Welcome to Facts on the Ground a new series brought to you by Natan Cramer, Pediatric Emergency Medicine fellow from the University of Pittsburgh. Facts on the Ground is designed to be a concise literature review that helps answer common clinical questions.

The Article

Clinical and laboratory features of children with community-acquired pneumonia are associated with distinct radiographic presentations
Falup-Pecurariu, et al.
Europena Journal of Pediatrics, 2018

Objective

To discover differences in clinical symptoms and laboratory results of three different types of WHO-SICR (World Health Organization Standardization of Interpretation of Chest Radiographs) defined pneumonia presentations

Alveolar Pneumonia – dense opacity of a portion or entire part of lung with and without air bronchograms or pleural effusion

Non-Alveolar Pneumonia – interstitial pattern affecting both lungs, patchy areas of consolidation, peribronchial thickening

Clinical Pneumonia – absence of CXR findings

The authors hypothesized that alveolar pneumonia would be more associated with symptoms and lab findings reminiscent of bacterial infection compared to the other two pneumonia types which would be more associated with viral presentations

Study Design

This was a Multicenter Prospective, Observational Study across multiple countries in Europe that included children under the age of 59 months presenting to the ED with chest radiograph performed within 24hrs of admission and diagnosed with CAP.

Survey data regarding demographics, symptomatology, physical findings, and laboratory data (CRP, WBC count, ESR, and ANC) were obtained on the included participants. A single pediatrician blinded to the clinical and lab criteria of each patient reviewed the radiographs and sorted them into one of the three groups defined by the WHO-SICR. 

Outcome

  • 1,107 children diagnosed with CAP <5 years were included. 74.9% had Alveolar CAP, 8.9% with Non-alveolar CAP, and 16.3% with Clinical CAP. 
  • Alveolar CAP seen in older children with higher WBC, ANC, ESR, CRP.
  • Duration of fever was longer in alveolar CAP compared to the other pneumonia types.
  • More abdominal pain and vomiting in the Alveolar CAP group
  • Adjusted for age and split patients into 0-23 months of age and 24-59 months of age. Those in the younger grouping showed higher respiratory rate in alveolar CAP. The opposite was seen in the older grouping, with the respiratory rate being higher in non-alveolar CAP.
  • Clinical CAP was more similar to alveolar CAP in symptoms, but more similar to non-alveolar CAP in laboratory findings. Possibly because this reflects an early pneumonia that has not yet progressed to a radiological finding.

Weaknesses

This study builds on previous literature linking specific symptoms and laboratory markers with bacterial infection, although this is a surrogate for determining the nature of a pneumonia infection as aspiration for culture was not done for confirmation. Additionally. exclusion criteria were not mentioned in the body of the paper

The Bottom Line

Alveolar CAP is associated with more abdominal pain, higher inflammatory markers, and a presentation concerning for bacterial infection as compared to non-alveolar CAP and clinical CAP. 

References

Falup-Pecurariu, et al. Clinical and laboratory features of children with community-acquired pneumonia are associated with distinct radiographic presentations. European Journal of Pediatrics, 2018.