months of life. It isclassically caused by C. trachomatis, but other agents, such as cytomegalovirus, M. hominis, andUreaplasma urealyticum, also are implicated. The clinical presentation is one of insidious onset ofrhinorrhea and tachypnea followed by a staccato cough pattern (individual coughs separated byinspirations). Physical examination typically reveals diffuse inspiratory crackles. Conjunctivitis may bepresent, or there may have been a past history of conjunctivitis [31]. (See "Chlamydia trachomatisinfections in the newborn", section on 'Pneumonia'.)
Viral – The onset of viral pneumonia is gradual and associated with preceding upper airway symptoms(eg, rhinorrhea, congestion). The child does not appear toxic. Auscultatory findings are usually diffuseand bilateral. In one study of 98 ambulatory children with pneumonia, wheezing was more frequent inpatients with viral than bacterial pneumonia (43 versus 16 percent), but other clinical features oftenassociated with viral illness, such as rhinorrhea, myalgia, and ill contacts, were not [32].
Some viral causes of pneumonia are associated with characteristic dermatologic findings:
Measles (picture 1AB) (see "Clinical manifestations and diagnosis of measles")•
Varicella (picture 2) (see "Clinical features of varicellazoster virus infection: Chickenpox")•
Herpes simplex virus (picture 3AB) (see "Clinical manifestations and diagnosis of herpes simplex•
11/11/2015 Community-acquired pneumonia in children: Clinical features and diagnosis
RADIOLOGIC EVALUATION — An infiltrate on chest radiograph is often used to define pneumonia,particularly in clinical research [23,33]. The radiographic definition is necessary because of the difficulty inobtaining appropriate specimens from the lower respiratory tract for culture or microbiologic evaluation. Thispeculiarity makes it difficult to assess the degree to which chest radiographs are actually needed todiagnose pneumonia in the clinical setting, as the likelihood ratio of a standard cannot be measured [4,7].
Indications — Routine chest radiographs are not necessary to confirm the diagnosis of suspectedcommunityacquired pneumonia (CAP) in children with mild, uncomplicated lower respiratory tract infectionwho are well enough to be treated as outpatients [1,2,7]. Indications for radiographs in children with clinicalevidence of pneumonia include [1,2,7]:
There are a number of caveats to consider when deciding whether to obtain radiographs and whetherradiographs will alter management. These include:
Views — When radiographs are indicated, the recommended views depend upon the age of the child [43].In children older than four years, the frontal posteroanterior (PA) upright chest view is usually obtained tominimize the cardiac shadow [44]. In younger children, position does not affect the size of the cardiothoracicshadow, and the anteroposterior (AP) supine view is preferred because immobilization is easier and thelikelihood of a better inspiration is improved [44].
There is a lack of consensus regarding the need for lateral radiographs to demonstrate infiltrates behind thedome of the diaphragm or the cardiac shadow that may not be visualized on AP or PA views [45]. In a
virus type 1 infection", section on 'Respiratory tract infections' and "Neonatal herpes simplex virusinfection: Clinical features and diagnosis", section on 'Disseminated disease')
Severe disease (table 3) (see 'Severity assessment' above)
Confirmation of the diagnosis when clinical findings are inconclusive
Hospitalization (to document the presence, size, and character of parenchymal infiltrates and evaluatepotential complications)
Exclusion of alternate explanations for respiratory distress (eg, foreign body aspiration, heart failure),particularly in patients with underlying cardiopulmonary or medical conditions (see 'Differentialdiagnosis' below)
Assessment of complications, particularly in children whose pneumonia is prolonged and unresponsiveto antimicrobial therapy [7] (see "Communityacquired pneumonia in children: Outpatient treatment",section on 'Treatment failure' and 'Complications' below)
Exclusion of pneumonia in young children (3 to 36 months) with fever >39ºC (102.2°F) andleukocytosis (≥20,000 white blood cell [WBC]/microL) and older children (<10 years) with fever >38ºC(100.4°F), cough, and leukocytosis (≥15,000 WBC/microL) [3,5] (see "Fever without a source inchildren 3 to 36 months of age")
Radiographic findings are poor indicators of the etiologic diagnosis and must be used in conjunctionwith other clinical features to make therapeutic decisions [2,3437] (see "Communityacquiredpneumonia in children: Outpatient treatment", section on 'Treatment failure')
Radiographic findings may lag behind the clinical findings [38]
Patients who are hypovolemic may have normalappearing chest radiography before volume repletion
There is variation in intraobserver and interobserver agreement [2,39]
Radiographic interpretation may be influenced by the clinical information that is provided to theradiologist [40]
Obtaining outpatient chest radiographs does not affect outcome [41,42]
11/11/2015 Community-acquired pneumonia in children: Clinical features and diagnosis
Indications — If possible, a microbiologic diagnosis should be established in children with severedisease (table 3), potential complications, and those who require hospitalization. Accurate and rapiddiagnosis of the responsible pathogen helps to determine the appropriate antimicrobial therapy [1]. (See"Pneumonia in children: Inpatient treatment", section on 'Overview'.)
