Multiple Episodes Of Pneumonia Research Articles

An Adjudication Protocol for Severe Pneumonia.

Clinical end points that constitute successful treatment in severe pneumonia are difficult to ascertain and vulnerable to bias. The utility of a protocolized adjudication procedure to determine meaningful end points in severe pneumonia has not been well described. This was a single-center prospective cohort study of patients with severe pneumonia admitted to the medical intensive care unit. The objective was to develop an adjudication protocol for severe bacterial and/or viral pneumonia. Each episode of pneumonia was independently reviewed by 2 pulmonary and critical care physicians. If a discrepancy occurred between the 2 adjudicators, a third adjudicator reviewed the case. If a discrepancy remained after all 3 adjudications, consensus was achieved through committee review. Evaluation of 784 pneumonia episodes during 593 hospitalizations achieved only 48.1% interobserver agreement between the first 2 adjudicators and 78.8% when agreement was defined as concordance between 2 of 3 adjudicators. Multiple episodes of pneumonia and presence of bacterial/viral coinfection in the initial pneumonia episode were associated with lower interobserver agreement. For an initial episode of bacterial pneumonia, patients with an adjudicated day 7-8 clinical impression of cure (compared with alternative impressions) were more likely to be discharged alive (odds ratio, 6.3; 95% CI, 3.5-11.6). A comprehensive adjudication protocol to identify clinical end points in severe pneumonia resulted in only moderate interobserver agreement. An adjudicated end point of clinical cure by day 7-8 was associated with more favorable hospital discharge dispositions, suggesting that clinical cure by day 7-8 may be a valid end point to use in adjudication protocols.

Association Between Oral Health and Swallowing Function in the Elderly.

Although the oral environment significantly affects the risk of pneumonia, there have been few studies regarding its relation with swallowing. There is no doubt that there is a significant link between the oral environment and the development of pneumonia; however, there have been few comparative studies of swallowing using video endoscopy (VE) and video fluorography (VF) as indicators to determine the actual availability of oral intake and the choice of food form. This study was performed to examine whether the oral environment or swallowing function contributes more to the development of pneumonia in the elderly. The study population consisted of 24 patients (7 men and 17 women; age range: 64-97 years; average age: 86 years) assessed using the Oral Health Assessment Tool (OHAT), VE and VF at Fukuoka Dental College Hospital. The most common disease was pneumonia (17 patients), followed by cerebral infarction (5 patients), pyelonephritis (4 patients), bronchitis (2 patients), Parkinson's disease (2 patients), scleroderma (1 patient), diabetes (1 patient), eosophageal cancer (1 patient) and Parkinson's syndrome> (1 patient). Some patients had multiple diseases. Oral intake was possible in 20 patients (80%), whereas tube feeding and gastric banding were required in 4 patients. The OHAT score was not correlated with either the VE or VF score. Furthermore, the OHAT score was not significantly different between the multiple- and no/single-pneumonia episode groups. The group with multiple episodes of pneumonia had lower VE and VF scores than those with no or only a single episode of pneumonia. Oral assessment, VE and VF are necessary to evaluate swallowing in patients with suspected dysphagia. Swallowing function, especially as assessed by VE and VF, is more important than examination of the oral environment for evaluating risk of recurrent aspiration pneumonia in the elderly. In addition, multiple factors contribute to recurrent pneumonia in patients with a good oral environment, including subclinical aspiration, pharyngeal clearance and delayed activation of the gag reflex.

