Surfactant for a Patient with Refractory Pyopneumothorax and Acute Respiratory Distress Syndrome Due to Pneumococcal Necrotizing Pneumonia Complicated by a Bronchopleural Fistula.

Background: Necrotizing pneumonia rarely occurs in children, but when it does it can be complicated by bronchopleural fistula, empyema, pneumothorax, sepsis, and acute respiratory distress syndrome (ARDS). Antimicrobial therapy is the cornerstone of its management; however, surgery is necessary in some cases. Ideally, surgical interventions are kept to a minimum, but this is not always possible if there is a mass effect from air and fluid in the pleural space, pulmonary necrosis leading to massive hemoptysis, uncontrolled sepsis, or difficulties with assisted ventilation. Case Presentation: Herein we present a patient with refractory pyopneumothorax and ARDS due to pneumococcal necrotizing pneumonia complicated by a bronchopleural fistula. The patient's clinical condition deteriorated despite antibiotics, surgical drainage, and assisted ventilation. Owing to pneumothorax with a high percentage of air leakage, bilateral diffuse collapse of the lungs, and insufficient oxygenation, surgical treatment was considered, but because of the patient's lack of tolerance for surgery due to hemodynamic reasons and the complications associated with surgery, medical treatment was determined to be more appropriate. Surfactant treatment was administered to the patient, resulting in significant clinical improvement. Conclusion: To the best of our knowledge, this is the first report of the use of surfactant to treat ARDS due to necrotizing pneumonia. Based on the presented case, we think surfactant can be considered as a salvage treatment for such patients.

Community Acquired Staphylococcus Aureus Necrotizing Pneumonia and Guillain Barre Syndrome: An Unusual Presentation in An Adolescent Patient.

Community-acquired Staphylococcus aureus (SA) pneumonia can present with multiple complications but has not been reported earlier to present as or lead to Guillain Barre syndrome (GBS). However, there are few case reports of GBS following SA infective endocarditis, polymyositis, and meningitis. We report an unusual presentation of GBS most probably secondary to community-acquired SA necrotizing pneumonia in a young immunocompetent adult. The clinical course, challenges in the management, and unfortunate death of the patient due to an unforeseen complication have been discussed. This report adds to the clinical knowledge of rare association of community-acquired SA necrotizing pneumonia and GBS.

Retrospective analysis of necrotizing pneumonia in children between 2015-2019.

INTRODUCTION: An increased incidence rate of cases of complicated pneumonia, reaching up to the stage of necrotizing pneumonia was observed at University Hospital Brno in the past period. The aim of this study was to perform a single-center retrospective analysis of patients with acquired inflammatory lung disease requiring surgical treatment, comprising a long-term follow-up group. METHODS: Patients hospitalized for community-acquired pneumonia and surgically treated in the years 2015-2019 were analyzed. The rates of necessary chest drainages, decortications and lung resections in relation to the whole group and individual years were monitored. Clinical and X-ray examinations were performed one year after hospitalization and the prognosis was determined for individual types of required treatments. The age, gender and etiological agents were also monitored. RESULTS: A total of 688 patients were included in the study with the incidence rising until 2018 and decreasing slightly in 2019. A statistically significantly higher number of community-acquired pneumonias and complications was recorded between 2017 and 2018 (p.

Septicaemia with deep venous thrombosis and necrotising pneumonia caused by acute community-acquired methicillin-resistant Staphylococcus aureus in an infant with a three-year follow-up: a case report.

BACKGROUND: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is a common pathogen that usually causes bacteraemia, osteomyelitis, as well as skin and soft tissue infections. However, deep venous thrombosis (DVT) and necrotising pneumonia are rare in infants. CASE PRESENTATION: We report the case of a one-month-five-day-old girl who was hospitalised for DVT and necrotising pneumonia due to septicaemia associated with Staphylococcus aureus. She recovered after treatment with intravenous antibiotics and multiple anticoagulant therapy, but DVT persisted at the three-year follow-up. Collateral circulation around the DVT was well-formed. Post thrombotic syndrome was not observed. CONCLUSIONS: Staphylococcus aureus complicated by DVT and necrotising pneumonia is rare and can be successfully treated.