A microbiologic diagnosis also should be established if there appears to be a community outbreak [71] or ifan unusual pathogen is suspected, particularly if it requires treatment that differs from standard empiricregimens (eg, S. aureus including methicillinresistant strains, Mycobacterium tuberculosis). (See 'Criticalmicrobes' below.)
Children with mild disease who are treated as outpatients usually can be treated empirically, based on ageand other epidemiologic features, without establishing a microbiologic etiology [2,72]. (See "Communityacquired pneumonia in children: Outpatient treatment", section on 'Empiric therapy'.)
Microbiologic diagnosis can be established with culture, rapid diagnostic testing (enzyme immunoassay,immunofluorescence, PCR, or serology).
Cultures
Blood cultures – We suggest that blood cultures be performed in children with CAP who requireadmission to the hospital and in children with parapneumonic effusion or other complication [1,2,73].Although blood cultures are positive in at most 10 to 12 percent of children with pneumonia, whenpositive they help to confirm the etiologic diagnosis [7478]. The yield of blood cultures increases to 30to 40 percent in patients with a parapneumonic effusion or empyema [76,79,80]. The utility of bloodculture is limited when antibiotics are administered before obtaining the specimen. (See "Blood culturesfor the detection of bacteremia".)
Blood cultures are not necessary in children with CAP who will be treated as outpatients [1,7,74,81]. Inthe outpatient setting, the likelihood of a positive blood culture in children with CAP is less than 3percent [74,75].
Nasopharyngeal cultures – We do not suggest obtaining nasopharyngeal (NP) cultures for etiologicdiagnosis in children with pneumonia. Bacterial organisms recovered from the nasopharynx do notaccurately predict the etiology of pneumonia because bacteria that cause pneumonia also may benormal upper respiratory flora. The results of NP cultures for viruses and atypical bacterial althoughhelpful may not be available soon enough to assist with management decisions [7]. Rapid diagnostictests for viruses and atypical bacteria are discussed below. (See 'Rapid diagnostic tests' below.)
Sputum cultures – We suggest that sputum samples for Gram stain and culture be obtained in childrenwho require hospital admission if they are able to produce sputum [1]. Children younger than five yearsusually swallow sputum, so it is rarely available for examination. Goodquality sputum samples can beobtained by sputum induction [82]. However, sputum induction is unpleasant and not routinelynecessary because most children respond to empiric antimicrobial therapy. It may be beneficial inchildren who require intensivecare therapy, have a pleural effusion, or fail to respond to empirictherapy [82,83]. (See "Pneumonia in children: Inpatient treatment", section on 'Empiric therapy'.)
As a general guide, an appropriate sputum specimen for examination is one with ≤10 epithelial cellsand ≥25 polymorphonuclear leukocytes (PMN) under low power (x100) [84]. A predominantmicroorganism and/or intracellular organisms suggest the etiologic agent. When the following criteriaare used, the specificity of the Gram stain for identifying pneumococci has been shown to be 85percent, with a sensitivity of 62 percent: predominant flora or more than 10 Grampositive, lancetshaped diplococci per oil immersion field (x1000) (picture 4) [85].
Pleural fluid cultures – Diagnostic (and possibly therapeutic) thoracentesis generally is warranted for
11/11/2015 Community-acquired pneumonia in children: Clinical features and diagnosis
Rapid diagnostic tests — When available, rapid diagnostic tests, such as molecular testing using PCRtechniques and immunofluorescence, on NP specimens and blood can be helpful in the management ofinfants and children who are admitted to the hospital with probable pneumococcal, mixed bacterial/viral,viral, atypical bacterial CAP. The results of rapid diagnostic tests can be used to make decisions abouttreatment and cohorting of patients [1].
In prospective studies, PCR of blood and respiratory samples had a higher yield than culture for S.pneumoniae [8688]. Quantitative S. pneumoniae PCR testing of a nasopharyngeal specimen may behelpful if mixed viral/bacterial pneumonia is a concern [89].
The rapid diagnostic tests that are available for the following viral pathogens are discussed separately:
The use of rapid diagnostic tests for identification of pathogens in children with parapneumonic effusion isdiscussed separately. (See "Epidemiology; clinical presentation; and evaluation of parapneumonic effusionand empyema in children", section on 'Pleural fluid analysis'.)
