Necrotizing Pneumonia In Children: A Review.

The objective of the review was to determine the long-term outcomes of necrotising pneumonia (NP). Studies published since 1990 in English, Portuguese, or Spanish, published on PubMed and Scielo were evaluated. Our findings showed ultrasound scanning is the diagnostic modality of choice. Despite prolonged hospitalisation (median 13-27 days) and fever (median 9-16 days), most patients recover completely. Empyema and bronchopleural fistulae are frequent in bacterial NP. Streptococcus pneumoniae is the most prevalent cause. Seventeen studies with 497 patients followed for 30 days to 8.75 years showed that most patients were clinically asymptomatic and had normal lung function. X-ray or CT chest imaging demonstrated that almost all lung lesions recovered within 4-6 months. We suggest that it is not necessary to request frequent chest X-rays during the treatment and recovery process. Chest CT scans should be reserved for specific cases not following the expected clinical course.

Complicated pneumonia caused by group A Streptococcus in children - 2022/2023 infectious season outbreak and update on clinical characteristics.

BACKGROUND: An increased incidence of group A Streptococcus (GAS) infections has been observed in pediatric population post-COVID-19 pandemic. While the majority of reports refer to scarlet fever or invasive GAS disease, detailed data on pulmonary manifestations such as complicated community-acquired pneumonia (CAP) are scarce. The aim of this study was to assess the contribution of GAS to complicated CAP in children during the 2022/2023 infectious season. METHODS: We retrospectively analyzed the etiology and clinical presentation of complicated CAP patients hospitalized in our tertiary care center in Warsaw, Poland, between August 2022 and May 2023. RESULTS: Among 91 patients with complicated CAP, GAS was the dominant cause constituting 24.2% (22/91; 95% CI 15.8-34.3%) of the study group. 68.2% of GAS pneumonia patients presented symptoms of scarlet fever, and 27.3% had preceding or concurrent viral infection. GAS complicated CAP was associated with longer hospitalization, higher incidence of chest tube insertion, but shorter duration of chest tube drainage than complicated CAP of other etiology. Children with GAS complicated CAP had higher procalcitonin concentration (28.1 vs. 1.5 ng/dL; p<0.0001) and a lower platelets level (254.5 vs. 422 × 103/µL; p = 0.0031) than those with non-GAS infection. CONCLUSIONS: GAS is currently the predominant pathogen of complicated CAP in children. Clinicians should be aware of the current epidemiological situation and a more severe course of GAS pneumonia in this age group, and should monitor patients presenting with symptoms of scarlet fever and preceding viral infection closely.

Role of systemic immune-inflammatory index and systemic inflammatory response index in predicting the diagnosis of necrotizing pneumonia in children.

BACKGROUND: Necrotizing pneumonia (NP) is a rare serious complication of community-acquired pneumonia (CAP) in children, which is characterized by a protracted course of the disease and a prolonged hospital stay. This study aimed to assess the role of systemic immune-inflammatory index and systemic inflammatory response index in predicting early lung necrotization in children with CAP. METHODS: This study included all children hospitalized in Pediatric Pulmonology Unit, Tanta University, Egypt, with CAP between the ages of two months and 18 years. Systemic inflammatory indices, including the neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), monocyte/lymphocyte ratio (MLR), systemic immune-inflammatory index (SII), and systemic inflammation response index (SIRI), were calculated on patients' admission. RESULTS: The study involved a total of 228 children, 42 patients had NP, 46 patients had parapneumonic effusion, and 140 patients had non-complicated CAP. Patients with NP were substantially younger (p = 0.002), stayed in the hospital longer (p < 0.001), had a longer duration of symptoms before hospital admission (p < 0.001), and had fever for a longer duration than those in the other groups (p < 0.001). Regarding the inflammatory ratios, patients with NP had significantly higher MLR, PLR, SII, and SIRI than those in the other groups (p = 0.020, p = 0.007, p = 0.001, p = 0.037, respectively). ROC curve analysis showed that the combined SII + SIRI + D-dimer showed the highest AUC with a good specificity in predicting the diagnosis of NP. CONCLUSIONS: SII, SIRI, and D-dimer may be beneficial biomarkers for predicting the occurrence of NP in children when performed on patients' admission. In addition, it was found for the first time that combined SII + SIRI + D-dimer had a good sensitivity and specificity in the diagnosis of NP.

