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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 4  |  Page : 180-182

Severe necrotising pneumonia complicated with bronchopleural fistulae in a neonate


Department of Neonatology, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India

Date of Submission27-Mar-2022
Date of Decision26-May-2022
Date of Acceptance19-Jul-2022
Date of Web Publication30-Aug-2022

Correspondence Address:
Dr. Ranjani Upadhyay
Department of Neonatology, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmrp.cmrp_30_22

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  Abstract 


Necrotising pneumonia (NP) is an uncommon condition in children when compared with the adult age group and is even more reported in the new-borns. The first published data on NP in children date back to 1994, but still there is a paucity of data when it comes to the new-borns. Pathologically, it is characterised by inflammation of the pulmonary tissue with consolidation and peripheral necrosis, thereby leading to local destruction of lung tissue and development of multiple small lung cavities. Bronchopleural fistula (BPF) is a rare complication of NP seen in new-born. In this case report, we discuss a case of new-born with severe NP complicated by BPF.

Keywords: Bronchopleural fistulae, methicillin-resistant Staphylococcus aureus, necrotising pneumonia


How to cite this article:
Upadhyay R, Saluja S, Modi M, Soni A. Severe necrotising pneumonia complicated with bronchopleural fistulae in a neonate. Curr Med Res Pract 2022;12:180-2

How to cite this URL:
Upadhyay R, Saluja S, Modi M, Soni A. Severe necrotising pneumonia complicated with bronchopleural fistulae in a neonate. Curr Med Res Pract [serial online] 2022 [cited 2022 Sep 27];12:180-2. Available from: http://www.cmrpjournal.org/text.asp?2022/12/4/180/355200




  Introduction Top


Necrotising pneumonia (NP) is an uncommon condition in neonates.[1] The number of NP cases reported have increased over the last decade, but it still encompasses only 0.8%–7% of all cases of community-acquired pneumonia, with an equal incidence in males and females.[2] Pathologically, it is characterised by inflammation of the pulmonary tissue with consolidation and peripheral necrosis, thereby leading to local destruction of tissue, development of multiple small cavities and ultimately empyema.[3],[4] Bronchopleural fistula (BPF) is a rare complication of NP in new-borns, which forms a communicating channel between the parenchymal tissue and the pleural space, thereby leading to persistent gas leakage. Streptococcus pneumoniae and Staphylococcus aureus are the most common causative organisms for NP in neonates. In the present report, we describe a case of a new-born with severe NP complicated by a BPF.


  Case Report Top


A female neonate was born to a primigravida mother through vaginal delivery at 39 weeks gestation. The antenatal course was unremarkable. The baby remained stable after birth and was discharged from the hospital after 48 h. On the 10th day of life (DOL), the neonate developed fever with fast breathing and was admitted to a nearby neonatal intensive care unit. The baby was intubated and started on meropenem and vancomycin along with supportive care. Blood sepsis work-up and X-ray chest were done. X-ray showed left pneumothorax, for which an ICD was inserted. Blood culture grew Enterobacter cloacae; antibiotic regimen was modified as per sensitivity report. The baby was shifted to our hospital on 14th DOL and continued on mechanical ventilation, and relevant investigations were done. Intravenous antibiotics (meropenem and amikacin) were continued along with supportive care. At the time of admission to our hospital, the patient was receiving mechanical ventilation (mean airway pressure 10, FiO2 50%), had severe respiratory distress; left-sided ICD was in situ. The neonate was continued on mechanical ventilation, relevant investigations including blood culture were sent and intravenous antibiotics (meropenem and amikacin) were continued along with supportive care. Blood investigations showed elevated CRP and thrombocytopenia. Chest X-ray revealed persistence of left pneumothorax [Figure 1].
Figure 1: Chest X-ray showing bilateral lung consolidation with left pneumothorax and left ICD in situ, ICD: Intercostal drainage tube

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Blood culture grew Candida utilis, for which injection amphotericin B was added as per sensitivity pattern. On 18th DOL, the patient developed signs of poor perfusion along with worsening of ventilatory parameters, following which the baby was shifted to high-frequency oscillatory (HFO) ventilator and inotropic support was initiated. Blood investigations and chest X-ray were repeated, and echocardiography was planned to evaluate cardiac functions. Chest X-ray showed persistent pneumothorax on the left with collapse/consolidation of the right lung. Echo showed mild–moderate pericardial effusion. Blood culture sent was sterile. Microbiological evaluation of endotracheal (ET) aspirates was done, which grew methicillin-resistant S. aureus sensitive to vancomycin. Perfusion improved over the next 48 h and inotropes were gradually tapered, but ventilatory requirements did not improve and the baby continued to be on HFO ventilator. Serial chest X-rays showed persisting pneumothorax; further, water column of ICD tube continued to have excessive bubbling raising the suspicion of BPF. Computed tomography (CT) chest was performed, which showed evidence of NP and pyo-pneumothorax on the left side along with multiple thin-walled cavities, areas of consolidation in the right and left lung along with pockets of pus in the mediastinum as well within the pleural and pericardial cavity [Figure 2].
Figure 2: Chest computed tomography scan showing multiple thin-walled cavities with consolidation in bilateral lung