Serology — We do not suggest routine serologic testing for specific pathogens (eg, S. pneumoniae, M.pneumoniae, C. pneumoniae) because the results usually do not influence management [7,90,91]. Serologicdiagnosis of viral pathogens is not practical because acute and convalescent specimens are needed. S.pneumoniae has too many potential infecting serotypes to make antibody determinations practical. Serologictests for Chlamydia spp are not readily available.
Although most older children with atypical pneumonia can be treated empirically for M. pneumoniae,serologic and PCR testing can be helpful in evaluating the younger child. These tests also may be helpful inestablishing the diagnosis of M. pneumoniae in patients with extrapulmonary manifestations, particularlycentral nervous system manifestations. (See "Mycoplasma pneumoniae infection in children", section on'Clinical features'.)
Other tests — Other tests that may be helpful in establishing less common microbiologic etiologies ofCAP in children include:
children with more than minimal pleural effusion. Specimens for culture of pleural fluid ideally should beobtained before administration of antibiotics. The evaluation of pleural fluid is discussed separately.(See "Epidemiology; clinical presentation; and evaluation of parapneumonic effusion and empyema inchildren", section on 'Pleural fluid analysis'.)
Respiratory syncytial virus (see "Respiratory syncytial virus infection: Clinical features and diagnosis",section on 'Diagnosis')
Influenza viruses (see "Seasonal influenza in children: Clinical features and diagnosis", section on'Diagnosis')
Parainfluenza viruses (see "Parainfluenza viruses in children", section on 'Diagnosis')
Adenovirus (see "Diagnosis, treatment, and prevention of adenovirus infection", section on'Pneumonia')
M. pneumoniae (see "Mycoplasma pneumoniae infection in children", section on 'Diagnosis')
Chlamydia spp (see "Pneumonia caused by Chlamydia species in children", section on 'Diagnosis')
Human metapneumovirus (see "Human metapneumovirus infections", section on 'Diagnosis')
Tuberculin skin and interferon gamma release assay if pulmonary tuberculosis is a consideration;additional diagnostic testing for tuberculosis in children is discussed separately (see "Tuberculosisdisease in children", section on 'Diagnosis')
Urine antigen testing for legionellosis due to serogroup 1 (see "Clinical manifestations and diagnosis ofLegionella infection", section on 'Urinary antigen testing')
11/11/2015 Community-acquired pneumonia in children: Clinical features and diagnosis
Invasive studies — Invasive procedures may be necessary to obtain lower respiratory tract specimensfor culture and other studies in children in whom an etiologic diagnosis is necessary and has not beenestablished by other means [1,9295]. These procedures are typically reserved for seriously ill patientswhose condition is worsening despite empiric therapy, or individuals with significant comorbidities (eg,immune compromise). They include [1,9294]:
Critical microbes — Some microbes are critical to detect because they require treatment that differsfrom standard empiric regimens or have public health implications. Diagnostic testing for these pathogens isdiscussed separately.
DIAGNOSIS — The diagnosis of pneumonia requires historical or physical examination evidence of anacute infectious process with signs or symptoms of respiratory distress or radiologic evidence of an acute
Serum and urine antigen testing for histoplasmosis (see "Diagnosis and treatment of pulmonaryhistoplasmosis", section on 'Antigen detection')
Urine antigen testing for S. pneumoniae in children should not be performed because of false positivereactions, some of which may merely indicate colonization with S. pneumoniae [1,2]
Bronchoscopy with bronchoalveolar lavage (BAL). Because the accurate identification of bacterialpathogens via bronchoscopy is hampered by specimen contamination with upper airway normal flora,quantitative culture techniques are utilized in many centers to differentiate true infection from upperairway contamination [9698].
Percutaneous needle aspiration of the affected lung tissue guided by computed tomography orultrasonography. A small study from Finland found that needle aspiration determined an infectiousetiology (21 bacteria and 2 viruses) in 20 of 34 patients (59 percent) studied and in 18 of 26 (69percent) of those in whom an adequate specimen was obtained [92]. Six patients developed apneumothorax, which spontaneously resolved over two to three days without intervention.
Lung biopsy either by a thoracoscopic or thoracotomy approach. Open biopsy yields diagnosticinformation that may affect medical management in up to 90 percent of patients [94]. In oneretrospective review, an infectious etiology was determined by open lung biopsy in 10 of 33 patientswith respiratory failure, eight of whom had a prior nondiagnostic BAL [93]. In another retrospectivereview, lung biopsy provided a definitive diagnosis in 25 of 50 immunocompromised patients, nine ofwhom had a prior nondiagnostic BAL [99].
