Pneumonia

1. Pneumonia Mohammed Kaashmiri, M.D.

2. Etiology • Birth through 3 months: • Group B Strep • E. Coli • Listeria Monocytogenes • Staph Epidermis • Staph Aureus • Herpes Simplex

3. Etiology • CMV • RSV • Influenza A • Influenza B • Parainfluenza • Adenoviruses

4. Viruses • Most Common – Infants & Preschoolers • More mucous membranes involved • Gradual Worsening • RSV • Influenza A and B • Parainfluenza • Adenoviruses

5. Bacteria • Abrupt onset • Lung usually sole affected organ • Strep Pneumonia • H. Influenza • Group a Strep • S. Aureus

6. Bacteria • M. Tuberculosis • Enteric Bacilli • Mycoplasma Sp. • Chlamydia Pneumonia (School Age & Adolescent)

7. Signs and Symptoms • (Fever, Tachypnea, Cough) Pneumonia • Malaise • Apprehension • Chills or Rigors • Toxicity & Lethargy • Intercostal Retractions, nasal flaring • Wheezing

8. Signs and Symptoms • Fine end – inspiratory crackles • Cyanosis, Grunting • Abdominal pain- Pleuritic chest pain • Asynchronous chest & abdominal movement • Diminished breath sounds

9. Evaluation • 1. Chest X-Ray • Bacteria - Lobular, lobar consolidation • Viral – Perihilar infiltrates, Bilateral interstitial pattern • Mycoplasma – Patchy alveolar & interstitial infiltrates, single or contagious lobe

10. Evaluation • 2. CBC with Differential – Normal Count – Bacterial etiology unlikely • Thrombocytosis – 500K, Bacteria? • Thrombocytopenia – viral • 3. ESR – CRP • 4. Gram Stain • 5. Blood Culture • 6. Direct Fluorescent antibody test • 7. Cold agglutinin antibodies

13. Bronchiolitis Mohammed Kaashmiri, M.D.

14. Bronchiolitis • Inflammatory process primarily involving the small airways • Infants under one year at increased risk • Most commonly affects infants between the age of 2&6 month • Bronchiolitis = Tachypnea+ Retraction+ Wheezing

15. ETIOLOGY • RSV- Responsible for majority of cases • Para influenza • Adenovirus • Influenza • M. Pneumonia • Incidence highest during the winter and early spring • Source: Usually a family member with minor URI

16. CLINICAL MANIFESTATION • History of exposure to sibling or adult with minor Respiratory illness within preceding week • Initial symptoms of sneezing, rhinorrhea and cough • Low grade fever • Irritability • Decreased appetite

17. CLINICAL MANIFESTATION • Within 1-2 days: Tachypnea Retraction Wheezing • May progress to: Respiratory failure Apnea

18. DIAGNOSIS • Age of child • Clinical presentation • Epidemic of RSV in community • Viral identification on nasal secretions • Chest X Ray Peribronchial thickening, Patchy atelectasis, Segmental collapse Hyperinflation

21. DIFFERENTIAL DIAGNOSIS • Asthma • Croup • Salicylate poisoning • Congestive Cardiac failure • Foreign body aspiration • Pertusis • Pneumonia

22. TREATMENT • Mild Bronchiolitis- Treat at home • Mild Resp. distress- Careful observation and adequate hydration • Moderate to severe Resp. distress should be hospitalized- Supportive care • Administration of Oxygen- O2 Sats >95% • Monitoring to detect Hypoxemia, Apnea and Resp. Failure

23. TREATMENT • Temperature regulation • Fluid administration • Bronchodilators • Steroids • Ribavirin • RSV Immunoglobulin • Mechanical Ventilation

24. TREATMENT • Prevention of transmission of infection to staff and other patients • Careful hand washing • Limit child to child contact • Glove and gown

25. COURSE, COMPLICATION AND PROGNOSIS • Most improve in 3-4 days with supportive care • By 2 weeks resp. rate, CO2, O2, and CXR resolve • 7% of hospitalized pts. Require mechanical ventilation • 30-50% with subsequent asthma

26. Croup Mohammed Kaashmiri, M.D.

27. “Croup”Acute Laryngo Tracheobronchitis • Subglottic Laryngitis • Commonest cause of acute upper airway obstruction in childhood • Infants and young children have a smaller airway which predisposes to greater narrowing

