What's Your Diagnosis?

A 7-year-old male with pneumonia

A previously healthy 7-year-old male was admitted to a local hospital on Jan. 20 due to bilateral pneumonia. The illness began about 5 days earlier with cough, congestion, fever to 103°F, with occasional vomiting and diarrhea.

James H. Brien

At that time, the patient was taken to his primary care physician, who diagnosed influenza A by rapid test and began Tamiflu (oseltamivir, Ganentech). Three days later, he returned to his PCP due to increased work of breathing, and he was admitted with secondary pneumonia. By this time, both of the patient’s parents were also diagnosed with influenza. It was quickly apparent that his condition was severe, and he was immediately transferred to the regional children’s hospital PICU.

Source: James H. Brien, DO

Figure 1: Initial chest radiograph.
Figures 2 and 3: A chest CT scan revealing multiple lung abscesses at the time of secondary fever.

The patient’s past medical history is unremarkable, and his immunizations were up to date, except for the seasonal influenza immunization.

Examination revealed a moderately ill 7-year-old with tachypnea, waxing between 50 and 60 breaths per minute, with some mild retractions and flaring. He had a fever of 102°F, and it soon rose to 104°F. His pulse oximetry reading was 85% saturation on room air. His breath sounds revealed coarse rhonchi with some inspiratory rales bilaterally.

Initial lab tests revealed a CBC with significant thrombocytopenia but no leukocytosis, and a C-reactive protein of 70, which rose to 103 in the first day. His initial chest radiograph is shown in Figure 1. A blood culture was obtained at the referring hospital, and the patient was given a dose of ceftriaxone and vancomycin prior to transfer.

He soon developed left-sided empyema, requiring chest tube placement. In the meantime, his blood culture returned positive for pan-sensitive Streptococcus pneumoniae, and the ID consultant recommended changing antimicrobial therapy to penicillin G alone. His fever resolved, and on hospital day 8, his chest tube was removed. However, within a few hours, he began spiking high fevers again, which initially was thought to be related to the pulling of the tube. However, when the fever persisted, a chest CT scan revealed multiple lung abscesses, mostly in the left lower lobe (Figures 2 and 3).

What is your next step?

A. Continue high-dose pen G

B. Return to ceftriaxone plus

vancomycin

C. Reinsert the chest tube

D. Have IR drain the largest abcess

Case Discussion

Our choice was A, to continue high-dose pen G and watch. Within a few days, the fever resolved, and the patient was discharged home on high-dose amoxicillin to complete an 8-week course of therapy, with no further complications. There are some teaching points in this case: (1) Believe your culture when it is from a normally sterile site and makes sense. The pneumococcus is a Gram-positive diplococcus, and a common cause of bacterial pneumonia, thus the name pneumococcus. When the organism is penicillin-sensitive, that is almost always the drug of choice. (2) Another chest tube would not help with lung abscesses. IR could certainly drain the larger abscess shown in Figure 3, but it would be impractical to try to drain the others, potentially causing more problems. Plus, we already know the causative organism, so there is no diagnostic reason to pursue it. (3) Common things occur commonly. There is no reason to think that the patient was infected with any other organism, as he was improving on pen G alone until the tube was removed. While not predictable in every case, it is not unusual to see a spike in inflammatory markers and fever when additional surgery is done in such cases, including tube removal. While I have never seen a study addressing this phenomenon, the presumption is that inflammatory debris is being “stirred up,” releasing mediators that cause more fever. Whatever the underlying cause, it is not unusual. Therefore, giving the patient a tincture of time seems most reasonable, which is all this patient needed, as shown in the patient’s fever curve in Figure 4. (4) Lastly, in the age of antimicrobial stewardship, avoiding broad-spectrum antimicrobial agents should be done when not needed.

Figure 4: The patient’s fever curve.

Disclosure: Brien reports no relevant financial disclosures.

Columnist’s Comments: Last winter (2017-2018), we had one of the worst influenza seasons in many years, complicated by a less-than-optimal immunization product. The CDC classified that season as high severity across all age groups. Nationwide, there were about 80,000 deaths reported, including 183 pediatric deaths; there most certainly must have been many more not reported. The majority of children we saw in our hospital were unimmunized, reflecting similar data reported to the CDC. In some cases, severe influenza with secondary complications occurred in babies too young to receive the immunization or in those with underlying immune defects, or both. Such was the case with a very special premature male we had, who was later found to have congenital asplenia, and succumbed to the complications of pneumococcal sepsis, pneumonia and meningitis in the wake of influenza A (see the August 2018 column). Due to concerns over a lack of efficacy, the live-attenuated nasal vaccine (FluMist, AstraZeneca) was not used in the 2016-2017 or 2017-2018 seasons. However, it is an FDA-approved vaccine and available for this 2018-2019 season. Nonetheless, since there remains some concern, the AAP recommends preferentially using the inactivated vaccine for all children 6 months of age and older. However, the CDC recommends that if parents insist on the nasal spray vaccine to avoid another needle stick, FluMist can be given to healthy children aged 2 years and older, without a contraindication, rather than not giving any vaccine at all.