Whole-exome sequencing identification of novel DNAH5 mutations in a young patient with primary ciliary dyskinesia

Primary ciliary dyskinesia (PCD) is a rare genetic disorder caused by structural and/or functional impairment of cilia throughout the whole body. Early diagnosis of PCD is important for the prevention of long-term sequelae, however early diagnosis is a challenge due to the phenotypic heterogeneity of PCD. In the current study, the patient with PCD was diagnosed at nine years old following several efforts to control intractable airway symptoms. The patient experienced a chronic productive cough beginning in early childhood and had multiple episodes of pneumonia and otitis media with effusion and sinusitis. No situs inversus or other heterotaxias were reported. Serial chest X-rays exhibited persistent atelectasis and bronchiectasis in the right middle lobe. When the patient was nine years old, electron microscopy of his cilia and genetic analysis were conducted. Electron microscopy of a biopsy specimen from the nasal mucosa indicated loss of the outer dynein arms. Whole-exome analysis of the genome demonstrated the presence of compound heterozygous mutations in DNAH5: NM_001369.2:c.5983C>T, p.Arg1995X in exon 36 and NM_001369.2:c.9101delG, p.Gly3034ValfsX22 in exon 54; neither of which have been previously reported in the literature in a Japanese patient. Notably, this case is, to the best of our knowledge, the first reported case of PCD caused by the DNAH5 mutation in a Japanese patient.

DOCK8 deficiency and guillain-barre syndrome

Results R. I. M., 10 year-old-boy that was referred to us with history of recurrent otitis media, sinusitis, and multiple episodes of pneumonia, palmo-plantar warts, and severe contagious molusco. He also has history of severe atopic dermatitis, asthma and food allergies. On evaluation he was noted to have persistent eosinophilia, lymphopenia, normal IgG levels, absent specific antibody response and decreased CD4 and CD8 T cells. Based on history of severe atopy, sinopulmonary infections, recurrent staphylococcal and viral skin infections DOCK8 deficiency was suspected. Since the suspicious, he started the use of daily cotrimazol and monthly immunoglobulin (500 mg/kg). DOCK8 gene sequencing and duplications/deletions analysis was done and there were found deletions in compound heterozygosis (Alelle 1: deletion of exons 3 to 33; Alelle 2: deletion of exons 16 and 20-24). The diagnosis was confirmed. At age 11 year, 2 weeks after a viral disease, he started a weakness involving the arms, legs, and truncal muscles, which had a rapid progression (less than 24 h). He performed an investigation with a normal magnetic resonance and the study of nerve conduction showed specific findings consistent with demyelination characteristic for classic Guilain-Barre Syndrome. He received immunoglobulin in a dose of 2g/kg and evaluated with resolution of the neurologic symptoms. Currently, he keeps receiving monthly immunoglobulin and prophylactic cotrimazol daily and showed no new serious infections. It was found a compatible bone marrow donor and he is being prepared to transplantation.

Co-morbidities Leading to Mortality or Hospitalization in Children with Down Syndrome and its Effect on the Quality of Life of their Parents

To study factors leading to mortality or hospitalization in children with Down syndrome and its effect on the quality of life of their parents. The study was retrospective questionnaire based study conducted over 2 mo period at a genetic outpatient setting of a teaching medical college hospital. Seventy children with suggestive phenotype and confirmed Trisomy 21 on karyotyping were included. An essential criterion was a reasonable understanding of the language to construct history. The primary outcome variable evaluated was the co-morbidity in these children which led to either hospitalization or mortality. Pretested and validated questionnaire was given to parents/primary caregiver and data was constructed with help of previous hospital records or from verbal autopsy in patients who had lost all papers. The mean age of Down syndrome (DS) patients in study group was 5.09 ± 2.5 y. All cases were diagnosed postnatally at a mean age of 5 y. The major reasons for hospitalization were congenital heart disease (cyanotic/acyanotic), multiple episodes of pneumonia and wheeze associated with lower respiratory infection. Cardiovascular failure was the major reason for mortality. Majority of parents in the study (57.5 %) agreed that there were changes requiring adaptation after the birth of a DS baby while 22.5 % reported this effort to cost them heavily and 3 % quoted that this had changed the life drastically. Cardiorespiratory system is major cause of morbidity/mortality in cases with DS. Majority of parents accepted the challenge of rearing a DS child but with adaptation.

