One-month-old infant with multilobar round pneumonias

Rare Immunodeficiency In A Two-Months-Old Infant

Chronic granulomatous disease is a diverse group of hereditary diseases characterized by neutrophils incapacity or difficulty to form reactive oxygen compounds, most important, the superoxide radical, used to kill certain pathogens. The consequence is recurrent infections with germs with normally low pathogenicity and formation of supurative granulomas. The authors present a pathology case of immunodeficiency rarely seen in pediatrics: chronic granulomatous disease in a 2 months old infant. The positive diagnosis was based on clinical presentation, dominated by lymphadenopathy, pemphigoid skin lesions, bilateral ear secretion, growth failure, hepatomegaly. Physical presentation correlated with laboratory studies (Bursttest), chest radiography and CT imaging, moderate inflammatory syndrome, low platelets level and the presence of fibrin monomers suggested a neonatal sepsis having on the background a X-linked immunodeficiency (the patient being the only male survivor in his family, with 4 healthy sisters). The specific feature in this case was early onset of the disease, with clinical, but most important, pulmonary radiological aspect characteristic for chronic granulomatous disease. The prognosis was poor; the baby is readmitted in the hospital after 2 months and he dies, having clinical aspect of sepsis unresponsive to the applied intensive therapy. The histological findings enhanced numerous pulmonary and hepatic microabscesses.

Invasive fungal infections in patients with chronic granulomatous disease

Invasive fungal infections are a major threat for chronic granulomatous disease (CGD) patients. The present study provides a comprehensive overview of published invasive fungal infections in the CGD host through an extensive review of epidemiological, clinical, diagnostic and therapeutic data. In addition to the often mild clinical presentation, the currently used diagnostics for invasive aspergillosis have low sensitivity in CGD patients and cannot be easily translated to this non-neutropenic host. Aspergillus fumigatus and A. nidulans are the most commonly isolated species. A. nidulans infections are seldom reported in other immunocompromised patients, indicating a unique interaction between this fungus and the CGD host. The occurrence of mucormycosis is mainly noted in the setting of treatment of inflammatory complications with immunosuppressive drugs. Candida infections are infrequently seen and do not cause mucocutaneous disease but do show an age-dependent clinical presentation. The CGD patient is susceptible to a wide range of fungal pathogens, indicating the need to determine the causative fungus, often by invasive diagnostics, to guide optimal and rational treatment. This review summarizes current understanding of invasive fungal infections in patients with CGD and will serve as a starting point to guide optimal treatment strategies and to direct further research aimed at improving outcomes.

Chronic granulomatous disease: a review of the infectious and inflammatory complications

Chronic Granulomatous Disease is the most commonly encountered immunodeficiency involving the phagocyte, and is characterized by repeated infections with bacterial and fungal pathogens, as well as the formation of granulomas in tissue. The disease is the result of a disorder of the NADPH oxidase system, culminating in an inability of the phagocyte to generate superoxide, leading to the defective killing of pathogenic organisms. This can lead to infections with Staphylococcus aureus, Psedomonas species, Nocardia species, and fungi (such as Aspergillus species and Candida albicans). Involvement of vital or large organs can contribute to morbidity and/or mortality in the affected patients. Major advances have occurred in the diagnosis and treatment of this disease, with the potential for gene therapy or stem cell transplantation looming on the horizon.

Observations in febrile children with round air space opacities

BACKGROUND

Community-acquired pneumonia in children is rarely depicted as round opacity. The aim of the present study was therefore to describe the clinical and laboratory characteristics of round pneumonia in children.

METHODS

The clinical series consisted of 30 children aged 1-7 years (mean age, 3.4 +/- 1.8 years) who were compared to an equal number of children with segmental or lobar pneumonia aged 3-11 years (mean age, 5.5 +/- 2.7 years).

RESULTS

Round pneumonia was localized more often in the lower lobe (17/30), and the right side was more commonly affected (20/30). The same, however, was the case for the control group. The two groups were not different regarding the severity of the disease but cough was much more common in the control patients. The white blood cells were considerably higher in round pneumonia, whereas the other inflammatory indices were not significantly different. All round consolidations responded promptly to antibiotics and resolved radiographically in 8 weeks.

