GROUP: 5

PEDIATRIC COMMUNITY
ACQUIRED PNEUMONIA
1. BILAOEN, Marianne 6. DUBEY, Aniruddh
2. CAOILI, Stephen 7. GOTI, Mansi
3. DAVE, Drumil 8. PARMAR, Mansi
4. DAVE, Pruthvi 9. PARMAR, Vishalkumar
5. DUBAL, Dimple 10. SAMA, Anjum
 OBJECTIVES

● To discuss a case of PCAP

● To discuss proper history and physical examination for a pediatric patient with
PCAP
● To discuss salient points of the case presented today.
 HISTORY
General Data:
• T.L.
• 8 Months old, Male
• Roman catholic
• Born on June 3,2021 at City of Canon Hospital
• Address: Balaoan La Union
• Date of admission: February 12, 2022 (1 st time)
• Informant: Mother and Patient
• Percent reliability: 95%
Chief Compliant
COUGH
 History of Present Illness
5 DAYS PTA: 3 DAYS PTA: Few Hours PTA:
(+) occasional coughing (+) productive cough - Condition persisted hence
episodes (+) associated fever and consult.
(+) febrile episode decrease feeling
(-) difficulty of breathing - No consult was done
(-) vomiting
(-) loss of appetite
(-) cyanosis
 Past Personal and Medical History
PRENATAL HISTORY NATAL HISTORY POSTNATAL HISTORY

o 23 y/o; G1P1 (1001)
o Cognizant at 16 weeks AOG
o Prenatal care: 20 weeks AOG
o Total of 3 prenatal check up
done irregularly
o UTZ - 24 weeks (live,
singleton pregnancy)
o (-) history of exposure
o Term via NSVD o Breastfed with good suck
o BW: 3kg o New born screening results
o BL: 54cm were unrecalled
o AS: 8 becoming 9
o Ballard score: 38 weeks
o No resuscitative measure
done
 Feeding history
o Breastfeeding – per demand
o Complementary foods (was introduce at 6 months of age – consumes
200ml/feeding (10x a day)
o Semi-solid foods – introduce at 5 months
o Currently with no supplementation
 Development
o At par with age

Social development:
-Patients sleeps 10 in the evening and wakes up at 8 in the morning.
-Non/toilet trained, interacts with family and peers with/without
discipline problems.
 Immunization History
VACCINE 1ST Dose 2nd Dose 3rd Dose Booster
BCG ✔
DPT ✔ ✔ ✔
OPV ✔ ✔ ✔
Hepatitis B ✔ ✔ ✔ ✔
Measles ✔
MMR ✔
Influenza ✔
Pneumococcal ✔
Rotavirus ✔ ✔
Meningococcal ✔ ✔
Varicella ✔ ✔
 Past Medical History
a. Past hospitalization c. Allergies
- none - none
b. Childhood illness d. Current medications
- none - none
 Family History
o Both parents are well
o (-) bronchial asthma
o (-) hypertension
o (-) DM
o (-) arthritis
o (-) CVD
o (-) CAD
o (-)malignancy
o (-) twinning,
 Social and Enivronmental History
o Father – 35y/o, farmer
o Mother – 35 y/o, a house wife
- Primary care giver
o Patient – 1ST child
o No family member with same illness
o Non - congested neighborhood
o Bungalow type house with 2 rooms with 3 occupants
o Source of water: Domestic purposes- deep well
: Drinking water – refilling station, not boiled
o No pets
o Garbage is collected regularly every Sunday
o Toilet is flushed type
o Handwashing practice not done
 REVIEW OF SYSTEM

General Survey (-)weight loss (-) febrile episodes (-)chills (-)sweats (-) incessant crying
(-) irritability; (+)Fair good oral intake; (-) lethargy

Integumentary (-)cyanosis, (-)pallor, (-)lesion, (-)dryness, (-)rash, (-)itching, (-)moles,

(-)sores, (-)hives, (-)pigmentation

Head and neck Head: (-)lesion (-)trauma (-)swelling (-)headache (-)pain (-)stiffness
Eyes: (-)tearing (-)itching (-)redness (-)discharges (-)pain (-)dryness (-)
diplopia (-)infection
Ears: (-)discharges (-)pain (-)tinnitus (-)vertigo (-) hearing loss
Nose: (-)dryness (-)congestion (-) colds (-)sneezing (-)pain (-)obstruction
(-)bleeding
Mouth and Throat: (-)soreness (-)pain (-)infection (-)ulcers (-)hoarseness
(-)dryness (-)gum bleeding (-)dental caries (-)tongue lesion (-)dysphagia
Breast discharges (-)lumps (-)bleeding (-)infection
respiratory (-)cough (-)sputum (-)pain (-)dyspnea (-)hemoptysis (-)cyanosis

