Preterm with non resolving pneumonia

Preterm with non resolving pneumonia

Dr Ira Shah.
Medical Services Department, Pediatric Oncall, Mumbai.

Dr Ira Shah, Medical Sciences Department, Pediatric Oncall, 1, B Saguna, 271, B St. Francis Road, Vile Parle {W}, Mumbai 400056.
Clinical Problem
Case Report: - A 38 day old girl born of non-consanguineous marriage presented with cough and cold since 1 week and breathlessness since 1 day. She was a preterm delivery at 32 week gestation with birth weight of 1.4 kg and required NICU stay for 18 days. At that time she received antibiotics for 10 days. She is on formula feeds since then. On examination, patient was gasping with heart rate of 160/min and poor peripheral pulses. On respiratory system examination, she had bilateral crepitations. Her blood pressure was normal and dextrostix was 121 mg%. She was immediately intubated and put on ventilator. She was started on IV antibiotics of Ceftriaxone-Sublactum and Amikacin with ionotropic support. X-Ray Chest showed bilateral interstitial pattern predominantly perihilar. Inspite of 100% FiO2 and maximal pressures, the child was hypoxic with paO2 of 52-58 mm of Hg and oxygen saturation of 88%. Septic screen in form of hemogram, blood culture, CRP and endotracheal secretion culture was negative. HIV tridot was negative. Echocardiography was normal and blood fungal culture was also negative. Patient was additionally given Fluconazole and Vancomycin in view of previous hospital stay at time of birth. However, the child continued to be hypoxic.

What is the cause of the pneumonia?
Expert’s opinion: - This child is a preterm child with an interstitial pneumonia and hypoxia. The child predominantly came with tachypnea and cough. There was no fever. Also the child had a negative septic screen. Cultures were negative for bacteria and fungal infection. Thus it is quite likely that the cause of pneumonia in this child is an atypical organism or a viral infection. Among, the viral infections, congenital cytomegalovirus (CMV) can present with pneumonia at around 6-8 weeks of life. Also, the child can acquire an infection such as Respiratory Synctial Virus (RSV) that can cause severe hypoxia in a neonate.

Another possibility is pneumocystis carinii (jiroveci) (PCP). Though classically seen in HIV infected infants, it may also be seen in neonates especially low birth weight babies and premature babies due to deficient immune system. PCP classically presents with cough and tachypnea leads to interstitial perihilar shadows and severe hypoxia.

Chlamydia can also lead to interstitial pneumonia and hypoxia. But usually there is history of conjunctivitis in the neonatal period.

This child was investigated for the same. CMV IgM & IgG were negative and RSV and Chlamydia antigen test was also negative. Cysts of PCP were seen in the endotracheal secretions. This child was treated with Cotrimoxazole & intravenous steroids to which her hypoxia and pneumonia responded and child could be weaned off the ventilator.

Hence all pneumonia in a neonate is not bacterial and fungal infection is not as common even as a nosocomial infection. In a child with interstitial pneumonia and hypoxia, one should look for other organisms especially viral and atypical organisms.
Compliance with ethical standards
Funding:  None  
Conflict of Interest:  None
Cite this article as:
Shah I. Preterm with non-resolving pneumonia. Pediatr Oncall J. 2008;5: 83.
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