Imaging in Immunocompetent Children WhoHave Pneumonia Lane F.. Donnelly, MDa,b,* aDepartment of Radiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati,
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Trang 2Imaging in Immunocompetent Children Who
Have Pneumonia
Lane F Donnelly, MDa,b,*
aDepartment of Radiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue,
Cincinnati, OH 45229 – 3039, USA
bRadiology and Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
In 1994, the year that I was a pediatric radiology
fellow at Cincinnati Children’s Hospital, there was a
dramatic increase in the number of children
hospi-talized with complications related to bacterial
pneu-monia This included an increase in the number of
purulent lung complications, such as cavitary
ne-crosis, and an increase in the number of empyemas as
compared with years past There was a lot of
speculation at the time as to why there had been a
sudden increase in the frequency of children with
complications related to pneumonia Some speculated
that it was related to an increased frequency of
anti-biotic-resistant streptococcal pneumonia infections.
Others speculated that there had been a strain of
in-fluenza A virus that went through the community and
was associated with injury to the respiratory mucosa
resulting in children who were predisposed to
de-veloping complications when they were infected with
bacterial pneumonia In subsequent years, however,
there again were increasing numbers of children
hos-pitalized for complications related to pneumonia each
year This trend continues today.
I became involved in several projects reporting
on our experience at Cincinnati Children’s with the
use of CT in these children with pneumonia-related
complications [1 – 5] Subsequently, I have been
in-volved in writing several review articles on the roles
of imaging in children with pneumonia [6,7] In
preparation for writing this article, I have done a recent literature search and, unfortunately, very little has changed in the past 10 years concerning what is known about the performance of imaging studies in the management of children with pneumonia Many
of the areas of controversy, such as how aggressively parapneumonic effusion should be managed, are still without definitive and agreed on plans of action.
In this article, the roles of imaging in children with pneumonia are discussed The contents of this article apply to when immunocompetent and previ-ously healthy children develop pneumonia or its complications The indications for imaging and implication of the findings at imaging are completely different in children who are immunodeficient or have underlying medical conditions, such as sickle cell anemia or cystic fibrosis A discussion of those chil-dren is beyond the scope of this article The following topics are covered concerning the roles of imaging in the management of pneumonia: evaluation for possi-ble pneumonia, determination of a specific etiologic agent, exclusion of other pathology, evaluation of the child with failure of pneumonia to clear, and evalua-tion of complicaevalua-tions related to pneumonia.
Evaluation for possible pneumonia Respiratory tract infections are the most common cause of illness in children and one of the most common indications for imaging in children Chest radiographs are often obtained as part of the evalua-tion to determine whether or not a child is likely to have bacterial pneumonia At first, it seems that
D 2005 Elsevier Inc All rights reserved
* Department of Radiology, Cincinnati Children’s
Hos-pital and Medical Center, 3333 Burnet Avenue, Cincinnati,
OH 45229-3039
E-mail address: Lane.Donnelly@cchmc.org
Trang 3Thoracic Disorders in the Immunocompromised Child
Caroline L Hollingsworth, MD
Division of Pediatric Radiology, Department of Radiology, Duke University Health System,
1905 McGovern-Davison Children’s Health Center, Box 3808, Erwin Road, Durham, NC 27710, USA
The population of children afflicted with primary
or secondary immunodeficiencies is in evolution.
The primary immunocompromised host was first
de-fined over 50 years ago when Bruton [1] discovered
X-linked agammaglobulinemia (XLA), a congenitally
acquired humoral immunodeficiency Delineation and
description of over 100 other primary
immunodefi-ciency syndromes has ensued, which includes a
diverse group of conditions caused by abnormalities
in antibody production, cell-mediated immunity, or
the phagocyte and complement activity Although the
number of children afflicted with primary
immuno-deficiencies remains relatively small, the impact of
such diseases on each child is considerable
Second-ary immunodeficiencies in childhood may result
from infection with HIV or can be caused by
chemo-therapy, radiochemo-therapy, or immunosuppressive therapy
aimed at treating childhood malignancies; transplant
rejection; rheumatologic disorders or inflammatory
or infectious diseases; and any state of debilitation.
Moreover, the development and success of many
ag-gressive cytotoxic regiments and immunosuppressive
therapies for children with cancer or autoimmune
disorders and the increasing use of stem cell or
bone marrow transplantation (BMT) have increased
the number of immunocompromised children This
complex and varied population of
immunocompro-mised children is at high risk for pulmonary
com-plications related to both their underlying disease
state and to various treatment regimes Although
infections obviously account for many
complica-tions, immunocompromised children are also at high
risk for development of many other types of tho-racic complications These include primary and secondary thoracic malignancies and nonmalignant lymphoid proliferation, noninfectious pneumonias, bronchiolitis obliterans, pulmonary edema, graft-versus-host disease (GVHD), radiation injury, and pulmonary thromboembolism.
Specific thoracic complications vary according
to the child’s underlying immune status and specific treatment protocols As such, the type of infection or other disease states encountered depends on the child’s type of immunologic abnormality, severity of immunologic deficit, therapeutic interventions, and environmental exposures [2] Although this discus-sion does not include all immunodeficiencies, the common primary immunodeficiencies and secondary immunocompromised states of childhood are ad-dressed with emphasis on the mechanism of the dis-order; imaging features of thoracic complications; and, where appropriate, imaging surveillance strategies.
Primary immunodeficiencies Humoral immunodeficiencies Humoral immunodeficiencies are the most com-monly encountered type of primary immunodefi-ciency, accounting for over 70% of all primary immunodeficiencies [3 – 5] This diverse group of disorders is characterized by defective antibody pro-duction causing increased susceptibility of affected individuals to recurrent pyogenic infections, par-ticularly caused by encapsulated bacteria, such as Haemophilus influenzae, Streptococcus pneumoniae, and Staphylococci Typical manifestations include
D 2005 Elsevier Inc All rights reserved
E-mail address: holli016@mc.duke.edu