Neonatal Manifestations of Chronic Granulomatous Disease: MAS/HLH and Necrotizing Pneumonia as Unusual Phenotypes and Review of the Literature.

Chronic granulomatous disease (CGD) is a rare inborn error of immunity (IEI), characterized by a deficient phagocyte killing due to the inability of NADPH oxidase to produce reactive oxygen species in the phagosome. Patients with CGD suffer from severe and recurrent infections and chronic inflammatory disorders. Onset of CGD has been rarely reported in neonates and only as single case reports or small case series. We report here the cases of three newborns from two different kindreds, presenting with novel infectious and inflammatory phenotypes associated with CGD. A girl with CYBA deficiency presented with necrotizing pneumonia, requiring a prolonged antibiotic treatment and resulting in fibrotic pulmonary changes. From the second kindred, the first of two brothers developed a fatal Burkholderia multivorans sepsis and died at 24 days of life. His younger brother had a diagnosis of CYBB deficiency and presented with Macrophage Activation Syndrome/Hemophagocytic Lympho-Histiocytosis (MAS/HLH) without any infection, that could be controlled with steroids. We further report the findings of a review of the literature and show that the spectrum of microorganisms causing infections in neonates with CGD is similar to that of older patients, but the clinical manifestations are more diverse, especially those related to the inflammatory syndromes. Our findings extend the spectrum of the clinical presentation of CGD to include unusual neonatal phenotypes. The recognition of the very early, potentially life-threatening manifestations of CGD is crucial for a prompt diagnosis, improvement of survival and reduction of the risk of long-term sequelae.

Resultados a largo plazo de la neumonía necrotizante / Long-term outcomes of necrotizing pneumonia

Introducción: La neumonía necrotizante (NN) es una complicación grave de la neumonía adquirida en la comunidad caracterizada por la destrucción del parénquima pulmonar normal. Ningún estudio ha evaluado las consecuencias de este daño pulmonar en los años posteriores al episodio. El objetivo es investigar el impacto a largo plazo sobre la función pulmonar y los síntomas respiratorios en niños ingresados por NN.Métodos: Seguimiento de niños diagnosticados de NN desde enero-2003 hasta abril-2016. Se seleccionó a los mayores de 4años, capaces de realizar una función pulmonar, y un seguimiento durante más de 2años. Los pacientes recibieron un cuestionario respiratorio y completaron una prueba de función pulmonar.Resultados: Se incluyeron 24 pacientes (12 hombres). La edad mediana en el momento del diagnóstico fue de 26 meses, 15 días de hospitalización y 18 pacientes necesitaron drenaje pleural. Los pacientes fueron seguidos durante un promedio de 8,75años después de la NN. Durante la evaluación, ningún paciente tuvo asma, tos o sintomatología inducida por el ejercicio. Tres niños sufrieron una segunda neumonía, que no requirió hospitalización. Los resultados de la espirometría fueron (media±desviación estándar): Z-score FEV1 −0,47 ±0,65, Z-score FVC −0,56±0,73, Z-score FEV1/FVC 0,19±0,98. No hubo evidencia de enfermedad pulmonar obstructiva o patrones restrictivos.Conclusiones: Los resultados a largo plazo de la NN pediátrica son buenos. Sin embargo, los pacientes tienen una función pulmonar ligeramente disminuida varios años después del episodio. Es aconsejable hacer un seguimiento de estos pacientes debido a la posible disminución de la función pulmonar en edad adulta. (AU)