Increase of Severe Pulmonary Infections in Adults Caused by M1UK Streptococcus pyogenes, Central Scotland, UK.

We characterized the epidemiology, host-pathogen characteristics, and outcomes of severe adult pulmonary Streptococcus pyogenes infections that coincided with a high community caseload in central Scotland, UK. The pulmonary infections had high illness and death rates and were associated with socioeconomic deprivation, influenza A co-infection, and the M1UK lineage of S. pyogenes.

Is abdominal pain after an injury just an injury? Case report of rare aspiration pneumonia with lung gangrene and peritoneal response in a 5-year-old child.

Although pneumonia presents a relatively common diagnosis, it does not always present with classic clinical symptoms, nor does it follow a regular course without complications. The presented case describes a rare case of aspiration necrotizing pneumonia, which despite intensive therapy, progressed to lung gangrene and required a lung lobectomy. Another peculiarity is that the correct diagnosis was established only after the onset of abdominal pain, surprisingly by a trauma surgeon. This case emphasizes the necessity of a thorough general examination and draws attention to a rare, but conservatively intractable necrotizing pneumonia complicated by lung gangrene.

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.

A role for nebulized tranexamic acid in veno-venous ECMO patients.

WHAT IS KNOWN AND OBJECTIVE: Although pulmonary haemorrhage as a complication of ECMO has been well documented, optimal management is not fully elucidated. We describe the role of nebulized tranexamic acid as a therapeutic alternative. CASE SUMMARY: We report a case series of three patients with ARDS on ECMO complicated by pulmonary haemorrhage. These patients were treated with 500 mg of nebulized tranexamic acid via the endotracheal tube. Key observations included significant stabilization of haemodynamics, reduced circuit changes and less time off of anticoagulation. WHAT IS NEW AND CONCLUSION: This series demonstrates successful bleeding management with nebulized tranexamic acid, reducing the frequency of ECMO circuit changes, time off of anticoagulation and blood loss.

[Analysis of clinical features and risk factors of necrotizing pneumonia in children].

OBJECTIVE: To investigate the clinical characteristics and risk factor analysis of necrotizing pneumonia in children. METHODS: A retrospective study was used to analyze the case data of 218 children with severe pneumonia hospitalized in the Department of Respiratory Medicine, Children's Hospital of Capital Institute of Pediatrics from January 2016 to January 2020, and they were divided into 96 cases in the necrotizing pneumonia group (NP group) and 122 cases in the non-necrotizing pneumonia group (NNP group) according to whether necrosis of the lung occurred. The differences in clinical characteristics (malnutrition, fever duration, hospitalization time, imaging performance, treatment and regression follow-up), laboratory tests [leukocytes, neutrophil ratio, platelet (PLT), C-reactive protein (CRP), procalcitonin (PCT), D-dimer, and lactate dehydrogenase (LDH)] and bronchoscopic performance between the two groups were compared, and Logistic regression analysis of clinical risk factors associated with necrotizing pneumonia was performed to further determine the maximum diagnostic value of each index by subject operating characteristic curve (ROC). The critical value of each index was further determined by the ROC. RESULTS: The differences in age, gender, pathogenic classification, and bronchoscopic presentation between the two groups of children were not statistically significant (P>0.05); whereas the imaging uptake time of the children in the NP group was higher than that in the NNP group (P < 0.05). The differences in malnutrition, fever duration, length of stay, white blood cell count, neutrophil ratio, CRP, PCT, and D-dimer were statistically significant between the two groups (P < 0.05). The imaging uptake time was lower in children under 6 years of age than in those over 6 years of age, and the imaging uptake time for bronchoalveolar lavage within 10 d of disease duration was lower than that for those over 10 d; the imaging uptake time was significantly longer in the mixed infection group than that in the single pathogen infection group. Logistic regression analysis of the two groups revealed that the duration of fever, hospital stay, CRP, PCT, and D-dimer were risk factors for secondary pulmonary necrosis (P < 0.001, P < 0.001, P < 0.001, P=0.013, P=0.001, respectively). The ROC curves for fever duration, CRP, PCT, and D-dimer were plotted and found to have diagnostic value for predicting the occurrence of pulmonary necrosis when fever duration >11.5 d, CRP >48.35 mg/L, and D-dimer > 4.25 mg/L [area under ROC curve (AUC)=0.909, 0.836, and 0.747, all P < 0.001]. CONCLUSION: Children with necrotizing pneumonia have a longer heat course and hospital stay, and the imaging uptake time of mixed pathogenic infections is significantly longer than that of single pathogenic infections. Children with necrotizing pneumonia under 6 years of age have more advantageous efficacy of electronic bronchoscopic alveolar lavage within 10 d of disease duration compared with children in the group over 6 years of age and children in the group with disease duration >10 d. Inflammatory indexes CRP, PCT, and D-dimer are significantly higher. The heat course, CRP, PCT, and D-dimer are risk factors for secondary lung necrosis in severe pneumonia. Heat course >11.5 d, CRP >48.35 mg/L, and D-dimer >4.25 mg/L have high predictive value for the diagnosis of necrotizing pneumonia.