Influenza A and B (see "Seasonal influenza in children: Clinical features and diagnosis", section on'Diagnosis')
Communityassociated methicillinresistant S. aureus (see "Methicillinresistant Staphylococcus aureusin children: Treatment of invasive infections", section on 'Pneumonia' and "MethicillinresistantStaphylococcus aureus infections in children: Epidemiology and clinical spectrum", section on'Epidemiology and risk factors')
M. tuberculosis (see "Tuberculosis disease in children")
Fungal etiologies (Coccidioides immitis, Blastomyces dermatitidis, Histoplasma capsulatum) (see"Primary coccidioidal infection" and "Mycology, pathogenesis, and epidemiology of blastomycosis" and"Treatment of blastomycosis" and "Diagnosis and treatment of pulmonary histoplasmosis")
Legionella species (see "Clinical manifestations and diagnosis of Legionella infection", section on'Specific laboratory diagnosis')
Avian influenza (see "Clinical manifestations and diagnosis of avian influenza", section on 'Diagnosis')
Hantavirus (see "Hantavirus cardiopulmonary syndrome")
Agents of bioterrorism (see "Identifying and managing casualties of biological terrorism")
11/11/2015 Community-acquired pneumonia in children: Clinical features and diagnosis
The diagnostic approach depends, to some extent, upon the setting and the severity of illness. In theappropriate clinical setting, the diagnosis can be made without radiographs. In children with severe illness,and in those who require hospital admission, the diagnosis should be confirmed with radiographs. Ifpossible, etiologic diagnosis should be established in children who require admission to the hospital and inthose who fail to respond to initial therapy. (See "Pneumonia in children: Inpatient treatment", section on'Overview'.)
Clinical diagnosis — The diagnosis of pneumonia should be considered in infants and children withrespiratory complaints, particularly cough, tachypnea, retractions, and abnormal lung examination [2,3,7].
The diagnosis of pneumonia can be made clinically in children with fever and historical or physicalexamination evidence of an infectious process with symptoms or signs of respiratory distress [7].Tachypnea, nasal flaring, grunting, retractions, crackles, and decreased breath sounds increase thelikelihood of pneumonia [4,9,30,100]. The absence of tachypnea is helpful in excluding pneumonia; theabsence of the other signs is not. (See 'Tachypnea' above.)
In developing countries where there is a high prevalence of pneumonia, a single positive respiratory signincreases the certainty of pneumonia [4]. The World Health Organization uses tachypnea (>60 breaths/minin infants <2 months; >50 breaths/min in infants 2 to 12 months; and >40 breaths/min in children 1 to 5years; and >20 breaths/min in children ≥5 years) as the sole criterion to define pneumonia in children withcough or difficulty breathing [15]. In developed countries with a lower prevalence of pneumonia, multiplerespiratory signs are necessary to increase the certainty of pneumonia [4,101].
Radiographic confirmation — An infiltrate on chest radiograph confirms the diagnosis of pneumonia inchildren with compatible clinical findings. Radiographs should be obtained in children in whom the diagnosisis uncertain and in those with severe, complicated, or recurrent pneumonia [1,2,102]. Radiographicconfirmation is not necessary in children with mild, uncomplicated lower respiratory tract infection who will betreated as outpatients. (See 'Indications' above.)
Radiographic findings cannot reliably distinguish between bacterial, atypical bacterial, and viral etiologies ofpneumonia. Radiographic findings should be used in conjunction with clinical and microbiologic data to maketherapeutic decisions [2,4]. (See "Communityacquired pneumonia in children: Outpatient treatment", sectionon 'Empiric therapy' and "Pneumonia in children: Inpatient treatment", section on 'Empiric therapy'.)
Etiologic diagnosis — The etiologic agent is suggested by host characteristics, clinical presentation,epidemiologic considerations, and, to some degree, the results of nonspecific laboratory tests and chestradiographic patterns (table 4). (See 'Clues to etiology' above and 'Etiologic clues' above and "Pneumonia inchildren: Epidemiology, pathogenesis, and etiology", section on 'Etiologic agents'.)
Specific microbiologic tests can be used to confirm the etiologic diagnosis. Confirmation of etiologicdiagnosis is not necessary in mildly ill patients who can be treated empirically in the outpatient setting.Confirmation of etiologic diagnosis should be attempted in children who are admitted to the hospital or aresuspected to be infected with an unusual pathogen, or a pathogen that requires treatment that differs fromstandard empiric regimens, so that therapy can be directed toward the appropriate pathogen. Etiologicdiagnosis also is necessary in children who fail to respond to initial therapy. (See 'Microbiology' above and'Critical microbes' above and "Pneumonia in children: Inpatient treatment", section on 'Empiric therapy'.)