Cardiovascular -)cyanosis (-)palpitations (-)murmur (-)known CHD (-)RF/RHD

Gastrointestinal good appetite (-)anorexia (-)abdominal pain (-)vomiting (-)nausea

(-)diarrhea (-)constipation (-)flatulence (-)melena (-)hematochezia
(-)change in bowel habits (-)hernia (-)jaundice (-)hepatitis
Urinary and renal (-)dysuria (-)nocturia (-)incontinence (-)frequency (-)stones (-)infections

Genital (-)pain (-)swelling (-)discharges (-)tenderness (-)itch

Musculoskeletal (-)deformities (+)pain (-)swelling (-)tenderness (-)cramps (-)weakness

(-)trauma (-)sprains (-)fractures (-)stiffness (-)backache
Endocrine (-)polydipsia (-)polyphagia (-)hair change (-)weight change (-)
temperature intolerance
Hematologic (-) bleeding (-)bruising (-)transfusions (-)malignancy (-) anemia

Neurologic (-)syncope (-)dizziness (-)seizures (-)convulsions (-)tremors

(-)coordination problems (-)sensory disturbances (-)motor problems
(-)memory problems
 PHYSICAL EXAM
General survey Awake, irritable, in respiratory distress

Vital sigs BP: 80/60 mmHg CR: 132 bpm RR: 65 bpm Temp: 39
Anthropometric Weight: 10 kg (0 SD) Height: 88 cm (0 SD)

Skin (-)pallor (-)jaundice cold to touch; good skin turgor (-)rashes

(-)petechiae (-)pigmentation with noted previously healed multiple scar lesions at
the lower extremities
HEENT Head: (-) scars (-) lesions (-) gross deformities, normal hair disatribution (-)
tenderness
Eyes: non-sunken eyeballs, (-) periorbital edema, anicteric sclera, pink
palpebral conjunctiva, intact corneal firm, pupils ERTL, (-)discharges
Ears: abnormally set ears (-) discharges (-) impacted cerumen, intact TM
Nose: (-) discharges (-) congestion (-) alar flaring
Mouth & pharynx: moist lips & mucosa (-) circumoral cyanosis (-) TP wall
congestion (-) ulcers (-) exudates (-) enanthem (-) pigmentation
Neck: supraclavicular and suprasternal retractions, (-)neck vein
engorgement (-) CLAD (-) tenderness
Chest and Lungs SCWE (-)lagging (-)retraction (+) diffuse rales (-)wheeze (-)rhonchi

Heart Adynamic precordium, PMI at 4th ICS LMCL, tachycardia and regular
rhythm (-)thrills (-)murmurs
Abdomen Flat, non-distended, normoactive bowel sounds, tympanitic, soft
(-)tenderness (-)masses (-)organomegaly
Genitalia Grossly male

Extremities No gross deformities, full and equal pulses, >2 sec capillary refill,
(+)Grade 3 bipedal edema
Neurologic Cerebellum: (-)tremors (-)nystagmus (-)ataxia
Cranial nerves: Cranial nerve IX and X : (+)gag reflex rest is
unremarkable
Sensory: 100% on all extremities
Motor: 5/5 in all extremities
Reflexes: 2+ on all extremities
 Laboratory results
complete blood count
Hgb 110 110-140

Hct 35 35-45

WBC 17 6-10

Neutrophils 80% 40-50

Lymphocytes 20% 30-40

Monocytes 0.3 1

Platelet 453 150-450

Chest X-ray Findings
 Salient Features

o General Data: 8 months old male

o Physical examination: In respiratory distress
o : vital signs- RR: 65 bpm, temperature: 39 degree
celsius
: Musculoskeletal – pain
: HEENT – supraclavicular and suprasternal
retraction
: Chest and lungs – diffuse rales
: Extremities – grade 3 bipedal edema
Admitting Diagnosis
PEDIATRIC COMMUNITY
ACQUIRED PNEUMONIA
 Differential Diagnosis
Community Acquired Pneumonia
RULE IN RULE OUT

