Induced sputum in the diagnosis of childhood community-acquired pneumonia.

BACKGROUND: The usefulness of induced sputum in searching for causative agents of pneumonia in children has not been studied. METHODS: The study involved 101 children, aged 6 months to 15 years, treated for community-acquired pneumonia at Turku University Hospital (Turku, Finland) from January 2006 to April 2007. Nasopharyngeal aspirate samples were first collected through both nostrils. Sputum production was then induced by inhalation of 5.0% hypertonic saline for 5-10 min and a sputum sample was either aspirated or expectorated. The presence and amount of bacteria and viruses in paired nasopharyngeal aspirate and sputum specimens was analysed and compared using semiquantitative bacterial culture and quantitative PCR techniques. RESULTS: A good quality sputum specimen was obtained from 76 children. The possible causative agent was found in 90% of cases. Streptococcus pneumoniae (46%) and rhinovirus (29%) were the most common microbes detected. Newly discovered viruses human bocavirus and human metapneumovirus were detected in 18% and 13% of the children, respectively. One-quarter of all bacterial findings were only detected in sputum, and the amount of bacteria in the remainder of the sputum specimens compared with nasopharyngeal aspirate was higher in 14% and equal in 70%. The amount of rhinovirus in sputum was higher than in nasopharyngeal aspirate in 82%. CONCLUSIONS: Sputum induction provides good quality sputum specimens with high microbiological yield in children with community-acquired pneumonia. Induced sputum analysis can be useful in the microbiological diagnosis of childhood community-acquired pneumonia.

Bacterial coinfections in children with viral wheezing.

Bacterial coinfections occur in respiratory viral infections, but the attack rates and the clinical profile are not clear. The aim of this study was to determine bacterial coinfections in children hospitalized for acute expiratory wheezing with defined viral etiology. A total of 220 children aged 3 months to 16 years were investigated. The viral etiology of wheezing was confirmed by viral culture, antigen detection, serologic investigation, and/or PCR. Specific antibodies to common respiratory bacteria were measured from acute and convalescent serum samples. All children were examined clinically for acute otitis media, and subgroups of children were examined radiologically for sinusitis and pneumonia. Rhinovirus (32%), respiratory syncytial virus (31%), and enteroviruses (31%) were the most common causative viruses. Serologic evidence of bacterial coinfection was found in 18% of the children. Streptococcus pneumoniae (8%) and Mycoplasma pneumoniae (5%) were the most common causative bacteria. Acute otitis media was diagnosed in 44% of the children. Chest radiographs showed alveolar infiltrates in 10%, and paranasal radiographs and clinical signs showed sinusitis in 17% of the older children studied. Leukocyte counts and serum C-reactive protein levels were low in a great majority of patients. Viral lower respiratory tract infection in children is often associated with bacterial-type upper respiratory tract infections. However, coexisting bacterial lower respiratory tract infections that induce systemic inflammatory response are seldom detected.

Radiographic follow-up of pneumonia in children.

This study assessed the clinical value of routine follow-up chest radiographs in hospitalized children with community-acquired pneumonia. The study population consisted of 196 children hospitalized for community-acquired pneumonia diagnosed between 1993-1995. Seventeen infective agents (10 viruses and 7 bacteria) were sought. Chest radiographs were taken on admission and 3-7 weeks later. All children were treated with antibiotics. Data on the course of illness over the following 8-10 years were obtained from patient files and questionnaires sent to parents. A potential causative agent was found in 165 (84%) of 196 cases. On follow-up chest radiographs, residual or new changes were seen in 30% of cases. The residual changes tended to be more common after mixed viral-bacterial infection (43%) than after sole viral (25%) or sole bacterial (20%) infection. Interstitial infiltrates (66%), atelectasis (46%), and enlarged lymph nodes were the most common sequelae seen on follow-up. Residual findings on follow-up radiographs did not affect the treatment of the children. No further chest radiographs were taken. During the 8-10-year follow-up of 194 children, no illnesses appeared that were associated with previous pneumonia. Twenty-six children had a new episode of pneumonia, 7 of them had asthma, and 6 had different underlying illnesses. In conclusion, routine follow-up chest radiographs are not needed in childhood community-acquired pneumonia if the child has a clinically uneventful recovery.

Differentiation of bacterial and viral pneumonia in children.