DIFFERENTIAL DIAGNOSIS — Although pneumonia is highly probable in a child with fever, tachypnea,cough, and infiltrate(s) on chest radiograph, alternate diagnoses and coincident conditions must beconsidered in children who fail to respond to therapy or have an unusual presentation/course [7].
The Table lists a number of other conditions that can mimic an infectious pneumonia (table 6). History and/orassociated clinical features usually help to distinguish the conditions in the table from infectious pneumonia.In some cases, laboratory studies or additional imaging may be necessary.
11/11/2015 Community-acquired pneumonia in children: Clinical features and diagnosis
Foreign body aspiration must be considered in young children. The aspiration event may not have beenwitnessed. (See "Airway foreign bodies in children", section on 'Presentation'.)
Other causes of tachypnea, with or without fever and cough, in infants and young children include [103]:
These conditions usually can be distinguished from pneumonia by history, examination, and laboratory tests.
Lemierre syndrome (jugular vein suppurative thrombophlebitis) is an important consideration in adolescentsand young adults whose illness began with pharyngitis. In Lemierre syndrome, the vessels of the carotidsheath become infected (typically with Fusobacterium spp), leading to bacteremia and metastatic spread ofinfection to the lungs and mediastinum. (See "Suppurative (septic) thrombophlebitis", section on 'Jugularvein'.)
Communityacquired pneumonia (CAP) can be misdiagnosed in young children with asthma who have viralrespiratory infections [104]. Many such children have respiratory distress and may have hypoxemia. Thediagnosis of CAP and treatment with antibiotics must be carefully considered in young children who have aprodrome compatible with a viral respiratory infection and wheezing, even if there are pulmonary infiltrates(versus atelectasis) on chest radiograph. (See "Asthma in children younger than 12 years: Initial evaluationand diagnosis", section on 'Respiratory tract infections'.)
Rare, noninfectious lung diseases may present with an intercurrent infectious illness. Pulmonary alveolarproteinosis, eosinophilic pneumonia, acute interstitial pneumonitis, and cryptogenic organizing pneumoniaare entities that should be considered, especially if the acute illness is atypical or the radiographic andclinical findings do not resolve as expected with uncomplicated CAP. (See "Clinical manifestations andetiology of pulmonary alveolar proteinosis in adults" and "Idiopathic acute eosinophilic pneumonia" and"Acute interstitial pneumonia (HammanRich syndrome)" and "Cryptogenic organizing pneumonia".)
COMPLICATIONS — Bacterial pneumonias are more likely than atypical bacterial or viral pneumonias to beassociated with complications involving the respiratory tract. Complications of bacterial pneumonia includepleural effusion (image 1AB), empyema, pneumatoceles, necrotizing pneumonia (image 2), and lungabscesses.
Pleural effusion and empyema — The clinical features, evaluation, and management of parapneumoniceffusion and empyema in children are discussed separately. Hypoalbuminemia is common in children withparapneumonic effusions and hypogammaglobulinemia may be encountered. (See 'Blood tests' above and"Epidemiology; clinical presentation; and evaluation of parapneumonic effusion and empyema in children"and "Management and prognosis of parapneumonic effusion and empyema in children".)
Necrotizing pneumonia — Necrotizing pneumonia, necrosis, and liquefaction of lung parenchyma, is aserious complication of communityacquired pneumonia (CAP). Necrotizing pneumonia usually followspneumonia caused by particularly virulent bacteria [102]. S. pneumoniae (especially serotype 3 andserogroup 19) is the most common cause of necrotizing pneumonia (image 2) [105110]. Necrotizingpneumonia also may occur with S. aureus and group A Streptococcus and has been reported due to M.pneumoniae, Legionella, and Aspergillus. [110115].
Clinical manifestations of necrotizing pneumonia are similar to those of uncomplicated pneumonia, but theyare more severe [115117]. Necrotizing pneumonia should be considered in a child with prolonged fever orseptic appearance [102]. The diagnosis can be confirmed by chest radiograph (which demonstrates a
Bronchiolitis (see "Bronchiolitis in infants and children: Clinical features and diagnosis", section on'Clinical features')
Heart failure
Sepsis
Metabolic acidosis (see "Approach to the child with metabolic acidosis", section on 'Clinical evaluationand diagnosis')
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radiolucent lesion) (image 4) or contrastenhanced computed tomography (image 2) [118]; the findings onchest radiograph may lag behind those of computed tomography [113].
Pleural effusion/empyema generally accompanies necrotizing pneumonia whereas bronchopleural fistula,pneumatocele, or abscess formation (which typically is insidious) is much less common. Drainage of thepleural fluid collection is frequently required but pneumonectomy is rarely needed. (See 'Pneumatocele'below and 'Lung abscess' below.)