• FEVER (+)
• COUGH(+)
• ABNORMAL LUNG SOUNDS
(RALES)(+)
• TACHYPNEA (RR-65)(+)
• AGE < 5 YRS (+)
• MALE(+)
• TACHYCARDIA(+)
 Cystic Fibrosis

RULE IN RULE OUT

• COUGH (+) • ANY OTHER ABNORMALITY IN

• TACHYPNEIC – RR 65(+)
• FEVER(+)
• LEUKOCYTOSIS(+)
• DECREASE FEEDING(+)
GI OR GENITOURINARY
PROBLEMS (-)
• CHEST PAIN (-)
• CLUBBING OF FINGERS(-)
• FAMILY HISTORY OF CYSTIC
FIBROSIS(-)
 Acute bronchitis

RULE IN RULE OUT

• NO OTHER FOCAL CHEST

• COUGH (+) SIGN, DULLNESS TO
• FEVER(+) PERCUSSION,
• LEUKOCYTOSIS(+) CREPITATIONS,VOCAL
• DECREASE FEEDING(+) FREMITUS
 Management
Relevant PE - Awake, weak-looking, in distress
- Cough
- Tachypnea (RR:65 bpm)
- Fever (39)
- Diffuse rales

Patient classification risks PCAP C (moderate risk)

- Less than 11 months old
- RR: 65 bpm
- Suprastrenal retraction
Management - Admit to regular ward
- Monitor oxygen saturation using pulse oximetry.
- Empiric antibiotic therapy: ampicillin (100mg/kg/day every 6 hrs)
- Bacterial culture: to determine etiologic agent and monitor treatment
Ancillary treatment - Adequate hydration
- Bronchodilator if wheezing is present
If patient does not - Repeat chest radiograph
improve - Consider viral etiology
Pediatric Community Acquired
Pneumonia
 Etiology

o Noninfectious causes include aspiration (of food or gastric acid, foreign bodies,
hydrocarbons, and lipoid substances), hypersensitivity reactions, and drug- or radiation-
induced pneumonitis.
o The cause of pneumonia in an individual patient is often difficult to determine because
direct culture of lung tissue is invasive and rarely performed
o Streptococcus pneumoniae (pneumococcus) is the most common bacterial pathogen in
children 3 wk to 4 yr of age, whereas Mycoplasma pneumonia and Chlamydophila
pneumoniae are the most frequent bacterial pathogens in children age 5 yr and older.
o S. pneumoniae, H. influenzae, and S. aureus are the major causes of hospitalization and
death from bacterial pneumonia among children in developing countries.
o Viral pathogens are a prominent cause of lower respiratory tract infections in infants and
children older than 1 mo but younger than 5 yr of age.
o Sensitivity and Specificity of Molecular Diagnostic tests for viruses are 40-80%
● Lower respiratory tract viral infections are
much more common in the fall and
winter in both the northern and southern
hemispheres in relation to the seasonal
epidemics of respiratory viral infection
that occur each year.
● Immunization status is relevant because
children fully immunized against H.
influenzae type b and S. pneumoniae are
less likely to be infected with these
pathogens.
 Epidemiology
o • Pneumonia, defined as inflammation of the lung
parenchyma.
o • Leading cause of death globally among children <
5 years old.
o • The World Health Organization (WHO) estimates
there are 156 million cases of pneumonia each year
in children younger than five years, with as many as
20 million cases severe enough to require hospital
admission.
o • Estimated 1.2 million (18% total) deaths annually.
o • South Asia and sub-Saharan Africa together bear
the burden of more than half of all childhood
pneumonia cases worldwide.
o • Almost three-quarters of all childhood pneumonia
cases occur in just 15 countries.
o Improved access to healthcare in rural areas and o
Introduction of vaccines were contributors to the
further reductions in pneumonia-related deaths
over the past decades.
The incidence of pneumonia is more than 10-fold
higher (0.29 episodes vs 0.03 episodes), and the
number of childhood-related deaths from
pneumonia ≈2,000 fold higher, in developing than in
developed countries.
 Pathophysiology