Introduction: Necrotizing pneumonia (NP) is a serious complication of community-acquired pneumonia characterised by the destruction of normal lung parenchyma. No study has evaluated the repercussions of the lung damage in the years following the episode. The aim of this study was to assess the long-term impact on lung function and respiratory symptoms in children hospitalised due to NP.Methods: We analysed outcomes in children given a diagnosis of NP between January 2003 and April 2016. We selected patients aged more than 4 years capable of undergoing a lung function test, that had been followed up for at least 2 years. The patients completed a respiratory questionnaire and underwent a lung function test.Results: We included a total of 24 patients (12 male). The median age at the time of diagnosis was 28 months, the median length of stay was 15 days, and 18 patients required pleural drainage. The mean duration of follow-up after NP was 8.75 years. During the evaluation, none of the patients exhibited asthma, cough, or exercise-induced symptoms. Three children had a second episode of pneumonia that did not require hospital admission. The spirometry results were the following (given as mean ± standard deviation): FEV1 z-score, −0.47±0.65; FVC z-score, −0.56±0.73; and FEV1/FVC z-score, 0.19±0.98. We found no evidence of obstructive pulmonary disease or restrictive patterns.Conclusions: The long-term outcomes of paediatric NP are good. However, patients exhibited mildly impaired lung function several years after the episode. We recommend follow-up of these patients due to potential impairments in lung function in adulthood. (AU)

Neumonía necrotizante: experiencia en el Hospital Roberto del Río período 2014 a 2020 / Necrotizing pneumonia: experience at the Roberto del Río Hospital from 2014 to 2020

La neumonía necrotizante se refiere a la necrosis del parénquima pulmonar producto de una infección. Existe escasa literatura nacional sobre esta complicación. OBJETIVO: Caracterizar a los pacientes que cursaron con neumonía necrotizante en el Hospital Roberto del Río entre los años 2014 y 2020. MÉTODO: Revisión retrospectiva y descriptiva. RESULTADOS: 22 pacientes. Promedio de edad 4 años 7 meses, 68% masculino, esta complicación correspondió a 1,3% de todos los casos de neumonía hospitalizados en ese periodo. Un 95,5% presentó fiebre y un 59% dificultad respiratoria y tos. La duración promedio de la hospitalización fue de 31 días y del tratamiento antibiótico de 30,3 días. El 63% de los pacientes requirió cirugía. En el laboratorio destaca la leucocitosis y proteína C reactiva elevados con 71,4% > a 90 mg/L (promedio: 211 mg/L) y 52,3% leucocitosis > 15.000 (promedio: 18.127). La ecografía torácica fue la imagen más frecuentemente utilizada (95,5%). Agentes identificados Streptococcus pneumoniae (40%) y Staphylococcus aureus (40%). Un 63,6% ingresó a UCI, 35,7% requirió ventilación mecánica invasiva, 35,7% recibió drogas vasoactivas, 9% requirió de soporte ECMO (Oxigenación por Membrana Extracorpórea) y 1 paciente falleció (4,5%). DISCUSIÓN: en nuestro estudio encontramos una baja incidencia de esta patología, un alto índice de gravedad y una evolución favorable en la gran mayoría de los casos.

Necrotizing pneumonia refers to necrosis of lung parenchyma resulting from an infection. There is little national literature on this complication. OBJECTIVE: To characterize patients with necrotizing pneumonia at the Roberto del Río Children´s Hospital between 2014 to 2020. METHOD: Retrospective and descriptive review. RESULTS: A total of 22 patients, average age 4 years 7 months, male (68%). Average incidence 1.3% in 7 years; 95.5% had fever 59% had respiratory distress and cough. Average duration of hospitalization was 31 days and antibiotic treatment 30.3 days. A 63% of the patients had surgery. Leukocytosis and C-reactive protein (CRP) were elevated, 71.4% CRP > 90 mg /L (average: 211 mg /L) and 52.3% leukocytosis > 15.000 (average: 18.127). Chest ultrasound was used in 95.5%. Main agents identified were Streptococcus pneumoniae (40%) and Staphylococcus aureus (40%). A 63.6% of patients were admitted to ICU, 35.7% required invasive mechanical ventilation, 35.7% received vasoactive drugs, 9% required ECMO (Extracorporeal Membrane Oxygenation), and one patient died (4,5%). DISCUSSION: In our study we found a low incidence of this pathology, a high severity index an a favorable evolution in most cases.

