Necrotizing pneumonia in children: Report of 25 cases between 2008 and 2018 at a French tertiary care center.

BACKGROUND: Necrotizing pneumonia (NP) is a serious and rare disease in children. Pediatric data on NP are limited and the impact of the 13-valent pneumococcal conjugate vaccine has been very poorly evaluated. PATIENTS AND METHODS: We conducted a retrospective study at Toulouse University Hospital between 2008 and 2018. Children who presented with thin-walled cavities in the areas of parenchymal consolidation on imaging were included in the study. RESULTS: The incidence of NP did not decrease during this period. Bacterial identification occurred in 56% of cases (14/25) and included six cases of Streptococcus pneumoniae, five of Staphylococcus aureus, two of Streptococcus pyogenes, and one of Streptococcus viridans. Streptococcus pneumoniae NP are more frequently associated with empyema/parapneumonic effusion compared to S. aureus NP (p = 0.02). Patients with S. pyogenes NP more often required volume expansion than did S. pneumoniae cases (p = 0.03). When comparing children born before and after implementation of the 13-valent pneumococcal conjugate vaccine, we identified a relative modification of the bacterial epidemiology, with an increase in the proportion of S. pyogenes NP and S. aureus NP and a decrease in the proportion of NP caused by S. pneumoniae. CONCLUSION: Future studies are needed to assess the epidemiology of NP in children. Continued surveillance of identified pneumococcal serotypes is essential to document epidemiological changes in the coming years.

Early predictors of lung necrosis severity in children with community-acquired necrotizing pneumonia.

OBJECTIVE: To analyze baseline clinical and laboratory characteristics and explore the possible predictors of lung necrosis severity in children with community-acquired necrotizing pneumonia (NP). METHODOLOGY: This retrospective observational study was performed in a tertiary referral center. A total of 104 patients aged <15 years with community-acquired pneumonia and radiologically confirmed NP by computed tomography (CT) were included. Patients were classified into the mild, moderate, or massive necrosis groups. RESULTS: Among them, 29, 41, and 34 patients had mild, moderate, and massive necrosis, respectively. Moreover, 34.6% of the patients were admitted to pediatric intensive care unit. Massive necrosis was more likely to occur during winter (p < 0.05) and was associated with more severe clinical outcomes, such as longer duration of fever, longer hospitalization, increased mortality, and a higher risk of subsequent surgical intervention (p < 0.05). Multivariate analysis demonstrated that the following were independent risk factors for massive necrosis in this study: C-reactive protein (CRP) (p = 0.036), serum albumin (p = 0.009), and immunoglobulin M (IgM) (p = 0.022). Receiver operating characteristic analysis showed that when the cut-off value for CRP, serum albumin, and IgM were set at 122 mg/L, 30.8 g/L, and 95.7 mg/dl, respectively, they showed good diagnostic performance for differentiating patients with massive necrosis from all patients with NP. CONCLUSION: NP is a potentially severe complication of pediatric community-acquired pneumonia. Different severities of lung necrosis can lead to different clinical outcomes. CRP, serum albumin, and IgM levels are independent predictors of the degree of lung necrosis.

A case of methicillin resistant Staphylococcus aureus necrotizing pneumonia with pulmonary cryptococcosis.

A 37-year-old healthy man was transferred to the emergency department of this hospital because of fever and hemoptysis. A radiograph of the chest revealed a cavitary lesion in the right upper lobe. Computed tomography of the chest showed necrotizing cavitary pneumonia. Urgent throacoscopic lobectomy was performed. Sputum and intraoperative pleural pus grew methicillin resistant Staphylococcus aureus (MRSA). The pathological examination reportedly revealed cryptococcal infection. He had a full recovery after intravenous linezolid treatment.

Anaerobic Necrotizing Pneumonia: Another Potential Life-threatening Complication of Vaping?

An adolescent girl with a history of frequent electronic cigarette use of nicotine was hospitalized with severe necrotizing pneumonia. Blood cultures obtained before the administration of empirical broad-spectrum intravenous antibiotics had positive results for the growth of Fusobacterium necrophorum The pathogen is an uncommon but well-known cause of anaerobic pneumonia with unique features that are collectively referred to as Lemierre syndrome or postanginal sepsis. The syndrome begins as a pharyngeal infection. Untreated, the infection progresses to involve the ipsilateral internal jugular vein, resulting in septic thrombophlebitis with direct spread from the neck to the lungs causing multifocal necrotizing pneumonia. The teenager we present in this report had neither a preceding pharyngeal infection nor Doppler ultrasonographic evidence for the presence of deep neck vein thrombi, leading us to explore alternative mechanisms for her pneumonia. We propose the possibility that her behavior of frequent vaping led to sufficient pharyngeal irritation such that F necrophorum colonizing her oropharynx was inhaled directly into her lungs during electronic cigarette use. Preexisting, but not yet recognized, vaping-related lung injury may have also contributed to her risk of developing the infection. The patient was hospitalized for 10 days. At follow-up one month later, she still became short of breath with minimal exertion.