o Pneumonia results from the proliferation of microbial pathogens at the alveolar level and
the host’s response to those pathogens.
o CAP caused by any infectious agents outside the hospital or health care environment.
o The extensive list of potential etiologic agents in CAP includes bacteria, fungi, viruses, and
protozoa.
o Mode of transmission: microorganisms gain access to the lower respiratory tract in
several ways.
1. Aspiration of infectious respiratory droplets
2. Hematogenous spread
3. Airborne
o The lower respiratory tract is normally kept sterile by
 physiologic defense mechanisms - mucociliary clearance, the properties of normal
secretions such as secretory immunoglobulin (Ig) A, and clearing of the airway by
coughing
 Immunologic defense mechanisms - macrophages that are present in alveoli and
bronchioles, secretory IgA, and other immunoglobulins.
 VIRAL PNEUMONIA BACTERIAL PNEUMONIA

results from spread of

infection along the airways occurs when respiratory tract organisms
colonize the trachea and subsequently
gain access to the lungs

accompanied by direct injury

of the respiratory epithelium

may also result from direct seeding of

lung tissue after bacteremia
results in airway obstruction from
swelling, abnormal secretions, and
cellular debris
• When bacterial infection is established in the lung parenchyma, the pathologic process
varies according to the invading organism.
a) M. pneumonia
• attaches to the respiratory epithelium, inhibits ciliary action, and leads to cellular destruction and
an inflammatory response in the submucosa
• As the infection progresses, sloughed cellular debris, inflammatory cells, and mucus cause airway
obstruction, with spread of infection occurring along the bronchial tree
b) S. pneumoniae
• produces local edema that aids in the proliferation of organisms and their spread into adjacent
portions of lung
• often resulting in the characteristic focal lobar involvement
b) Group A streptococcus
• results in more diffuse infection with interstitial pneumonia
• pathology includes necrosis of tracheobronchial mucosa; formation of large amounts of exudate,
edema, and local hemorrhage, with extension into the interalveolar septa; and involvement of
lymphatic vessels and the increased likelihood of pleural involvement
c) S. aureus
• confluent bronchopneumonia, which is often unilateral and characterized by the presence of
extensive areas of hemorrhagic necrosis and irregular areas of cavitation of the lung parenchyma,
resulting in pneumatoceles, empyema, or, at times, bronchopulmonary fistulas

 Recurrent pneumonia
• defined as 2 or more episodes in a
single year or 3 or more episodes ever,
with radiographic clearing between
occurrences
• An underlying disorder should be
considered if a child experiences
recurrent pneumonia
 Pattern of involvement
1) Bronchopneumonia - pneumonia affecting the
tissue around the bronchi and/or bronchioles
and adjacent alveoli
2) Lobar pneumonia - pneumonia affecting one
lobe of a lung
o Multilobar pneumonia refers to the
involvement of multiple lobes in a single lung or
both lungs.
oPanlobar pneumonia involves all the lobes of
a single lung.
3) Interstitial pneumonia - pneumonia affecting
the tissue between the alveoli, manifests as atypical
pneumonia
 Diagnostics
o Diagnosis of community-acquired pneumonia (CAP) is primarily based on history
and physical findings.
o Laboratory and radiographic exams may aid in the diagnosis of severe cases or in
patients who failed to show clinical improvement after initiation of antibiotic
therapy.

History
o Patient’s age
o Age is a good predictor of the causative agent
o Viruses are often linked in up to 50% of pneumonia in young children
o S.pneumoniae followed by atypical pneumonia (eg Mycoplasma and Chlamydia)
is the most likely pathogen in older children with pneumonia of bacterial origin
 Immunization status
o is important because children fully immunized against Haemophilus influenza type B and
S pneumoniae are less likely to be infected with these pathogens
o Symptoms may include fever, difficulty in breathing, cough, chest or abdominal pain with
or without vomiting, headache

Physical Examination
o Combination of clinical findings are more predictive in diagnosing community-acquired
pneumonia (CAP)
Check for temperature
o Fever in viral pneumonia is generally lower than in bacterial pneumonia; bacterial
pneumonia presents with persistent or recurrent temperatures of ≥38.5°C over the prior
24-48 hours
Respiratory rate (RR)
o Study shows significant correlation between RR and oxygen saturation
o Less sensitive and specific in the first 3 days of illness
o Tachypnea may be a marker for respiratory distress and/or hypoxemia but may also be
secondary to fever, dehydration or concurrent metabolic acidosis
o Criteria for tachypnea based on age as defined by World Health Organization (WHO):
o ≥60 breaths/minute in <2 months old
o ≥50 breaths/minute in 2-11 months old
o ≥40 breaths/minute in 1-5 years old
o >20 breaths/minute in ≥5 years old
Respiratory signs
o may include intercostal, subcostal, or suprasternal retractions, nasal flaring, crackles or
wheezing on auscultation
o Decreased breath sounds, scattered crackles, or rhonchi are usually heard over the
affected lung field in the early course of illness
o Dullness on percussion and decreased breath sounds are usually appreciated when
increased consolidation and complication develops
o Ancillary diagnostic test:
- Complete blood count
- Pulse oximetry
- Chest x ray
Microbiology
Aids in determining the causative agent to
provide a narrow-spectrum antimicrobial
therapy that targets a specific bacteria or virus
Blood culture is not routinely done in a nontoxic,
fully immunized children with community-
acquired pneumonia (CAP)
Sputum Gram stain and culture
is recommended in hospitalized older children
and adolescents with more severe disease or in
those in whom outpatient therapy has failed
 Treatment
o Hospitalized child requires an approach based on the clinical manifestations
at the time of presentation.

