Childhood necrotising pneumonia, empyema and complicated parapneumonic effusion secondary to community acquired pneumonia: report of 158 cases from a tertiary hospital in Egypt

Abstract

Background: Incidence of childhood complicated community acquired pneumonia (cCAP) is increasing worldwide. Necrotising pneumonia (NP), empyema and complicated parapneumonic effusion (CPPE) are the most common local complications.

Methods: This retrospective observational study describes clinical characteristics, aetiology and management of children hospitalized with cCAP in one of the largest tertiary centers in Egypt, over 5 years (December 2017 till September 2022).

Results: A total of 158 cases were identified. Seasonal variation was observed, as more cases were hospitalized during Winter and Spring. NP, empyema and CPPE, were diagnosed in 85 (54%), 52 (33%) and 21 (13%) children, respectively. 54 (64%) of children presented with NP had associated empyema or CPPE. The yield of pleural fluid, sputum and blood cultures were 23%, 18% and 17%, respectively. Community acquired MRSA was the predominant causative organism, followed by S pneumoniae. 87% of the patients had pleural interventions. 29 (18%) children received fibrinolytics. Three children presented with CAP and highly septated effusion, developed NP and persistent air leaks following fibrinolytic administration. Patients had prolonged hospitalization (median 17 days). 15 (10%) children had surgery. Children presented with NP had more morbidities and longer length of hospital stay, compared to children presented with CPPE and empyema. ICU admission, mechanical ventilation, severe anemia requiring blood transfusion, broncho-pleural fistula and surgical interventions were significantly higher in NP cohort. We report 5 mortalities, 4 of them below 1 year of age.

Conclusions: This study describes the largest cohort of children hospitalized with cCAP from Egypt till this date. Management of cCAP remains challenging worldwide and the current guidelines requires updating. Improvement of microbial detection and reporting is needed to promote antimicrobial stewardship.

Keywords: COVID-19; Children; Community acquired pneumonia; Complicated pneumonia; Empyema; Necrotising pneumonia; Necrotizing pneumonia; Parapneumonic effusion; Pleural effusion; Pleural fibrinolytics.

Fig. 1

Number of children presented with CPPE, Empyema and NP differed through different seasons. There is observed peaks during Winter and Spring, with exception of Spring 2020 and Spring 2021 following the 2 lockdown periods of the 1 st and 2nd COVID-19 waves. Note the Arrow marks the start of the 1 st COVID wave, Spring 2020. Also, note the increase in NP admissions over the years

Fig. 2

a Pleural fluid culture yield. b N (%) of organisms out of positive isolates from the pleural cultures

Fig. 3

A Blood culture yield. b N (%) of organisms out of positive isolates from the blood cultures

Fig. 4

a Sputum culture yield. b N (%) of organisms out of positive isolates from the sputum cultures

Fig. 5

Antibiotic Sensitivity (%) of Gram Positive Organisms isolated from pleural, blood, and sputum cultures

Fig. 6

Antibiotic Sensitivity (%) of Gram Negative Organisms isolated from pleural, blood, and sputum cultures

Fig. 7

8-year-old female patient presented with grade III respiratory distress and a) chest X-ray showed massive left sided pleural effusion. Nasopharyngeal SARS-CoV-2 RT-PCR was positive. Chest drainage yielded 800 cc pus over 24 h. She also had persistent tachycardia, elevated troponins and echocardiography confirmed diagnosis of carditis and mild pericardial effusion. Two days later, she had worsening respiratory distress and CT chest showed evidence of air-filled cavities and pyo-pneumothorax confirming progression to necrotising pneumonia. She received systemic steroids, intravenous immunoglobulins, in addition to antibiotics. Pleural, blood and sputum cultures were negative. Despite 3 weeks of chest drainage and suction, she had persistent air leak and chest X-ray b) shows a trapped lung, 3 weeks after admission. Air leak resolved after 4 weeks and chest drain was removed, however, c) due to failure of lung expansion and persistent pneumothorax, she was referred for decortication

Fig. 8

3-year-old male presented with a) severe pneumonia and associated effusion. Lung ultrasound showed highly turbid and septated effusion. b Following administration of intrapleural fibrinolytic, he developed air filled cavities, pneumothorax and worsening respiratory distress requiring escalation of respiratory support to high frequency oscillatory ventilation. Among the study cohort, we reported 3 patients with similar presentation of extensive consolidation and highly septated effusion, and all 3 developed air-filled cavities, BPF and PALS following fibrinolytic administration. This deterioration after fibrinolytics could be part of disease progression to necrotising pneumonia and coincided with fibrinolytics administration, however, we provide alternative hypothesis that administration of fibrinolytics destabilized the fibrinous inflammation which is part of inflammatory reaction in complicated pneumonia. We propose a slower rate of drainage than 10 ml/kg/hour in children, who present with massive effusion and significant underlying lung collapse

Fig. 9

18 months old infant presented with history of high-grade fever, oral thrush and dyspnea for 2 weeks. She presented to the A&E with cyanosis and marked respiratory distress. She had tension pneumothorax on the right side requiring urgent decompression, followed by chest drain insertion. Pleural fluid culture showed growth of MRSA and sputum culture showed growth of Klebsiella pneumoniae. a CT chest showed bilateral necrotizing pneumonia. Immunodeficiency, HIV and TB were excluded. She showed good clinical recovery after 3 weeks of IV antibiotics, with regression of inflammatory markers and radiological improvement. b The pulmonary lesions resolved completely at the 1 year follow up

Fig. 10

3-year-old child presented with a) extensive necrotising pneumonia. Follow up X-ray at 1 year showed marked improvement

Fig. 11

3-year-old child presented with a) severe respiratory distress, pancytopenia, rapidly progressive consolidation and highly septated effusion. Respiratory support escalated quickly form high flow nasal cannula to high frequency oscillatory ventilation in 12 h. Two days later, laboratory picture changed to leukocytosis, severe anemia and extreme thrombocytosis. Fibrinolytics were not administered as the patient was hemodynamically unstable. Nasopharyngeal respiratory panel by multiplex PCR was positive for adenovirus, H influenza and S. pneumoniae. Pleural fluid and endotracheal aspirate cultures showed no growth of organisms. Blood culture was positive for Staphylococcus Hominis. After 60 days of hospital admission, he had bronchopleural fistula, persistent air leak and lung collapse intractable to drainage and suction (b, c). He was referred for surgery 3 months after discharge. Decortication and right lower lobectomy were performed. Follow up chest X-ray 2 months after surgery d) shows compensatory hyperinflation on the contralateral side