Treatment of necrotizing pneumonia is discussed separately. (See "Pneumonia in children: Inpatienttreatment", section on 'Complicated CAP'.)
Lung abscess — A lung abscess is an accumulation of inflammatory cells, accompanied by tissuedestruction or necrosis that produces one or more cavities in the lung [45]. Aspiration is the most importantpredisposing factor for lung abscess, which may develop one to two weeks after the aspiration event; otherpredisposing factors include airway obstruction and congenitally abnormal lung [45]. S. aureus is theorganism most frequently involved [103].
Clinical manifestations of lung abscess are nonspecific and similar to those of pneumonia [45]. They includefever, cough, dyspnea, chest pain, anorexia, hemoptysis, and putrid breath [45,102,119121]. The coursemay be indolent.
The diagnosis is suggested by a chest radiograph demonstrating a thickwalled cavity with an airfluid level(image 4) [45], and confirmed by contrastenhanced computed tomography [118]. Lung abscess is oftenaccompanied by parapneumonic effusion [122,123]. Lung abscess should be suspected when consolidationis unusually persistent, when pneumonia remains persistently round or masslike, and when the volume ofthe involved lobe is increased (as suggested by a bulging fissure) [45,124].
Interventional radiology may be helpful in obtaining a specimen from the abscess cavity for diagnosticstudies. Treatment of lung abscess is discussed separately. (See "Pneumonia in children: Inpatienttreatment", section on 'Complicated CAP'.)
The most common complication of lung abscess is intracavitary hemorrhage. This can cause hemoptysis orspillage of the abscess contents with spread of infection to other areas of the lung [116]. Other complicationsof lung abscess include empyema, bronchopleural fistula, septicemia, cerebral abscess, and inappropriatesecretion of antidiuretic hormone [116].
Pneumatocele — Pneumatoceles are thinwalled, aircontaining cysts of the lungs. They are classicallyassociated with S. aureus, but may occur with a variety of organisms [125,126]. Pneumatoceles frequentlyoccur in association with empyema [125]. In most cases, pneumatoceles involute spontaneously, and longterm lung function is normal [125,127,128]. However, on occasion, pneumatoceles result in pneumothorax[126].
Hyponatremia — Hyponatremia (serum sodium concentration ≤135 meq/L) occurs in approximately 45percent of children with CAP and onethird of children hospitalized with CAP, but is usually mild [129131].Inappropriate secretion of antidiuretic hormone (ADH) is the most frequent cause [129,130]. Hyponatremia isassociated with increased length of hospital stay, complications, and mortality. (See "Pathophysiology andetiology of the syndrome of inappropriate antidiuretic hormone secretion (SIADH)", section on 'Pulmonarydisease'.)
INDICATIONS FOR HOSPITALIZATION — Indications for hospitalization are discussed separately. (See"Pneumonia in children: Inpatient treatment", section on 'Indications'.)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics”and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5 to 6grade reading level, and they answer the four or five key questions a patient might have about a givencondition. These articles are best for patients who want a general overview and who prefer short, easytoread materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more
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11/11/2015 Community-acquired pneumonia in children: Clinical features and diagnosis
detailed. These articles are written at the 10 to 12 grade reading level and are best for patients who wantindepth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or emailthese topics to your patients. (You can also locate patient education articles on a variety of subjects bysearching on “patient info” and the keyword(s) of interest.)
SUMMARY AND RECOMMENDATIONS
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Basics topic (see "Patient information: Pneumonia in children (The Basics)")
The presenting signs and symptoms of communityacquired pneumonia (CAP) are nonspecific; nosingle symptom or sign is pathognomonic for pneumonia in children. The combination of fever andcough is suggestive of pneumonia, but the presentation may be subtle, or misleading (eg, abdominalpain or nuchal rigidity). (See 'Clinical presentation' above.)
The history should focus on features that can help to define the clinical syndrome (eg, pneumonia,bronchiolitis) and narrow the list of potential pathogens (table 1). (See 'History' above and "Pneumoniain children: Epidemiology, pathogenesis, and etiology", section on 'Etiologic agents'.)
Examination findings that have been correlated with radiographic pneumonia include tachypnea,increased work of breathing (retractions, nasal flaring, grunting, use of accessory muscles), hypoxemia,and adventitious lung sounds. Combinations of findings are more predictive than single findings. Theabsence of tachypnea is useful in excluding pneumonia. (See 'Examination' above.)
The history and examination are used to determine the severity of illness (table 3), which determines,in part, the need for radiologic and laboratory evaluation. (See 'Severity assessment' above.)