High Rates of Pneumonia in Children under Two Years of Age in a South East Asian Refugee Population

BackgroundThere are an estimated 150 million episodes of childhood pneumonia per year, with 11–20 million hospital admissions and 1.575 million deaths. Refugee children are particularly vulnerable, with poorly defined pneumonia epidemiology.MethodsWe followed a birth cohort of 955 refugee infants, born over a one-year period, until two years of age. Clinical and radiographic pneumonia were diagnosed according to WHO criteria. Detailed characteristics were collected to determine risk factors for clinical, radiological and multiple episodes of pneumonia. Investigations were taken during a pneumonia episode to help determine or to infer an aetiological diagnosis.FindingsThe incidence of clinical pneumonia was 0.73 (95% CI 0.70–0.75) episodes per child year (/CY) and of radiological primary endpoint pneumonia (PEP) was 0.22/CY (95% CI 0.20–0.24). The incidence of pneumonia without severe signs was 0.50/CY (95% CI 0.48–0.53), severe pneumonia 0.15/CY (95% CI 0.13–0.17) and very severe pneumonia 0.06/CY (0.05–0.07). Virus was detected, from a nasopharyngeal aspirate, in 61.3% of episodes. A reduced volume of living space per person (IRR 0.99, 95% CI 0.99–1.0, p = 0.003) and young maternal age (IRR 1.59, 95% CI 1.12–2.27, p = 0.01) were risk factors for developing pneumonia. The risk of a child having >1 episode of pneumonia was increased by having a shorter distance to the next house (IRR 0.86, 95% CI 0.74–1.00, p = 0.04). Infants were at risk of having an episode of PEP if there was a shorter distance from stove to bed (IRR 0.89, 95% CI 0.80–0.99, p = 0.03). Raised CRP and neutrophil values were associated with PEP.ConclusionsThere was a high incidence of pneumonia in young children in this SE Asian refugee population. Viral infections were important, however CXR and non-specific marker findings suggested that bacteria may be involved in up to a third of cases.

Case report of right lung agenesis: is there a role for the use of CPAP?

Introduction: Congenital lung agenesis is a rare congenital malformation. Both lungs are equally affected but right lung agenesis has poorer prognosis compared to the left due to its associated mediastinal shift with heart rotation and compression of the trachea by displaced great vessels. Objective: To report a case of right lung agenesis and the use of continuous positive pressure ventilation (CPAP). Methodology: Case report. Case Description: We report an eleven-month-old girl with right lung agenesis who first presented with chronic cough since she was two months old. On her first presentation at four months old, she was noted to have stridor with generalized crepitations and rhonchi. Her chest X ray showed opaque right hemithorax with mediastinal shift and hyperlucency of left lung field. Bronchoscopic examination revealed patent left main bronchus, with obliterated right main bronchus. A high-resolution computed tomography (HRCT) of the thorax showed absent right pulmonary artery associated with agenesis of the right lung and compensatory hyperinflation of the left lung. There is dextroposition of the heart with compression on the trachea at levels T4/5 and T6 when the aortic arch and pulmonary trunk traverse the anterior part of the trachea respectively. While awaiting surgical intervention, she has presented with four episodes of pneumonia and respiratory distress, with one episode requiring ventilation for nineteen days. After the fourth episode of pneumonia, she was started and discharged home with continuous positive pressure ventilation (CPAP). Since she was started on CPAP, she only had one episode of pneumonia with mild respiratory distress, and her chronic cough has improved. Conclusion: As she is symptomatic with multiple episodes of pneumonia, the definitive management for her is surgical intervention. However, we have started her on CPAP in the meantime to alleviate her symptoms of chronic cough and recurrent pneumonia.

