Necrotizing Pneumonia in a Pediatric Patient

A report describes a case of a 20-month-old girl who presented with progressive respiratory distress and fever since 1 day before admission. Her weight was 14 kg, with a body temperature of 40oC, and rapid breathing without stridor or cyanosis. Her history revealed prior treatment by general practitioner 5 days ago with complaints of fever, cough, and difficulty in breathing, who gave her antipyretic and antiviral drugs with no significant response. No history of febrile seizures or administration of Streptococcus pneumoniae and Haemophilus influenzae Type b (Hib) vaccine was rendered.

Her total white blood cell count of 10.100 μl−1 showed 50% segmented neutrophils, her hemoglobin was 10.2 g/dL, platelet count was 470.000 μl−1, and the C-reactive protein (CRP) was 24 mg/l. 

Anteroposterior (AP) view of chest X-ray (CXR) showed left inferior lobar pneumonia. Hospitalization for 5 days caused significant improvement in the clinical and laboratory findings, so was discharged at her parent's request.

On discharge, her symptoms of fever and shortness of breath worsened. She was readmitted and her AP and lateral view demonstrated a focal area of consolidation dominant in the left inferior lobe. The frontal view showed multiple small lucency in the left lung field suspicious of possible pneumonia with air cavitation or suspected combination with congenital pulmonary airway malformation (CPAM). Compared to the previous chest X-ray, no lucency was observed, possibly pneumonia with air cavitation. Her condition worsened during the hospitalization, and on day 8, she was followed by a follow-up by CXR combined with lung ultrasonography (LUS) which revealed multiple large air-filled cavitary lesions in the left lung. Pleural effusion (transudative), pleural thickening, heterogeneous parenchymal echotexture, and no pneumothorax were observed. Chest CT scan images revealed consolidation with multiple cavities or pneumatoceles consistent with necrotizing pneumonia, left pleural effusion density was <25 Hounsfield units (HU), and collapse of the partial left superior lobe. 

Aggressive intravenous antibiotic therapy with meropenem, amikacin, and azithromycin made her condition better. She started showing significant clinical improvement, including resolution of fever and respiratory distress after 3 days of hospitalization. She was discharged on day 7 and advised to continue oral antibiotic therapy. She resumed her usual activities without any respiratory symptoms. A Follow-up chest radiograph, obtained 6 months after hospitalization, revealed no abnormalities.

SOURCE- Uinarni H, Nike F, Bahagia AD. A Successful Medical Treatment of Necrotizing Pneumonia in a Pediatric Patient, Case Reports in Pediatrics,2020;2020.

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