29. Epidemiology • 3 cases per 100 children less that 6 years of age • Range 3 months to 6 years most cases between 1 & 3 years • Up to 1.3 % of affected children are hospitalized • Most commonly during the winter season

30. EtiologyMajority --- Viruses • Para influenza type 1, 2 and 3- 2/3 cases • Influenza virus A & B • Adenovirus • RSV • 15% of patients have strong family history of croup

31. “Viral Croup” • URI symptoms for few days prior to brassy cough • Intermittent inspiratory stridor • Prolonged exp. Phase • Temp 38-40 C • Symptoms worse at night • Hypoventilation > Hypoxemia • Hypercapnia > Dyspnea • Nasal Flaring > Retractions

32. “Viral Croup” • Most patients progress only as far as stridor and slight dyspnea • The duration of illness ranges from several days to several weeks • Recurrence > 3-6 Years Decreases with growth of the airway

33. Pathogenesis • Viruses primarily infect ciliated respiratory epithelium • Inflammatory response to the virus • Influx of PMN’s and mononuclears • Vascular congestion • Edema – Laryngospasm • Obstructive symptoms

34. Diagnosis • History and physical exam • Radio graph – lateral neck • CBC – TLC < 10,000 • Lymphomcytosis • Blood gas – hypoxia – CO2 retention

35. Treatment • Approach in calm reassuring manner • Reduce anxiety – delay unnecessary lab work • Hot or cold steam - Oxygen • Racemic epinephrine • Cortico steroids • Artificial airway

36. Urinary Tract Infection Mohammed Kaashmiri, M.D.

37. Prevalence and Etiology • Varies with age and sex • Newborn infants 1.4/1000 • School age female 1.2-1.9% • More common – uncircumcised male infants • Infancy – males more likely with anatomical basis

38. Etiology • Hematogenous • Urinary tract abnormalities (VUR) • Most common causes: • E. Coli, Klebsiella, Proteus, Enterobacter, Pseudomonas, and Enterocci • Contributing factors: • Infrequent or incomplete voiding • Poor perineal hygiene • Older girls – sexual activity • Pinworms, constipation, bubble bath

39. Clinical Manifestation • Newborn: Fever, Hypothermia • Poor feeding, jaundice • Sepsis, failure to thrive • Vomiting and Diarrhea • Pre-school children: • Abdominal pain • Vomiting, and Enuresis • Strong smelling urine • Increased frequency, dysuria, or urgency

40. Signs and Symptoms • School age children: • “Classic” signs include: Enuresis, Increased frequency Dysuria, urgency, fever costovertebral angle tenderness • Some infections may be relatively asymptomatic

41. Laboratory Tests • Urinalysis and urine culture • Microscopic analysis for bacteria, and white cells • Leukocytosis – neutrophilia • Increased ESR on C-reactive protein • 30% increase in serum creatinin • Blood cultures

42. Diagnostic Studies • Renal ultrasonography hydronephrosis/ pyoephrosis, renal/peri renal abscesses • Cystourethrography • CT – Diagnostic for Pyelo • DMSA Scan • Power Dopler Ultra Sound • MRI

43. Treatment • “Treat promptly to prevent progression to pyelonephritis.” • Cystitis/Urethritis Bactrim, amoxil, or cephalosporin • Pyelonephritis Cefotaxime & amino glycoside Subsequent changes according to culture sensitivity

44. Treatment • Recurrence: Bactrim Nitrofurantoin • Obtain periodic urine cultures • Refer to Urologist: Uretral reflux Obstructive anomalies

45. Gastroesophageal Reflux Mohammed Kaashmiri, M.D.

46. Gastroesophageal Reflux • “Dysfunction of the lower esophageal sphincter (LES) mechanism with return of gastric contents into the esophagus”

47. Pathogenesis • Lower esophageal sphincter dysfunction • Transient relaxation of the sphincter • Increase intragastric pressure

48. Clinical Presentation • Irritability (infantile heart burn) • Failure to thrive • G.I. Bleed, Hematemesis /occult blood in stool • Anemia • Esophagitis • Stricture

49. Clinical Presentation • Reflex bronchospasm • Reflex laryngospasm • Reflex central apnea • Reflex brady cardia • Aspiration / Aspiration pneumonia • Obstructive apnea • Stridor

50. Diagnostic Evaluation • History • Upper gastrointestinal series (UGI) • Upper GI endoscopy / biopsy • PH Probe Study • Radio nuclide scans • Bronchoscopy