o Mildly ill children - amoxicillin is recommended. High doses of amoxicillin (80-

90 mg/kg/24 hr) should be prescribed (due to emergence of penicillium
resistant pneumococci). cefuroxime axetil and
amoxicillin/clavulanate( alternatives).

o For school-age children and in children having infection with M. pneumoniae

or C. pneumoniae -macrolide antibiotic such as azithromycin .

o In adolescents, a respiratory fluoroquinolone (levofloxacin, moxifloxacin)

 Treatment
● The World Health Organization and other international groups have
developed systems to train mothers and local healthcare providers in the
recognition and treatment of pneumonia.
● Despite substantial gains over the past decade, in developing countries only
≈60% of children with symptoms of pneumonia (≈50% in sub-Saharan Africa)
are taken to an appropriate caregiver, and less than one-third receive
antibiotics.
● For children who do not meet these criteria, ceftriaxone or cefotaxime should
be used.
● If clinical features suggest staphylococcal pneumonia (pneumatoceles,
empyema), initial antimicrobial therapy should also include vancomycin or
clindamycin.
● If viral pneumonia is suspected and are in no respiratory distress - give
antibiotic therapy.
 Treatment
● However, up to 30% of patients with known viral infection, particularly
influenza viruses, may have coexisting bacterial pathogens.

● Therefore, if the decision is made to withhold antibiotic therapy on the basis

of presumptive diagnosis of a viral infection, deterioration in clinical status
should signal the possibility of superimposed bacterial infection, and antibiotic
therapy should be initiated.

● Antibiotics should generally be continued until the patient has been afebrile
for 72 hr, and the total duration should not be less than 10 days (or 5 days if
azithromycin is used). Shorter courses (5-7 days) may also be effective,
particularly for children managed on an outpatient basis.

● In developing countries, oral zinc (10 mg/day for <12 mo, 20 mg/day for ≥12
mo) reduces mortality in children with clinically defined severe pneumonia.
 Prevention
● Some evidence exists to suggest that vaccination has reduced the incidence of
pneumonia hospitalizations.
● In February 2000, the 7-valent pneumococcal conjugate vaccine (PCV7) was
licensed and recommended. In 2006, the pneumonia hospitalization rate in
this age group was 8.1 per 1,000 children, a 35% decrease from the prevaccine
rate. Although these data do not
● establish that PCV7 directly reduced pneumonia hospitalization rates, they do
suggest that vaccination has resulted in a sustained benefit in preventing
hospitalization for young children with pneumonia.

● In 2010, the 13-valent pneumococcal conjugate vaccine (PCV13) was licensed

in the United States; it may prevent even more cases of pneumococcal disease
not covered by the PCV7 vaccine.

● The expansion of influenza vaccine recommendations to include all children

>6 mo of age in 2010 might be expected to affect pneumonia hospitalization
rates in a similar fashion, and ongoing surveillance is warranted.
 Reference
o Nelson textbook of pediatrics 20th Edition
o World Health Organization. Pneumonia is the leading cause of death in children. World
Health Organization resource page; 2011 [Accessed 16 April 2020]. Available at:
https://www.who.int/maternal_child_adolescent/news_events/news/2011/pneumonia/en
o Bernadeta Dadonaite and Max Roser - "Pneumonia". Published online at
OurWorldInData.org. Retrieved from: 'https://ourworldindata.org/pneumonia' [Online
Resource]
o http://specialty.mims.com/pneumonia%20-%20community-acquired%20(pediatric)/
diagnosis? channel=paediatricst