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Repeat culture of ET aspirate grew Acinetobacter baumannii, sensitive to minocycline only, which was added to the antimicrobial regimen. In view of nonresolution of condition and radiographic evidence of pyothorax, thoracotomy was done on 21st DOL. Intraoperative findings showed multiple large air leaks with collapsed hepatised lung, thickened pleura with a large cavity at the base of the left lung [Figure 3]. Ligation of BPF could not be achieved; due to the intense fragility of lung tissue, histopathological sample could not be sent. Thorough lavage of the thoracic cavity was done and two ICDs were inserted, which were connected to a negative suction.
Figure 3: Lung showing areas of necrosis with white pleural peel

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Postoperatively, the patient was kept on HFO ventilator. Pleural peel culture was sent, which was positive for  Escherichia More Details coli sensitive to tigecycline and A. baumanii sensitive to minocycline. Tigecycline was added in accordance with the sensitivity. On postoperative day 5, the patient again developed signs of poor systemic perfusion. Inotropes were restarted and gradually increased to maximal dosage. Lung condition also worsened necessitating escalation of ventilatory settings. Chest X-ray and echocardiographic assessment revealed no alteration in findings. Despite above measures, the patient expired on DOL 29th.


  Discussion Top


Necrotising pneumonia is an uncommon condition in the neonatal population and is associated with high mortality.[1] A diagnosis of NP should be considered as a possibility when, despite appropriate antibiotic therapy, the patient shows no signs of improvement.[1],[2] Failure to identify this condition and delay in initiating appropriate antimicrobial therapy may result in increased risk of complications such as empyema, pneumatocele, pulmonary haemorrhage, lung abscess and pneumothorax.[3] At times, NP can be further complicated by sepsis, respiratory failure and multi-organ failure, leading to a grim prognosis.[4] On radiography, the highlighting diagnostic features are poor or absent vascularity, loss of pulmonary architecture and cavity formation.[5] The contrast-enhanced CT scan is found to be more sensitive than chest radiography in identification of NP.[5],[6] Blood culture and molecular testing of the pleural fluid may yield organisms in more than half of the cases.[6] BPF is one of the severe complications of NP and is diagnosed by the presence of persistent leak from chest tubes.[7] The various modalities for management of BPF include thoracostomy, selective bronchial occlusion, and pleurodesis using talc or antibiotics.[7] In cases where these interventions are unsuccessful, thoracotomy and repair of leak is considered.[7] There are very few case reports in neonates with NP complicated by BPF. In a study which included 36 children with NP, 55% of children had BPF, of which 66% required surgical correction and mortality rate were 5.5%.[8] In this report, we have described an unusual case of a new-born with severe NP and BPF which was initially managed conservatively with antibiotics and other supportive measures. In lieu of progressive worsening, thoracotomy was performed, which revealed severely necrotic parenchyma with areas of abscess formation and multiple air leaks. The NP ran its full course of disease spectrum with multiple complications ultimately, leading to demise of neonate.


  Conclusion Top


NP is one of the rare complications of pneumonia in neonates that presents with severe morbidity. NP is usually aggressive and does not respond despite appropriate antibiotic treatment. NP is confirmed by finding of consolidation with multiple cavities on chest CT scan and it should be suspected on clinical grounds so as to initiate timely diagnosis and appropriate management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tsai YF, Ku YH. Necrotizing pneumonia: a rare complication of pneumonia requiring special consideration. Curr Opin Pulm Med 2012;18:246-52.  Back to cited text no. 1
    
2.
Urbankowska E, Kraj G, Krawiec M, Urbankowski T, Peradzyńska J, Kulus M. Necrotizing Pneumonia and Its Complications in Children. Adv Exp Med Biol 2015;857:9-17.  Back to cited text no. 2
    
3.
Lemaître C, Angoulvant F, Gabor F, Makhoul J, Bonacorsi S, Naudin J, et al. Necrotizing pneumonia in children: report of 41 cases between 2006 and 2011 in a French tertiary care center. Pediatr Infect Dis J 2013;32:1146-9.  Back to cited text no. 3
    
4.
Zapata H, Wahba A. Severe necrotizing pneumonia complicated by empyema in a neonate. Respir Med Case Rep 2020;31:101248.  Back to cited text no. 4
    
5.
Masters IB, Isles AF, Grimwood K. Necrotizing pneumonia: an emerging problem in children? Pneumonia (Nathan) 2017; 9:11.  Back to cited text no. 5
    
6.
Fretzayas A, Moustaki M, Alexopoulou E, Nychtari G, Nicolaidou P, Priftis KN et al. Clinical notations on bacteraemic cavitating pneumococcal pneumonia in nonvaccinated immunocompetent children. J Trop Pediatr 2009;55:257–61.  Back to cited text no. 6
    
7.
Hsieh YC, Wang C-W, Lai S-H, Lai J-Y, Wong K-S, Huang Y-C, et al. Necrotizing pneumococcal pneumonia with bronchopleural fistula among children in Taiwan. Pediatr Infect Dis J 2011;30:740-4.  Back to cited text no. 7
    
8.
Hacimustafaoglu M, Celebi S, Sarimehmet H, Gurpinar A, Ercan I. Necrotizing pneumonia in children. Acta Paediatr 2004;93:1172-7.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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