Neither clinical nor radiologic features reliably distinguish between bacterial, atypical bacterial, and viralpneumonia. (See 'Clues to etiology' above and 'Etiologic clues' above.)
Radiographs are not necessary for children with pneumonia who are well enough to be treated asoutpatients. We suggest that chest radiographs be obtained for the following indications:
Severe disease (table 3) (see 'Severity assessment' above)•
Confirmation of the diagnosis when clinical findings are inconclusive•
Exclusion of alternate explanations for respiratory distress (see 'Differential diagnosis' above)•
Evaluation for complications (see 'Complications' above)•
Exclusion of occult pneumonia in young children (3 to 36 months) with fever >39ºC (102.2°F),leukocytosis (white blood cell count >20,000/microL), and no obvious focus of infection (see'Radiologic evaluation' above)
•
Routine laboratory evaluation is not necessary for children with clinical evidence of mild uncomplicatedlower respiratory tract infection who will be treated as outpatients unless the findings will help indeciding whether antimicrobial therapy is necessary. (See 'Laboratory evaluation' above.)
We recommend that attempts be made to establish an etiologic diagnosis in children with CAP whorequire hospital admission. A complete blood count with differential and blood culture should beobtained in all such patients. If produced, a good quality sputum should be submitted for Gram stainand culture. Other specimens for microbiologic testing should be obtained as indicated by the clinicalscenario. (See 'Microbiology' above.)
Attempts also should be made to establish (or exclude) an etiologic diagnosis in patients suspected tohave CAP caused by pathogens that require treatment regimens that differ from standard empiricregimens (eg, influenza, communityassociated methicillinresistant Staphylococcus aureus,Mycobacterium tuberculosis, fungi, Legionella, hantavirus). (See 'Critical microbes' above.)
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Important aspects of the history in a child with pneumonia
Historical feature Possible significance
Age of the child Viral etiologies are most common in infants and preschoolchildren
Atypical bacterial pathogens are more common in schoolagechildren
Recent viral upperrespiratory tract infection
May predispose to bacterial superinfection with Streptococcuspneumoniae or Staphylococcus aureus
Associated symptoms Mycoplasma pneumoniae is often associated withextrapulmonary manifestations (eg, headache, photophobia,rash)
Cough, chest pain,shortness of breath,difficulty breathing
"Classic" features of pneumonia, but nonspecific
Increased work ofbreathing in the absenceof stridor or wheezing
Suggestive of severe pneumonia
Choking episode May indicate foreign body aspiration
Duration of symptoms Chronic cough (>4 weeks) suggests etiology other than acutepneumonia (refer to UpToDate topic on causes of chronic coughin children)
Previous episodes Recurrent episodes may indicate aspiration, congenital oracquired anatomic abnormality, cystic fibrosis,immunodeficiency, asthma, missed foreign body
Immunization status Completion of the primary series of immunizations forHaemophilus influenzae type b, Streptococcus pneumoniae,Bordetella pertussis, and seasonal influenza decreases, but doesnot eliminate, the risk of infection with these organisms
Previous antibiotic therapy Increases the likelihood of antibioticresistant bacteria
Maternal history ofchlamydia duringpregnancy (for infants <4months of age)
May indicate Chlamydia trachomatis infection
Exposure to tuberculosis May indicate Mycobacterium tuberculosis infection
Ill contacts More common with viral etiologies
Travel to or residence incertain areas that suggestendemic pathogens
Measles: Developing world
Coccidioidomycosis: Southwestern US, northern Mexico, Centraland South America
Blastomycosis: Southeastern and central US; states borderingthe Great Lakes
Histoplasmosis: Ohio, Missouri, and Mississippi River valleys inthe United States; Canada; Central America; eastern and
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Important aspects of the physical examination in a child withsuspected pneumonia
Examinationfeature
Possible significance
Generalappearance (stateof awareness,cyanosis)*
Most children with radiographically confirmed pneumonia appear ill
Vital signs
Temperature Fever may be the only sign of pneumonia in highly febrile youngchildren; however, it is variably present and nonspecific
Respiratory rate Tachypnea correlates with radiographically confirmed pneumonia andhypoxemia
Absence of tachypnea helps to exclude pneumonia
Degree ofrespiratorydistress
Respiratory distress is more specific than fever or cough for lowerrespiratory infection
Tachypnea
Hypoxemia Predictive of pneumonia
Increased work of breathing:
Retractions More common in children with pneumonia than without; absence does not
exclude pneumonia
Nasal flaring More common in children with pneumonia than without; absence does not
exclude pneumonia
Grunting Sign of severe disease and impending respiratory failure
Accessory
muscle use
Sign of severe disease
Head bobbing Sign of severe disease
Lung examination
Cough Nonspecific finding of pneumonia
Auscultation Findings suggestive of pneumonia include: crackles (rales,crepitations), decreased breath sounds, bronchial breath sounds,egophany, bronchophony, and whispered pectoriloquy
Wheezing more common in viral and atypical pneumonias
Tactile fremitus Suggestive of parenchymal consolidation
Dullness topercussion
Suggestive of parenchymal consolidation or pleural effusion
Mental status Altered mental status may be a sign of hypoxia
* For young infants: Ability to attend to the environment, feed, vocalize, and be consoled.¶ World Health Organization definitions of tachypnea according to age are as follows: <2 months:>60 breaths/min; 2 to 12 months: >50 breaths/min; 1 to 5 years: >40 breaths/min; ≥5 years:
¶
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Fungal Appropriate geographic or environmentalexposure
Mediastinal or hilaradenopathy
Mycobacteriumtuberculosis
Children of any ageChronic cough
Constitutional symptomsExposure history
Mediastinal or hilaradenopathy
WBC: white blood cell; CBC: complete blood count.* The clinical features frequently overlap and cannot reliably distinguish between bacterial, atypicalbacterial, and viral etiologies; up to onehalf of communityacquired pneumonias in children may bemixed bacterial/viral infections. Chest radiography generally is not helpful in determining thepotential causative agent of pneumonia. Nonetheless, these features may facilitate decisionsregarding empiric therapy.