BACKGROUND: A study was undertaken to investigate the differential diagnostic role of chest radiographic findings, total white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and serum C reactive protein (CRP) in children with community acquired pneumonia of varying aetiology. METHODS: The study population consisted of 254 consecutive children admitted to hospital with community acquired pneumonia diagnosed between 1993 and 1995. WBC, ESR, and CRP levels were determined on admission. Seventeen infective agents (10 viruses and seven bacteria) were searched for. Chest radiographs were retrospectively and separately reviewed by three paediatric radiologists. RESULTS: A potential causative agent was found in 215 (85%) of the 254 cases. Bacterial infection was found in 71% of 137 children with alveolar infiltrates on the chest radiograph, while 72% of the 134 cases with a bacterial pneumonia had alveolar infiltrates. Half of the 77 children with solely interstitial infiltrates on the chest radiograph had evidence of bacterial infection. The proportion of patients with increased WBC or ESR did not differ between bacterial and viral pneumonias, but differences in the CRP levels of >40 mg/l, >80 mg/l, and >120 mg/l were significant although the sensitivity for detecting bacterial pneumonia was too low for use in clinical practice. CONCLUSIONS: Most children with alveolar pneumonia, especially those with lobar infiltrates, have laboratory evidence of a bacterial infection. Interstitial infiltrates are seen in both viral and bacterial pneumonias.

Clinical profile of serologically diagnosed pneumococcal pneumonia.

OBJECTIVE: To describe the characteristics of serologically diagnosed pneumococcal pneumonia and compare them with those of respiratory syncytial virus (RSV) pneumonia and bacteremic pneumococcal pneumonia. METHODS: IgG antibodies to pneumococcal pneumolysin and C-polysaccharide as well as immune complexes containing IgG antibodies to pneumolysin and C-polysaccharide were measured from acute and convalescent sera of 254 children with community-acquired pneumonia. Evidence of pneumococcal infection was found in 93 children. Clinical and laboratory data were retrospectively collected from the records of 38 children with sole (all tests for 16 other microbes negative) pneumococcal pneumonia and compared with 26 sole RSV-induced pneumonia from the present series and with the data of our 85 bacteremic pneumococcal pneumonia cases reported earlier. RESULTS: Serologically diagnosed sole pneumococcal pneumonia clinically overlapped with RSV pneumonia, but RSV pneumonia was more often associated with tachypnea (45% vs. 17%, P < 0.05) and low white blood cell counts (means, 12.0 x 109/l vs. 20.8 x 109/l; P < 0.001) as well as low serum C-reactive protein levels (means, 28 mg/l vs. 137 mg/l; P < 0.001). Alveolar infiltrates were found in 15% of chest radiographs of children with RSV pneumonia compared with 76% of those in children with sole pneumococcal pneumonia (P < 0.001). Patients with bacteremic pneumonia more often appeared ill (79% vs. 50%, P < 0.001) and more often had typical pneumococcal pneumonia with high fever, leukocytosis and lobar infiltrates in their chest radiographs (70% vs. 34%, P < 0.05) than those with serologically diagnosed pneumococcal pneumonia. CONCLUSIONS: Serologically detected pneumococcal pneumonia differs significantly from RSV pneumonia in laboratory and chest radiography findings, but the clinical signs and symptoms overlap considerably. Bacteremic pneumococcal pneumonia is a more severe illness than the serologically diagnosed one.

Streptococcus pneumoniae and Mycoplasma pneumoniae coinfection in community acquired pneumonia.

The characteristics of nine children with community acquired pneumonia with evidence of Streptococcus pneumoniae and Mycoplasma pneumoniae coinfection are described.

Serum procalcitonin, C-reactive protein and interleukin-6 for distinguishing bacterial and viral pneumonia in children.

OBJECTIVE: Serum procalcitonin (PCT), C-reactive protein (CRP) and interleukin-6 (IL-6) concentrations were measured in 126 children hospitalized for community-acquired, radiologically confirmed pneumonia to assess whether these host response values could be used to distinguish bacterial from viral pneumonia. METHODS: The samples for PCT, CRP and IL-6 measurements were obtained on admission or the first day of hospitalization. The etiology of pneumonia was studied with an extensive panel of methods that detected 6 bacteria and 11 viruses. RESULTS: In all, 54% had evidence of bacterial pneumonia, and 32% had evidence of sole viral pneumonia. In 14% of the cases the etiology could not be determined. Children with bacterial pneumonia had significantly higher PCT (median 2.09 ng/ml vs. 0.56 ng/ml, P = 0.019) and CRP concentrations (96 mg/l vs. 54 mg/l, P = 0.008) than those with sole viral etiology. However, the values markedly overlapped. No significant difference in IL-6 concentrations was seen between the two patient groups. Using PCT > or = 2.0 ng/ml, CRP > or = 150 mg/l or IL-6 > or = 40 pg/ml, the specificity was > or =80% for bacterial pneumonia. The sensitivities with these cutoff values were 50% for PCT, 31% for CRP and 34% for IL-6. CONCLUSIONS: The results indicate that the measurement of serum PCT, CRP and IL-6 has little value in the differentiation of bacterial and viral pneumonia in children. However, in some patients with very high serum PCT, CRP or IL-6 values, bacterial pneumonia is probable.