CNS Involvement In A Patient with Waldenstrom's Macroglobulinemia-A Diagnostic Challenge

Abstract 4595Various neurological manifestations have been described in association with Waldenstrom's macroglobulinemia, including autoimmune demyelinating peripheral neuropathy and axonal peripheral neuropathy.CNS involvement, while rare, has been described. The presence of multiple demyelinating lesions in the CNS in a patient with Waldenstrom's, treated with Rituximab and with lymphopenia, warrants the exclusion of the rapidly fatal condition, progressive multifocal leukoencephalopathy.The diagnosis is rendered even more challenging if the lesions cannot be biopsied. We present a 66y/o white female, diagnosed with Waldenstrom's macroglobulinemia and treated with Rituximab and Bendamustine due to cytopenias.Rituximab dose was 375mg/m2 day 1 and Bendamustine dose was 90mg/m2 on days 1 and 2, repeated every 21days. After 4 cycles, she became progressively lymphopenic.Her serum IgM 'M' protein declined significantly with therapy.She developed tingling and numbness in her lower extremities, about 2 weeks after last chemotherapy. She also had gait disturbance and unsteadiness with 3 episodes of falls with in her house. She had bilateral lower extremity weakness, left more than right with intermittent episodes of confusion. She also had several episodes of urinary and fecal incontinence. Detailed neurologic evaluation was significant for trace deep tendon reflexes in both UE, 2+ in both knees and muted in ankles. No extensor plantar response or myoclonus.Asymmetry of vibration and pinprick sensation was noted distally in the lower extremities, with persistent sense of paresthesias in both lower extremities extending upto the torso and both upper extremities, right worse than left. Romberg was negative, though she did have difficulty balancing on each leg. Standard Folstein MMSE examination score at a clinic visit was 29/30, with poor copying skills. MRI cervical spine revealed an enhancing, hyperintense, 9mm lobulated focus along the posterior aspect of spinal cord at C4-C5, which was intramedullary, without cord enlargement. No clear leptomeningeal enhancement was noted.MRI brain also revealed multiple, hyperintense, T2/FLAIR foci in the periventricular and subcortical white matter (See Figure). More than 9 supratentorial lesions were noted, with at least one juxtacortical and one periventricular lesions.A lymphomatous process or subacute infarct or a demyelinating process was suspected initially. Biospy was considered high risk in view of the anatomical location of these lesions. She had a lumbar puncture done to rule out progressive multifocal leukoencephalopathy(PML),in view of recent Rituximab therapy, enhancing white matter lesions and lymphopenia.CSF chemistries, cell counts were normal.JC virus DNA was negative.Infectious etiology was ruled out. Myelin basic protein was <2.0(0–4mcg/l).CSF flow cytometry did not reveal monoclonal cell population.No oligoclonal bands were noted in the CSF.CSF albumin was 25.8(8.0 – 42mg/dl),serum albumin was 2.9(3.2–4.6g/dl),CSF IgG was 0.7(0.8–7.7mg/dl),serum IgG was 173(723–1685mg/dl).CSF glucose and protein were norma.Serum cryoglobulin was normal.Anti myelin associated glycoprotein(MAG) antibody (IgM) was negative. Patient had persistently low CD 4 counts. Her HIV serology was negative. She had multiple episodes of pneumonia. She had 13 sessions of plasmapheresis, as her symptoms were thought to be from Waldenstrom's macroglobulinemia related paraneoplastic neuropathy. Her symptoms improved partially. She also received 4 doses of IVIG, 0.5grams/kg post plasmapheresis.Repeat imaging studies have demonstrated stable lesions and the patient is clinically stable. Disclosures:No relevant conflicts of interest to declare.

Case 1: Chronic cough in a Vietnamese adolescent: Should we be sweating?

A 14-year-old Vietnamese boy presented with chronic cough and fever. Since childhood, he had been diagnosed and managed as a difficult asthmatic case despite multiple episodes of pneumonia. On examination, he was tachypneic, hypoxic and clubbed. Auscultation revealed bilateral crackles. A chest radiograph demonstrated significant bronchiectasis (Figure 1). A sputum culture grew Pseudomonas aeruginosa. His lung function was abnormal, with a forced vital capacity of 79% and a forced expiratory volume in 1 s of 72% of predicted. Figure 1) Extensive, diffuse bronchiectasis and bronchial wall thickening are noted throughout both lungs The patient was investigated for bronchiectasis; this ultimately revealed his true diagnosis. Four months later, he returned febrile with colicky abdominal pain and, again, proved to be a diagnostic dilemma. He was found to have intestinal obstruction, which was relieved with a barium contrast enema.

