5-year-old patient in respiratory distress

Issue: July 2010

A 5-year-old boy was admitted to the hospital with respiratory distress. He was seen in the clinic earlier in the day with fever, chills, cough and dehydration. The history of this illness included a brief, febrile, coughing illness about 7 days earlier, along with three other family members. Several days into their illnesses, one of the family members was diagnosed with influenza A. As they were all recovering, this child had the sudden worsening that took him back to his primary provider’s office.

His past medical history was that of a healthy 5-year-old male, whose immunizations are up to date.

Examination revealed an alert child with a respiratory rate of 55 with good saturations on room air, pulse of 145, and a temperature of 102°F. His capillary refill was 3 seconds after a fluid bolus in the ER. His lung sounds consisted of some rales with no air movement in the right base. He had nasal flaring and mild retractions. His chest was dull to percussion on the right. His color was a bit pale, but the rest of his exam was unremarkable.


The patient’s chest radiograph (right lateral decubitus) and CT scan. Photos courtesy of James H. Brien

His WBC count was 22,000 with 78% granulocytes, and a blood culture is pending. His chest radiograph (right lateral decubitus) and CT scan are shown in Figures 1 and 2. The impression at this point was bacterial pneumonia with effusion and possible sepsis with early shock. An additional 20 mL/kg bolus of normal saline was given and treatment was begun with IV ceftriaxone at 100 mg/kg every 24 hours plus vancomycin at 60 mg/kg/day, divided every 6 hours.

What’s Your Diagnosis (most likely cause)?

Staphylococcus aureus
Streptococcus pneumoniae
Group A Streptococcus
Haemophilus influenzae b

Case Discussion

Statistically, the most likely cause is (B), Streptococcus pneumoniae. That is why it is often called the pneumococcus. There is no reliable clinical feature that would point more toward staph and away from Strep. pneumoniae, except one might expect Staphylococcus aureus to result in a more aggressive course in some cases, and may be more likely to result in abscess formation (Figures 3 & 4), but I am never surprised anymore as to what may be grown in cases like this.


Abcess formed by Staphylococcus aureus, shown in the figures above.

One of the most difficult cases of pneumonia with effusion with which I have been involved was caused by Bacillus cereus in an otherwise healthy child. Group A strep pneumonia is also very likely to result in a severe empyema. After all, it is also known as Streptococcus pyogenes. Sometimes the name says a lot more than simply identifying the organism. Etiology may be influenced by underlying conditions, such as cystic fibrosis, immune deficiency, immunization status (especially against Haemophilus influenzae b), and underlying anatomic abnormalities such as bronchiectasis (Figure 5) or by geography. According to Sarah Long’s textbook, Staph. aureus appears to be the most common cause of complicated parapneumonic effusion in South Asia. It always helps to know your own geographic area.

CT scan of a patient with bronchiectasis.

Management of these complicated parapneumonic effusions has been controversial, certainly not standardized and certainly not in children.

One basic premise that never changes is that knowing the organism is key to proper antimicrobial therapy. This usually involves obtaining some of the fluid for culture and sensitivity testing. This can be done by needle thorocentesis or by tube thoracotomy. In some cases, a good specimen may be obtained by bronchoscopy. In any case, available scientific data would indicate that further management might include tube drainage. Adjunctive therapy with intrathoracic antibiotics and/or fibrinolytics are frequently recommended. However, intrathoracic antibiotics have not been shown to make any difference. Intrathoracic fibrinolytics are recommended by some experts and are often used in the ICU setting, and while additional fluid can often be drained with their use, they also lack good scientific evidence for benefit in affecting the overall outcome in children and may actually be detrimental in some when they are absorbed. In most cases, nothing can take the place of drainage and physical debridement of purulent material and debris, as shown in Figures 6 and 7 (the patient presented). There are growing data supporting the early use of video-assisted thorascopic surgery (VATS), as shown in Figure 8, to achieve the same results with a less invasive procedure. This technique can also allow for better placement of the chest tube after the procedure. I will not argue with anyone wanting to take a more conservative approach, as the most will eventually get better over time without this more aggressive approach. But, at least in our experience, those children remain in the hospital much longer, sometimes even going home with a chest tube still in place. Maybe someone out there is doing a good large, randomized prospective study of treating complicated pneumonias that will give better guidance. Till then, read the mixed literature and make your own choice.


Drainage and physical debridement of purulent material and debris.

There are many antibiotic choices for this situation, but for a child who is very sick with severe pneumonia, I would recommend empiric therapy with vancomycin plus ceftriaxone (or similar broad-spectrum cephalosporin), pending culture results.

The procedures shown in Figures 6 and 7 can be done less invasively with video-assisted thorascopic surgery (VATS), as shown above.

It would be very rare to see Haemophilus influenzae type b causing pneumonia nowadays, but that was the cause of one of the first cases I saw early in my career. Always ask about immunizations. If incomplete for Hib, it should remain in the differential pending cultures. Also, if you see gram-negative diplococci in the exudate of one of these incompletely immunized children, consider H. influenza with bipolar staining in the differential until culture results identify the organism.

Our patient recovered without complications.

Columnist confession (that’s right, confession)

I read and pay attention to all the evaluations and feedback provided to me after meetings where I have been on the program. Over the years, I have made numerous changes in my content and presentation style based on this feedback. I value constructive criticism above all else, even praise. No one improves by hearing how great they are.

I saw a comment from a meeting last year that said (in so many words) that the speaker for the Visual Diagnosis presentation should be more knowledgeable and be a better presenter. I could not agree more. I am an academic phony; little more than a fair photographer of patients and reporter of other people’s research, as I put together cases I have seen, or that have been sent to me by others. I have published very few peer-reviewed papers. I would like to think that I had (or have) some sort of learning disorder, perhaps brought on by my mother’s drinking and smoking during pregnancy, but alas, I think I’m just not that bright. All I have is a strong work ethic and the ability to know where to find the answers, and I suspect there are many of you out there who are just like me.

James H. Brien, DO

Vice Chair for Education at The Children’s Hospital at Scott and White and Associate Professor of Pediatrics at Texas A&M University, College of Medicine, Temple, Texas. E-mail: jhbrien@aol.com.
e-mail:jhbrien@aol.com

The reason I am bringing up this confession now is to give credit where it belongs. When I was a student, I worked hard to get into a very strong Army residency, then immediately began struggling to keep up. By December of my PL-1 year, I was on probation with some tough choices to make; either stay the course with remediation or get out and be a general medical officer. With the support of my chairman and other staff and the commitment of two of my upper-level residents, I obviously stayed the course. These residents, Jim Bowen (now a child psychiatrist in Arizona) and Dick Eckert (pediatric emergency medicine in Georgia), tutored me every day of the week at noon for more than a month and many nights on call for the rest of the year, filling in the cracks in my foundation. I learned that with hard work, you can do just about anything, eventually making it to fellowship with Jim Bass about 4 years later.

Well, Dick Eckert died May 12 of complications of a lung transplant due to pulmonary fibrosis. His obituary can be found at: www.plattsfuneralhome.com/common/content.asp?PAGE=339.

Please take a moment to read about this remarkable physician, educator and human being. He was an airborne ranger and warrior; West Point honor graduate with two tours in Vietnam, earning two purple hearts, three bronze stars, and two silver stars, among others. He then decided that pediatrics was his calling. That’s where, to my good fortune, our paths crossed.

So, because of Dick and the example he set, I will keep working hard, trying to appear to belong among the more academically talented, but now you know, it’s just a facade. Even so, without Dick’s role in my remediation in 1977, I don’t know what I would be doing today, but it probably would not be this.