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.

Differences of clinical features and prognosis between Mycoplasma pneumoniae necrotizing pneumonia and non-Mycoplasma pneumoniae necrotizing pneumonia in children.

BACKGROUND: In the past few years, Mycoplasma pneumoniae (Shi et al. Lancet 390:946-958, 2017) infection has been reported more in China. However, there are few studies on the clinical characteristics and prognosis of necrotizing pneumonia (NP) (Griffiths et al. Nature 583:615-619, 2020) caused by different pathogens. METHODS: A retrospective analysis was performed, including 31 children with a clinical diagnosis of NP in the hospital from January 1, 2013 to January 31, 2020. A total of 11 children with MPNP were included in the observation group and the other 20 children with other pathogens were included in the control group. The clinical manifestations, laboratory data, imaging findings, treatments and outcomes were analyzed. RESULTS: The proportion of dyspnea cases was significantly higher in the non-Mycoplasma pneumoniae necrotizing pneumonia (N-MPNP) group than that in the Mycoplasma pneumoniae necrotizing pneumonia (MPNP) group (P = 0.02).The LDH level of all patients in the MPNP group was higher than the normal value, with a median value of 805.0 U/L, which was significantly higher than those in the N-MPNP group (414.0 [299.9-540.6] U/L; Z = - 2.518; P = 0.012). The white blood cells (WBCs) count of the N-MPNP group was 17.8 (11.1-21.7) × 109/L, which was significantly higher than that of the MPNP group (10.2 [6.3-14.1] × 109/L; P < 0.05). The mean time of pulmonary necrosis in the MPNP group was 20.9 ± 6.9 days, which was higher than that of the N-MPNP group (16.8 ± 6.1 days; t = 3.101; P = 0.004). The incidence of pleural effusion in the N-MPNP group (19 patients, 95%) was significantly higher than that in the MPNP group (six patients, 54.55%) (P = 0.013). Among them, two patients received bronchoscopy lavage at a maximum four times, and the cases of plastic bronchitis were seen only in the MPNP group (3 cases; P = 0.037).The length of stay was 18 (10-22) days in the MPNP group and 23.5 (13.5-47) days in the N-MPNP group and no significant difference was observed between the two groups (Z = - 1.923, P = - 0.055). CONCLUSIONS: 1. MP infection is the most common infection in children with NP in the Suzhou area. There is no gender and age difference between MPNP and N-MPNP, but the bacterial infection was mainly observed in the N-MPNP group. 2. Children in the N-MPNP group have more severe clinical symptoms, were more prone to shortness of breath, had a longer hospital stay, and had earlier imaging manifestations of necrosis, whereas children in the MPNP group were more likely to have plastic bronchitis. The level of WBC and LDH and the nature of pleural effusion can be used to identify MPNP and N-MPNP to some extent. 3. The prognosis of MPNP was better than that of N-MPNP. There were no death cases. Pleural thickening, pulmonary fibrosis, and bronchiectasis were the most common sequelae. Compared with N-MPNP, the recovery time of lung imaging in MPNP was shorter.

Contrast-enhanced ultrasound of pediatric lungs.