Primary IgA and IgG subclass deficiency in a 17-year-old Pakistani girl: a case report

Primary immunodeficiency disorders pose a diagnostic dilemma for physicians in the developing countries such as Pakistan because of lack of adequate diagnostic facilities. We present here the case of a 17-year-old girl who had a history of recurrent respiratory tract infections since childhood and had been treated with anti-tuberculous medications thrice; for a total of 24 months. She had also received multiple courses of antibiotics. Her initial presentation to our hospital was with acute bronchopneumonia. Her past medical history of recurrent infections also alerted the treating physician to the possibility of bronchiectasis secondary to a variety of underlying potential pathologies such as post-infection, immunodeficiency syndromes or ciliary dyskinesia disorders. Cystic fibrosis was also an important consideration. Direct enquiry revealed that there was no history of consanguineous marriage in her parents. Her sweat chloride test was within normal range (<40 mmol/L). Blood analysis was performed which showed IgA, IgG2 and IgG4 deficiency. She has been following up at our hospital for the past few years. In that course of time, she has had multiple episodes of pneumonia, gastroenteritis and maxillary sinusitis. She was successfully treated with intravenous immunoglobulins on four occasions when she presented with systemic crisis secondary to severe systemic infection. She also developed biopsy proven intermediate grade non-Hodgkin’s lymphoma five years after the diagnosis of immunoglobulin deficiency was first made. This appeared to be a complication of her immunodeficient state. She has been receiving chemotherapy for the lymphoma. Physicians should be cognizant of the morbidity that primary immunodeficiency syndromes such as immunoglobulin deficiency can have in the form of multiple infections and increased risk of malignancies as seen in our patient.

Strategies To Reduce the Incidence of Pneumonia in a Pediatric Long Term Care Population

ISSUE: A pediatric long-term care organization includes a number of residents with limited mobility due to cerebral palsy with spastic quadriplegia, or encephalopathy. Pneumonia is a leading cause of morbidity and mortality in this population. The hospital's infection control statistics indicated a steady increase in incidence of healthcare-associated pneumonia throughout 2003: 1.34 episodes per 1,000 patient days in the First Quarter to 2.65 episodes per 1,000 patient days in the Fourth Quarter. PROJECT: A study was undertaken to determine compliance with current pneumonia prevention measures, and to implement additional measures which may reduce pneumonia risk for these patients. Pneumonia in these patients is caused by host susceptibility, microbial colonization of the oropharynx or stomach, increased risk of aspiration or reflux. Standard prevention strategies include use of influenza and pneumococcal immunization, and aspiration precautions. The 2003 healthcare-associated pneumonia cases were reviewed: 38 episodes of pneumonia occurred in 23 long-term care residents. Eleven residents had two or more episodes of pneumonia. Residents with multiple episodes of pneumonia were selected for further monitoring. Review of immunization records for these residents showed annual influenza and pneumococcal immunization rates over 90%. Audits of compliance with aspiration precautions ranged from 91% to 100%. "The Vest" is an airway clearance system that uses high-frequency chest wall oscillation to mobilize respiratory secretions, which can then be cleared by coughing or suctioning. Several clinical trials have demonstrated efficacy of "The Vest" in decreasing the incidence of pneumonia in pediatric patients with diagnoses similar to this population. In 2004, Vest Therapy was initiated in three patients at each of two long-term care facilities. The rate of healthcare-associated pneumonia for patients while on Vest Therapy was compared to pneumonia rates in these same patients for the year prior to Vest Therapy. RESULTS: Audits of compliance with standard pneumonia prevention measures indicated overall compliance rates above 90%. The healthcare-associated pneumonia rate for the first cohort of three patients on Vest Therapy decreased from 8.2 episodes per 1,000 patient days to 0.9 episodes per 1,000 patient days. A cohort of three patients at a second facility has shown a decrease in the pneumonia rate from 4.6 episodes per 1,000 days to 1.8 per 1,000 patient days. LESSONS LEARNED: The addition of a new modality for secretion mobilization proved effective in reducing the number of episodes of pneumonia in this population. Studies are continuing to determine if these measures are effective in sustaining the reduction in infection over a longer time period. Priliminary data from this study was presented in a poster session at a Pediatric Nursing conference held September 2005 in Philadelphia, PA.