CONCLUSION

Round consolidations in febrile children associated with elevated inflammatory indices seem to be attributed to round pneumonia, which responds promptly to antibiotics without complications.

Imaging of round pneumonia and mimics in children

Various diseases in the pediatric age group can present as an intrathoracic rounded opacity on a chest radiograph. The purpose of this pictorial essay is to emphasize the imaging appearance of round pneumonia, an entity that occurs especially in the pediatric population. Additional pathologies with similar chest radiographic appearances are also presented. The diagnosis of round pneumonia should be made in children who have the typical clinical presentation along with chest radiographs demonstrating the characteristic findings.

Round pneumonia: imaging findings in a large series of children

BACKGROUND

Although round pneumonia is a well-known clinical entity, there have been no large case reviews, with most knowledge based on case reports and small series from the 1960s and 1970s.

OBJECTIVE

To review the imaging findings of a large series of children with round pneumonia.

MATERIALS AND METHODS

A retrospective review of radiographic and CT findings in all children reported to have round pneumonia at a large children's hospital from 2000 to 2006 was performed. Children with underlying medical conditions were excluded. Epidemiologic characteristics, radiographic and CT findings, and follow-up imaging were reviewed.

RESULTS

The review identified 109 children (mean age 5 years, range 4 months to 19 years). Round pneumonias tended to be solitary 98% (107/109), have well-defined borders 70% (77/109), and be posteriorly located 83% (91/109), with the following lobar distribution: left lower lobe (36), right lower lobe (33), right upper lobe (28), left upper lobe (7), right middle lobe (4), and lingula (2). Round pneumonia tended to resolve on follow-up imaging (95%, 41/43) as compared to progression to lobar pneumonia (4.6%, 2/43). Three patients (2.6%, 3/112) originally suspected to have round pneumonia were later shown to have other diagnoses: cavitary necrosis in pneumonia (two) or pleural pseudocyst (one).

CONCLUSION

Round pneumonia occurs in young children (mean age 5 years), tends to be a solitary lesion, and is most commonly posteriorly located. Misdiagnosis of other pathology as round pneumonia is uncommon.

Fungal infections in primary immunodeficiencies

Patients with phagocytic, cellular, combined and other primary immunodeficiencies exhibit immune deficits that confer increased susceptibility to fungal infections. A number of yeasts and moulds, most commonly Candida and Aspergillus but also Cryptococcus, Histoplasma, Paecilomyces, Scedosporium, Trichosporon, Penicillium and other, rarely isolated, fungal organisms, have been variably implicated in causing disease in patients with chronic granulomatous disease, severe combined immunodeficiency, chronic mucocutaneous candidiasis, hyper-IgE syndrome, myeloperoxidase deficiency, leukocyte adhesion deficiency, defects in the interferon-gamma/interleukin-12 axis, DiGeorge syndrome, X-linked hyper-IgM syndrome, Wiskott-Aldrich syndrome and common variable immunodeficiency. Differences in the spectrum of fungal pathogens as well as in the incidence and clinical presentation of the infections may be observed among patients, depending upon different immune disorders. Fungal infections in these individuals may occasionally be the presenting clinical manifestation of a primary immunodeficiency and can cause significant morbidity and potentially fatal outcome if misdiagnosed or mistreated. A high degree of suspicion is needed and establishment of diagnosis should actively be pursued using appropriate imaging, mycological and histological studies. A number of antifungal agents introduced over the last fifteen years, such as the lipid formulations of amphotericin B, the second-generation triazoles, and the echinocandins, increase the options for medical management of these infections. Surgery may also be needed in some cases, while the role of adjunctive immunotherapy has not been systematically evaluated. The low incidence of primary immunodeficiencies in the general population complicates single-center prospective or retrospective clinical studies aiming to address diagnostic or therapeutic issues pertaining to fungal infections in these patients.