In addition to radiography, ultrasound (US) has long proved to be a valuable imaging modality to evaluate the pediatric lung and pleural cavity. Its many inherent advantages, including real-time performance, high spatial resolution, lack of ionizing radiation and lack of need for sedation make it preferable over other imaging modalities such as CT. Since the introduction of ultrasound contrast agents (UCAs), contrast-enhanced ultrasound (CEUS) has become a valuable complementary US technique, with many well-established uses in adults and evolving uses in children. Lung CEUS applications are still not licensed and are performed off-label, although the added value of CEUS in certain clinical scenarios is increasingly reported. The limited evidence of CEUS in the evaluation of pediatric lungs focuses primarily on community-acquired pneumonia and its complications. In this clinical setting, CEUS is used to confidently and accurately diagnose necrotizing pneumonia and to delineate pleural effusions and empyema. In addition to intravenous use, UCAs can be administered directly into the pleural cavity through chest catheters to improve visualization of loculations within a complex pleural effusion, which might necessitate fibrinolytic therapy. The purpose of this paper is to present the current experience on pediatric lung CEUS and to suggest potential additional uses that can be derived from adult studies.

Unusual case of necrotizing pneumonia caused by Fusobacterium nucleatum complicating influenza a virus infection.

We report a rare case of Fusobacterium nucleatum necrotizing pneumonia following an influenza viral infection. This rare bacterial lung infection can have severe complications such as respiratory failure and septic shock, so early recognition and treatment are necessary.

Panton-Valentine Leukocidin-Secreting Staphylococcus aureus Pneumonia Complicating COVID-19.

Necrotizing pneumonia induced by Panton-Valentine leukocidin-secreting Staphylococcus aureus is a rare but life-threatening infection that has been described in patients after they had influenza. We report a fatal case of this superinfection in a young adult who had coronavirus disease.

Protective Efficacy of Monoclonal Antibodies Neutralizing Alpha-Hemolysin and Bicomponent Leukocidins in a Rabbit Model of Staphylococcus aureus Necrotizing Pneumonia.

Staphylococcus aureus is a major human pathogen that causes a wide range of infections by producing an arsenal of cytotoxins. We found that passive immunization with either a monoclonal antibody (MAb) neutralizing alpha-hemolysin or a broadly cross-reactive MAb neutralizing Panton-Valentine leukocidin, leukocidin ED, and gamma-hemolysins HlgAB and HlgCB conferred only partial protection, whereas the combination of those two MAbs conferred significant protection in a rabbit model of necrotizing pneumonia caused by the USA300 methicillin-resistant S. aureus epidemic clone.

The clinical characteristics and risk factors for necrotizing pneumonia caused by Mycoplasma pneumoniae in children.

BACKGROUND: The incidence of necrotizing pneumonia (NP) caused by Mycoplasma pneumoniae (MP) is increasing. We analyzed the clinical characteristics and the risk factors for NP caused by MP. METHODS: A retrospective observational study was conducted in 37 patients with NP caused by MP (NP group) and 74 patients diagnosed with lobar M. pneumoniae pneumonia with no necrosis (control group) who were admitted to our hospital between January 2013 and December 2017. The clinical manifestations, laboratory data, imaging findings, treatments and outcomes were analyzed. RESULTS: The proportion of females, the incidence of pleural effusion, fever duration, hospitalization days, white blood cell count, neutrophil ratio, D-dimer level and use of other types of antibiotics were higher in the NP group than in the control group (P < 0.05). The control group exhibited a greater use of low molecular weight heparin (LMWH) than the NP group (P < 0.05). According to the multivariate logistic regression analysis, a white blood cell count > 12.3 × 109/L (Odds ratio, OR = 6.412), a neutrophil ratio > 73.9% (OR = 6.081) and D-dimer level > 1367.5 ng/mL (OR = 8.501) were risk factors for pulmonary necrosis caused by MP. Furthermore, the use of LMWH (OR = 0.074) reduced the risk of pulmonary necrosis. CONCLUSIONS: NP is a rare complication of severe Mycoplasma pneumoniae pneumonia (SMPP), and although the clinical course is longer than common MP infection, the necrotic area is absorbed gradually. In patients with SMPP presenting with lobar consolidation, a white blood cell count > 12.3 × 109/L, a neutrophil ratio > 73.9% and D-dimer level > 1367.5 ng/mL are risk factors for pulmonary necrosis, and the use of LMWH reduces the risk of pulmonary necrosis.

Severe Necrotizing Pneumonia in Children: A Challenge to Intensive Care Specialist.