Data from: 1. Bartlett JG, Mundy LM. Communityacquired pneumonia. N Engl J Med 1995; 333:1618.
2. Boyer KM. Nonbacterial pneumonia. In: Textbook of Pediatric Infectious Diseases, 6th ed,
Vesicular lesions on an erythematous base are characteristic ofchickenpox. The lesions occur in crops and are present in a variety ofstages from maculopapular to vesicular or even pustular. Centralnecrosis and early crusting is also visible.
Courtesy of Lee T Nesbitt, Jr. The Skin and Infection: A Color Atlas and Text,Sanders CV, Nesbitt LT Jr (Eds), Williams & Wilkins, Baltimore 1995.
http://www.lww.comGraphic 55533 Version 5.0
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Suggested criteria for full Haemophilus influenza type b andStreptococcus pneumoniae immunization status when consideringempiric antibiotics for community acquired pneumonia in children
Current age* Criteria for full immunization
Haemophilus influenzae type b
12 to 15 months ≥2 doses of Hib conjugate vaccine, with at
least one dose at ≥12 months of age
15 months to 5 years ≥2 doses of Hib conjugate vaccine, with at
least one dose at ≥12 months of age, or
≥1 dose of Hib conjugate vaccine at ≥15
months of age
≥5 years, not high risk Hib immunization not necessary
Streptococcus pneumoniae
12 to 24 months ≥3 doses of PCV at <16 months, with ≥1
dose at ≥12 months, or
2 doses of PCV, both at ≥12 months
24 months through 5 years ≥3 doses of PCV at <16 months, with ≥1
dose at ≥12 months, or
2 doses of PCV, both at ≥12 months, or
≥1 dose of PCV at ≥24 months
>5 years, not high risk PCV immunization not necessary
Hib: Haemophilus influenzae type b; PCV: pneumococcal conjugate vaccine.
* Children younger than 12 months are incompletely immunized against Hib and S. pneumoniae.
¶ Immunizations must be completed at least two weeks before pneumonia diagnosis.
Δ Children at high risk for invasive Hib disease include chemotherapy recipients and those with
anatomic or functional asplenia (including sickle cell disease), human immunodeficiency virus (HIV)
infection, immunoglobulin deficiency, or early component complement deficiency. Please refer to the
UpToDate topic on prevention of Haemophilus influenzae infection for a discussion of full Hib
immunization in children at high risk for invasive Hib disease.
◊ Children at high risk for invasive S. pneumoniae disease include those with chronic heart disease
Gram stain of sputum (x1000) shows abundant inflammatory cells andgrampositive diplococci; Streptococcus pneumoniae was identified fromthis specimen by culture and by the optochin disk test.
Courtesy of Harriet Provine.
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Radiographic images of the complications of pneumococcal pneumonia.(Left panel) Lung abscess with an airfluid level in the right lung. Abscesscavity material is nearly always culture positive, and patients commonlydefervesce within 48 hours of interventional drainage.(Right panel) Radiograph of necrotizing pneumonia in the left lung.
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[vaccine (PCV13)]. George B Mallory, MD Nothing to disclose. Mary M Torchia, MD Nothing to disclose.Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting
through a multilevel review process, and through requirements for references to be provided to support the content. Appropriately
referenced content is required of all authors and must conform to UpToDate standards of evidence.