Desarrollo de enfermedades concomitantes en pacientes críticos con COVID-19 / Development of concomitant diseases in COVID-19 critically ill patients

Puede ser necesaria una reflexión sobre cuál es el mejor abordaje para las enfermedades agudas concomitantes que pueden desarrollar los pacientes críticos con COVID-19. Estos requieren una sospecha diagnóstica y un tratamiento precoz, basados en el trabajo de equipos multidisciplinares. Presentamos dos casos de enfermedades concomitantes en pacientes con COVID-19. Un paciente diagnosticado de COVID-19 con buena evolución respiratoria que tras extubación presentó una colecistitis acalculosa y un paciente con neumonía por COVID-19 que presentó una sobreinfección con neumonía necrotizante, cuyo primer síntoma fue hemoptisis y fue finalmente tratado con embolización arterial por radiología intervencionista

It may be necessary a consideration about the best approach to the acute concomitant problems that critical COVID-19 patients can develop. They require a rapid diagnosis and an early treatment by a multidisciplinary team. As a result, we would like to describe two clinical cases a patient with diagnosis of COVID-19 pneumonia with good respiratory evolution that, after extubation suffered an acalculous cholecystitis and a patient with COVID-19 pneumonia that suffered an overinfection with necrotising pneumonia that presented with haemoptysis and was finally treated with arterial embolisation by the interventional radiologist's team

Getting the wind knocked out of him - Report of a broncho-cutaneous fistula caused by staphylococcal pneumonia, and review of literature.

A broncho-cutaneous fistula (BCF) refers to the formation of an abnormal fistulous connection between the tracheobronchial tree and the cutaneous surface of skin. A rare occurrence in and of itself, the disease entity may have varied etiologies, and may or may not be associated with a broncho-pleural fistula. We describe a case of a young patient who developed a BCF as a complication of a necrotizing pneumonic process, and his subsequent clinical course. In so doing, we review the clinical features of this peculiar disease entity, analyzing the available medical literature similarities in etiology and variations in management strategies described in the literature thus far.

A 21-Year-Old Immunocompetent Man With Hemoptysis and Rash.

CASE PRESENTATION: A 21-year-old man presented to the ED of The George Washington University Hospital complaining of chills, shortness of breath, hemoptysis, and a generalized rash. Three days before admission, he noticed a productive cough, severe sore throat, and subjective fever. He also experienced extreme fatigue, generalized sweating, and chest pain with coughing. On the day before admission, he experienced a nonpruritic rash on his neck, palms, and dorsal surfaces of his feet and sputum with streaks of blood. The patient had no significant medical or family history. He had no sick contacts, and his only recent travel was to an outdoor concert in a woody area of the northeastern United States about a month earlier. He did not report recent contact with birds or visits to caves. He is single, lives alone in an apartment, and consumes about 4 alcoholic beverages a week. Occasionally, he smokes cannabis and e-cigarettes. He is sexually active with men, and his last unprotected sexual encounter was a month earlier. He denied photophobia, rhinorrhea, ear pain, nasal congestion, abdominal pain, nausea, vomiting, diarrhea, or dysuria.

Influenza virus infection complicated by bacterial necrotising pneumonia: two case reports.

Necrotising pneumonia (NP) is a potentially severe complication of community-acquired pneumonia characterised by necrosis of consolidated lung tissue. A 7-year-old boy and a 6-year-old boy are presented, both of whom had a complicated influenza infection which evolved into severe NP caused by Streptococcus pneumoniae. Both needed intensive care for invasive respiratory support. Despite extensive pleural involvement in both cases, only one required thoracic surgery. Case 1 also developed anaemia, hyponatraemia and hypo-albuminaemia, resulting in generalised oedema. Despite the severe morbidity, both boys made a full recovery. The diagnosis of NP should always be considered in a child with pneumonia who remains unwell despite 72 hours of appropriate antibiotics, particularly if there is evidence of pleural disease. Although S. pneumoniae is the main agent for NP, the influenza virus may be a precipitating factor.

Dual RVAD-ECMO Circuits to Treat Cardiogenic Shock and Hypoxemia Due to Necrotizing Lung Infection: A Case Report.

Utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) is expanding, but dual VA-ECMO circuits to treat cardiogenic shock with refractory hypoxemia is unreported. We describe the case of combined cardiogenic and distributive shock due to necrotizing pulmonary blastomycosis. After initial central VA-ECMO cannulation, acute respiratory distress syndrome (ARDS) with increasing shunt resulted in significant central hypoxemia due to progressive ventilation-perfusion mismatch. An additional circuit provided complete oxygenation of the high circulating volume. After 4 months on support, he underwent successful heart-lung-kidney transplantation. Dual ECMO circuits are technically feasible and may be advantageous in specific circumstances of high pulmonary shunting resulting in excessive hypoxemia unbalanced with appropriate oxygen delivery.

Successful Right Atrium-Pulmonary Artery ECMO in an Infant With Severe Necrotizing Pneumonia and Bilateral Bronchopleural Fistula.

We report an infant with necrotizing pnuemonia and bilateral broncho pleural fistula, who failed on conventional and high frequency ventilation and was managed successfully on Veno-venous Extra Corporeal Membrane Oxygenator (V-V ECMO) with a unique configuration for 12 days, and weaned off successfully.

Mielopatía isquémica con múltiples microinfartos renales y esplénicos tras embolización de arterias bronquiales: a propósito de un caso / Ischemic myelopathy with multiples renal and splenic microinfarctions after bronchial artery embolization: a case report

La hemoptisis puede representar una situación de riesgo vital que requiere de un inmediato diagnóstico y tratamiento con una gran variedad de causas subyacentes. Se recomienda una rápida intervención mediante fibrobroncoscopia para localizar e intentar controlar el sangrado. En los casos en los que no se puede controlar el sangrado, la embolización de las arterias bronquiales (EAB) es un tratamiento no quirúrgico seguro y efectivo para los pacientes con una hemoptisis masiva. Se han descrito complicaciones asociadas a la EAB, siendo la isquemia de la médula espinal la más grave. Informamos del caso de un paciente con hemoptisis masiva en contexto de una neumonía necrotizante, en el que se realizó una EAB tras no conseguir controlar el sangrado mediante fibrobroncoscopia

Hemoptysis may represent a life-threatening situation requiring immediate diagnosis and therapy and it can have a variety of underlying causes. It is recommended an early investigation with bronchoscopy for localization and control of bleeding. In those cases with non-controlled bleeding, bronchial artery embolization (BAE) is a safe and effective nonsurgical treatment for patients with massive hemoptysis. Complications of BAE have been reported, being spinal cord ischemia the most dangerous one. We report a case of a patient with massive hemoptysis in the context of necrotizing pneumonia, in whom a BAE was performed after an unsuccessful control of bleeding by bronchoscopy

Giant lung cysts following necrotizing pneumonia: Resolution with conservative treatment.

RATIONALE: Necrotizing pneumonia is characterized by destruction and liquefaction of the lung tissue and loss of the normal pulmonary parenchymal architecture. During the course of resolution areas of hyperlucency are formed, sometimes with the development of giant lung cysts that can be a field with fluid resembling lung abscess. There is no consensus on the management of these abnormalities. OBJECTIVE: To assess the prevalence of giant lung cysts as a complication of necrotizing pneumonia and to report our experience with conservative treatment that achieved complete resolution. METHODS: Medical chart reviews of all children aged 0 to 18 years hospitalized with necrotizing pneumonia in a single tertiary center from 2015 to 2017, demographic data, and clinical course during and after hospitalization as well as serial chest imaging were collected. RESULTS: During the study period, 761 children were diagnosed with community-acquired pneumonia, 16 of 761 (2.3%) had necrotizing pneumonia and 6 of 16 (37.5%) with necrotizing pneumonia complicated by a giant lung cyst or lung abscess. All were closely observed and showed complete clinical and radiographic resolution with antibiotic treatment. CONCLUSIONS: Treatment of giant lung cyst formation following necrotizing pneumonia by a conservative approach with prolonged antibiotics results in complete recovery with no need for invasive procedures.