Necrotizing pneumonia (aetiology, clinical features and management).

PURPOSE OF REVIEW: Necrotizing pneumonia is a severe form of community-acquired pneumonia characterized by rapid progression of consolidation to necrosis and cavitation which may lead to pulmonary gangrene. Morbidity and mortality are high and chronic sequelae are frequent. The lack of guidance supports the review of the latest recommendations in the management of these pneumonias. RECENT FINDINGS: Antibiotic therapy alone may not be enough to alter the course of the infection, and regimens, adjunctive therapies like intravenous immunoglobulins, surgery may be required to alter the course of the disease especially with pulmonary gangrene. SUMMARY: The causative agents, clinical features and management of necrotizing pneumonias are discussed.

Portable CT Pulmonary Angiogram in an Infant on Veno-Arterial Extracorporeal Membrane Oxygenation in the Pediatric Intensive Care Unit.

PURPOSE: Computed tomography (CT) has been shown to change management in children on extracorporeal membrane oxygenation (ECMO). Although techniques have been described to transport these critically ill patients to the CT suite in the radiology department, transport out of the intensive care setting is not without risk, and using portable CT is a practical alternative. However, obtaining a CT pulmonary angiogram (CTPA) in a patient on veno-arterial (VA) ECMO presents unique challenges due to bypass of the cardiopulmonary system, which may lead to suboptimal opacification of the pulmonary arteries. METHODS: We describe a method to obtain a diagnostic CTPA study in an infant on VA ECMO in the intensive care unit using portable CT. Our solution involved temporary withholding ECMO and using the venous cannula to deliver a compact contrast bolus to the right atrium to adequately opacify the pulmonary arteries. Special attention was given to the delivery of the contrast bolus, which was given by hand injection, to ensure it coincided with image acquisition and minimized the time ECMO was withheld. RESULTS: We were able to successfully obtain a diagnostic CTPA study in an infant on VA ECMO in the intensive care unit using portable CT. CONCLUSION: This case demonstrates that in select instances CTPA in infants on VA ECMO can be achieved using a portable CT system.

Rapidly Progressive Multiple Cavity Formation in Necrotizing Pneumonia Caused by Community-acquired Methicillin-resistant Staphylococcus aureus Positive for the Panton-Valentine Leucocidin Gene.

A 66-year-old man was transferred to our hospital for pneumonia that was resistant to sulbactam/ampicillin and levofloxacin therapy. Chest computed tomography showed the rapidly progressive formation of multiple cavities. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated, and the patient was diagnosed with necrotizing pneumonia caused by community-acquired MRSA (CA-MRSA). The MRSA strain had type IV staphylococcus cassette chromosome mec and genes encoding Panton-Valentine leucocidin (PVL). CA-MRSA necrotizing pneumonia with the PVL gene is rare; only three cases have been previously reported in Japan. We administered anti-MRSA antibiotics and the patient achieved complete clinical and radiological improvement.

Necrotizing Pneumonia Caused by Chromobacterium violaceum: Report of a Rare Human Pathogen Causing Disease in an Immunodeficient Child.

Chromobacterium violaceum is a rare, potentially serious pathogen. Most clinicians have no experience with its clinical appearance or treatment. We describe a case of a child presenting with necrotizing pneumonia caused by C. violaceum. We describe case complexities, including the need for a multidisciplinary approach to diagnosis and treatment.

Necrotising pneumonia caused by non-PVL Staphylococcus aureus with 2-year follow-up.

Necrotising pneumonia (NP) is a rare but life-threatening complication of pulmonary infection. It is characterised by progressive necrosis of lung parenchyma with cavitating foci evident upon radiological investigation. This article reports the case of a 52-year-old woman, immunocompetent healthcare professional presenting to Accident and Emergency with NP and Staphylococcus aureus septicaemia. The cavitating lesion was not identified on initial chest X-ray leading to a delay in antimicrobial optimisation. However, the patient went on to achieve a full symptomatic recovery in 1 month and complete radiological recovery at 2-year follow-up. Long-term prognosis for adult cases of NP currently remains undocumented. This case serves as the first piece of published evidence documenting full physiological and radiological recovery following appropriate treatment of NP in an immunocompetent adult patient.

Non-dysbaric arterial gas embolism associated with chronic necrotizing pneumonia, bullae and coughing: a case report.

Arterial gas embolism (AGE) can be clinically devastating, and is most often associated with exposure to changes in ambient pressure, medical procedure or congenital malformation. Here we report a case of AGE in a 78-year-old male without these traditional risk factors. Rather, the patient's history included chronic obstructive pulmonary disease, necrotizing pneumonia, bullous disease and coughing. He was safely treated with hyperbaric oxygen (HBO2) therapy for AGE, with initial clinical improvement, but ultimately died from his underlying condition. Pathophysiology is discussed. This case illustrates the possibility that AGE can occur due to rupture of lung tissue in the absence of traditional risk factors. HBO2 therapy should be considered in the management of such patients.