Bacteremic pneumococcal pneumonia in children.

We carried out a nationwide retrospective study on bacteremic pneumococcal pneumonia diagnosed from 1985 to 1994 in Finland. The records of 85 children were reviewed for symptoms, signs, laboratory data, and response to antibiotic therapy. The chest radiographs were reevaluated. Bacteremic pneumococcal pneumonia was characterized by high fever (> or =39.0 degrees C in 93%), leukocytosis (WBC count on admission of > or =15x10(9)/L in 84%), and ill appearance (in 79%). Lobar or segmental consolidation was found in 79% of the chest radiographs. Of the patients, 28% had no respiratory symptoms, 6% presented with only gastrointestinal symptoms in addition to fever, and 4% had fever only. Tachypnea was recorded in 19% and rales in 14% of the patients. After onset of antimicrobial treatment, children became afebrile within an average of 22 hours. One patient developed pleural empyema, and none of the patients died.

Exercise thallium-201 scintigraphy in the localization of myocardial ischaemia.

We performed a retrospective study in order to study the ability of thallium-201 exercise scintigraphy to detect and to localize coronary artery perfusion defects (in comparison with a recent coronary angiogram). We studied 81 patients (67 males); their average age was 52.3 years (men 50.5 and women 54.1 years). They performed a pulse-conducted cycle exercise test, and 2 min before end of exercise 75 MBq of thallium-201 was infused intravenously, and tomographic images were reconstructed by using a Siemens-Rota SPECT gamma camera immediately and 4 h after exercise. The thallium-201 uptake defects were attributed to different coronary arteries, and the results were compared with a coronary angiogram made afterwards in 48 patients. The groups of one-, two- and three-vessel disease were 27, 21, and 21 patients, and only 12 patients did not have significant (over 50%) stenoses. The latter had the highest ejection fraction and working capacity. Sensitivity of thallium-201 exercise scintigraphy was 65%, whereas that of exercise ECG was 41% in patients with a low ejection fraction, while in the whole material the sensitivity of thallium-201 scintigraphy was 91% and that of exercise ECG was 54%. A stenosis in the right coronary artery was best localized by the thallium-201 scintigram (86% correctly); a stenosis in the left anterior descending artery was localized correctly in 75% of the cases, but a stenosis in left circumflex artery was localized correctly only in 44%. We conclude that exercise thallium-201 scintigraphy is a useful method not only in detecting but also in localizing coronary artery disease.

Low residual diet and hydration improving double contrast examination of the colon.

Light food diet and low residual diet with hydration, both combined with Proctosal and Bisacodyl cleansing, were compared in 268 patients in the preparation of the colon for double contrast examination. Low residual diet with hydration resulted in significantly less residual fecal material, no flocculation of the barium coating and significantly denser mucosal coating. The examination had to be repeated more often (8.6%) after light food diet than after low residual diet with hydration (1.7%), but there was no statistically significant difference in the diagnostic accuracy. The hydration is important in avoiding patient discomforts and flocculation of the barium coating. Despite the use of laxatives, a strict diet restriction is needed to obtain consistently clean colon.

Dimethylpolysiloxane as an adjuvant in double-contrast barium enema.

The value of Dimethylpolysiloxane (Simethicone) in the reduction of gas bubbles and foam formation, and in the prevention of flocculation of contrast medium during the double-contrast barium enema examination is presented. Altogether 600 unselected patients were studied, 300 with barium suspension diluted with 10 vol % of distilled water only, and 300 with the same suspension into which dimethylpolysiloxane was added. Simethicone significantly reduced gas bubbles and foam formation. It also prevented flocculation and cracking of mucosal coating, while it had no effect on the density of mucosal coating.