OBJECTIVE: Necrotizing pneumonia (NP) is recently recognized as a complication of pneumonia. The data on NP are scant from developing world and we aimed to describe the characteristic features of NP in our children. STUDY DESIGN: Single center retrospective cohort analysis. PATIENT SELECTION: Institutional database of children treated for pneumonia between September 2014 and May 2018 was searched to identify children with NP. METHODS: The demographic characteristics, laboratory results, and clinical information were recorded for patients selected as NP and analyzed. RESULTS: In total, 10 patients (3.7%) of NP were identified out of 272 patients with pneumonia. Median age was 3 years (range: 3 months to 12years). All cases had severe respiratory distress and 70% required mechanical ventilation and inotropic support. The causative pathogens were identified in 6/10 children (60%) with Staphylococcus aureus being most common (4/10). Pleural effusion and pneumothorax were seen in six cases. Four cases had bilateral pleural effusion and three had bilateral pneumothorax. Intercostal drainage (ICD) was placed in 70% and bilateral ICD was placed in 40% cases. Bronchopleural fistula (BPF) developed in two cases and one had bilateral BPF. Median [inter quartile range] ICD days and hospital stay were 9 (6-14) and 13.5 (7.5-18.5) days, respectively. Mean (±SD) total antibiotic (in hospital plus outpatient) days were 28.8 ± 9.6 days. Four cases had airway hemorrhage and in three cases this was massive and fatal. CONCLUSION: NP is a relatively rare but severe complication of pneumonia distinct from pediatric acute respiratory distress, pleural effusion and empyema. Airway hemorrhage is the most fatal complication.

Severe Hemoptysis Associated with Bacterial Pulmonary Infection: Clinical Features, Significance of Parenchymal Necrosis, and Outcome.

PURPOSE: Severe hemoptysis (SH) associated with non-tuberculosis bacterial lower respiratory tract infection (LRTI) is poorly described, and the efficacy of the usual decision-making process is unknown. This study aimed at describing the clinical, radiological patterns, mechanism, and microbiological spectrum of SH related to bacterial LRTI, and assessing whether the severity of hemoptysis and the results of usual therapeutic strategy are influenced by the presence of parenchymal necrosis. METHODS: A single-center analysis of patients with SH related to bacterial LRTI from a prospective registry of consecutive patients with SH admitted to the intensive care unit of a tertiary referral center between November 1996 and May 2013. RESULTS: Of 1504 patients with SH during the study period, 65 (4.3%) had SH related to bacterial LRTI, including non-necrotizing infections (n = 31), necrotizing pneumonia (n = 23), pulmonary abscess (n = 10), and excavated nodule (n = 1). The presence of parenchymal necrosis (n = 34, 52%) was associated with a more abundant bleeding (volume: 200 ml [70-300] vs. 80 ml [30-170]; p = 0.01) and a more frequent need for endovascular procedure (26/34; 76% vs. 9/31; 29%; p < 0.001). Additionally, in case of parenchymal necrosis, the pulmonary artery vasculature was involved in 16 patients (47%), and the failure rate of endovascular treatment was up to 25% despite multiple procedures. CONCLUSIONS: Bacterial LRTI is a rare cause of SH. The presence of parenchymal necrosis is more likely associated with bleeding severity, pulmonary vasculature involvement, and endovascular treatment failure.

Prolonged extracorporeal membrane oxygenation for pediatric necrotizing pneumonia due to Streptococcus pneumonia and influenza H1N1 co-infection: how long should we wait for native lung recovery?

Most children with severe respiratory failure require extracorporeal membrane oxygenation (ECMO) for 7-10 days. However, some may need prolonged duration ECMO (> 14 days). To date, no consensus exists on how long to wait for native lung recovery. Here we report the case of a 3-year-old boy who developed severe necrotizing pneumonia requiring venovenous (VV) ECMO after 19 days of mechanical ventilation. In the first 4 weeks of his ECMO run, he showed no lung aeration, requiring total extracorporeal support. However, after we started strategies for promoting lung recovery such as daily prone positioning and regular use of toilet bronchoscopy and inhalative DNAse to clear secretions, by week five his tidal volumes gradually increased and he was successfully decannulated after 43 days. Moreover, we decided not to proceed to a surgical removal of the necrotic lung area. At present, he is 1-year post discharge and has fully recovered. This report shows that unexpected native lung recovery is possible even after prolonged loss of lung function and that a previous healthy lung can recover from apparent irreversible lung injury.