A previously healthy 7-year-old male was admitted to a local hospital on Jan. 20 due to bilateral pneumonia. The illness began about 5 days earlier with cough, congestion, fever to 103°F, with occasional vomiting and diarrhea.

James H. Brien

At that time, the patient was taken to his primary care physician, who diagnosed influenza A by rapid test and began Tamiflu (oseltamivir, Ganentech). Three days later, he returned to his PCP due to increased work of breathing, and he was admitted with secondary pneumonia. By this time, both of the patient’s parents were also diagnosed with influenza. It was quickly apparent that his condition was severe, and he was immediately transferred to the regional children’s hospital PICU.

Source: James H. Brien, DO

Figure 1: Initial chest radiograph.
Figures 2 and 3: A chest CT scan revealing multiple lung abscesses at the time of secondary fever.

The patient’s past medical history is unremarkable, and his immunizations were up to date, except for the seasonal influenza immunization.

Examination revealed a moderately ill 7-year-old with tachypnea, waxing between 50 and 60 breaths per minute, with some mild retractions and flaring. He had a fever of 102°F, and it soon rose to 104°F. His pulse oximetry reading was 85% saturation on room air. His breath sounds revealed coarse rhonchi with some inspiratory rales bilaterally.

Initial lab tests revealed a CBC with significant thrombocytopenia but no leukocytosis, and a C-reactive protein of 70, which rose to 103 in the first day. His initial chest radiograph is shown in Figure 1. A blood culture was obtained at the referring hospital, and the patient was given a dose of ceftriaxone and vancomycin prior to transfer.

He soon developed left-sided empyema, requiring chest tube placement. In the meantime, his blood culture returned positive for pan-sensitive Streptococcus pneumoniae, and the ID consultant recommended changing antimicrobial therapy to penicillin G alone. His fever resolved, and on hospital day 8, his chest tube was removed. However, within a few hours, he began spiking high fevers again, which initially was thought to be related to the pulling of the tube. However, when the fever persisted, a chest CT scan revealed multiple lung abscesses, mostly in the left lower lobe (Figures 2 and 3).

What is your next step?

A. Continue high-dose pen G

B. Return to ceftriaxone plus

vancomycin

C. Reinsert the chest tube

D. Have IR drain the largest abcess

PAGE BREAK

Case Discussion

Our choice was A, to continue high-dose pen G and watch. Within a few days, the fever resolved, and the patient was discharged home on high-dose amoxicillin to complete an 8-week course of therapy, with no further complications. There are some teaching points in this case: (1) Believe your culture when it is from a normally sterile site and makes sense. The pneumococcus is a Gram-positive diplococcus, and a common cause of bacterial pneumonia, thus the name pneumococcus. When the organism is penicillin-sensitive, that is almost always the drug of choice. (2) Another chest tube would not help with lung abscesses. IR could certainly drain the larger abscess shown in Figure 3, but it would be impractical to try to drain the others, potentially causing more problems. Plus, we already know the causative organism, so there is no diagnostic reason to pursue it. (3) Common things occur commonly. There is no reason to think that the patient was infected with any other organism, as he was improving on pen G alone until the tube was removed. While not predictable in every case, it is not unusual to see a spike in inflammatory markers and fever when additional surgery is done in such cases, including tube removal. While I have never seen a study addressing this phenomenon, the presumption is that inflammatory debris is being “stirred up,” releasing mediators that cause more fever. Whatever the underlying cause, it is not unusual. Therefore, giving the patient a tincture of time seems most reasonable, which is all this patient needed, as shown in the patient’s fever curve in Figure 4. (4) Lastly, in the age of antimicrobial stewardship, avoiding broad-spectrum antimicrobial agents should be done when not needed.

Figure 4: The patient’s fever curve.

Disclosure: Brien reports no relevant financial disclosures.

Columnist’s Comments: Last winter (2017-2018), we had one of the worst influenza seasons in many years, complicated by a less-than-optimal immunization product. The CDC classified that season as high severity across all age groups. Nationwide, there were about 80,000 deaths reported, including 183 pediatric deaths; there most certainly must have been many more not reported. The majority of children we saw in our hospital were unimmunized, reflecting similar data reported to the CDC. In some cases, severe influenza with secondary complications occurred in babies too young to receive the immunization or in those with underlying immune defects, or both. Such was the case with a very special premature male we had, who was later found to have congenital asplenia, and succumbed to the complications of pneumococcal sepsis, pneumonia and meningitis in the wake of influenza A (see the August 2018 column). Due to concerns over a lack of efficacy, the live-attenuated nasal vaccine (FluMist, AstraZeneca) was not used in the 2016-2017 or 2017-2018 seasons. However, it is an FDA-approved vaccine and available for this 2018-2019 season. Nonetheless, since there remains some concern, the AAP recommends preferentially using the inactivated vaccine for all children 6 months of age and older. However, the CDC recommends that if parents insist on the nasal spray vaccine to avoid another needle stick, FluMist can be given to healthy children aged 2 years and older, without a contraindication, rather than not giving any vaccine at all.