Diagnosis of primary immunodeficiency; can review of medical history help?

Rationale Primary immunodeficiency (PI) diseases can be treated effectively, especially if recognized early. We studied patients referred to a large immunodeficiency program for a suspicion of PI, asking if historical clinical information would allow us to identify patients with PI. Methods New patients referred to Mount Sinai Hospital, New York City, from 1998-2003 were studied. Clinical information for the previous 5 years was compiled on initial visit by standard questionnaire. Each patient then underwent laboratory testing for PI. Subjects diagnosed with PI and those with a negative immunologic evaluation were compared. Data was analyzed using SAS and Excel statistical software. Results 240 patients were evaluated. 113 had PI (47%). 54% were females. 70% were Caucasians; 30% were children <5 years old. Multiple episodes of pneumonia, bronchitis, and sinusitis were the most common historical illnesses. Chronic otitis media was seen twice as often in the PI group ( p=0.0001). Neutropenia, lymphopenia and splenomegaly were also seen more in patients with proven PI ( p value of 0.02, 0.01, 0.01). Conclusions The data suggests that out of this group of patients referred to a tertiary referral clinic, many of whom have had episodes of pneumonias, bronchitis and chronic sinusitis, patients with proven PI are more likely to have more frequent episodes of otitis media and neutropenia, lymphopenia and splenomegaly.

Characterization of Streptococcus pneumoniae from human immunodeficiency virus--seropositive patients with acute and recurrent pneumonia.

Thirty-two isolates of clinically significant Streptococcus pneumoniae from 11 human immunodeficiency virus (HIV)-seropositive patients with single or multiple episodes of pneumonia were characterized by antibiotic susceptibility testing, serotyping, ribotyping, and repetitive extragenic palindromic polymerase chain reaction (REP-PCR). The isolates comprised 10 serotypes, 12 ribotyping patterns, and 12 REP-PCR patterns. There was close but not absolute correlation between techniques. By combining these characterization methods, 14 strains were identified. Five strains were found in > 1 patient, suggesting their frequent occurrence in this population. Two isolates of different serotype from 1 patient were highly related by ribotyping and REP-PCR, suggesting possible in vivo serotype change. Acute infection was associated with single strains or coinfection by distinct strains. Recurrent pneumonia was identified as relapse with the same strain or reinfection with new strains. The molecular characterization of pneumonococci from HIV-seropositive persons refines our understanding of pneumonococcal infection in these patients.

Tonsillar calculi: Report of a case and review of the literature

A large tonsillar calculus in a 77-year-old demented woman with a history of chronic oral infections and multiple episodes of pneumonia is reported. Earlier literature describes these calcium-laden tonsilloliths as occurring in adolescence following chronic tonsillitis. Improvement in health care of the young and antibiosis militate against tonsilloliths as a serious problem in the young patient. Conversely, an ever-increasing aged population, with impaired self-care abilities or diminished cerebral function, many of whom populate nursing care facilities, and increased routine oropharyngeal screening of the aged may add significantly to the number of reported cases. In view of the potential for continuous oropharyngeal disease and the possibilities of swallowing disturbances, pneumonia, or food or liquid aspiration, which may result in lethal complications the authors urge the clinician to assess masses or calcified objects viewed on physical examination or radiographs, explore their etiology, evaluate them for removal, and not dismiss them as clinically insignificant.