Lung Abscess as a Complication of Pneumonia in 19-month Old Child A

Introduction: Community-acquired pneumonia is one of the most common diseases in infancy but most of these diseases have relatively simple course. We are presenting a case of child who developed lung abscess as a complication of pneumonia. Case Report: The goal of our case report is to point out that lung abscess is a relatively rare entity whose development is not always typical, sudden and acute, but also hidden, inconspicuous and perfi dious. Although clinical picture and laboratory fi ndings indicated that the pneumonia was cured, a single control CT scan showed that there was infl ammation (hotspot) in the organism. Discussion: Lung abscess is a rare state which is developed as a complication only at 1% of pneumonias. Complications are rare and depend on the previous immunological status of the child and the presence of comorbidity. The duration of antibiotic therapy depends on the clinical and radiographic response of the patient. The chosen antibiotics have to cover a wide specter of Gram-positive and Gram-negative bacteria. Conclusions: The key role in making a diagnosis played radiological methods which were crucial in monitoring the evolution of the change itself, from its creation to regression. The triple antibiotic therapy with meropenem, vancomycin and metronidazole enabled an (excellent) recovery outcome.


INTRODUCTION
Although community-acquired pneumonia (CAP) mortality in well-developed countries decreased signifi cantly in the last decades [1], it remains one of the leading causes of morbidity in childhood. At the same time, an increasing incidence of local CAP complications has been reported [2]. Th ese include parap-neumonic eff usion (PPE)/pleural empyema (PE), necrotizing pneumonia (NP), and lung abscess [3]. In some patients, the signs and symptoms associated with local complication may be the initial manifestations of CAP [4]. However, in the vast majority of children, these complications develop later in the course of the disease [5]. Th e increasing incidence of local complications was observed not only in untreated or inadequately treated children but also in patients treated in accordance with current guidelines [4]. Lung abscess is a relatively rare CAP complication in immunocompetent children with incidence rates below one percent (1%) of all cases [6]. We are presenting a case of child who developed lung abscess as a complication of pneumonia.

CASE REPORT
Th is case report refers to second child from second regularly controlled pregnancy ended within the term with an elective caesarean section (C-section), somatometric parameters at the level of the referent values for that age. Th e child has been regularly vaccinated (with an exception of the MMR vaccine) and without allergic reactions to food and medicaments. Th e child has had two bronchial obstructions treated with bronchodilator -short acting β2 receptor agonist fenoterol and anticholinergic ipratropium bromide (Berodual N® solution for inhalation 0.5 mg/ml + 0.25 mg/ml Boehringer Ingelheim Pharma GmbH & Co. KG, Germany) at a dose of 0.3 ml every eight hours and corticosteroid budesonide (Pulmicort Respules®, 500 μg/dose, Astra Zeneca, Sweden) inhalations at a dose of 1 ml -twice a day along with the antibiotic so far.
A 19-month old boy was admitted to our hospital with the symptoms of high (elevated) body temperature, fatigue, non-productive cough, severe dyspnea and increased nasal congestion. Th e fi rst symptoms had appeared four days before admission in the form of fever (up to 40 degrees Celsius) and irritating dry cough. He was examined by a pediatrician in healthcare center and the initial treatment included two antibiotics: clarithromycin (Klac-id® 125 mg/5ml, AbbVie S.R. L., Italy) at a dose of 3 ml twice a day and cefpodoxime (Tridox® 40 mg/5 ml, Alkaloid AD Skopje, North Macedonia) at a dose of 5 ml every twelve hours in the form of a peroral suspension. Additionally, the inhalation of fi xed-dose combination of two bronchodilators short acting β2 receptor agonist fenoterol and anticholinergic ipratropium bromide (Berodual N® (0.05 + 0.21) mg/ dose, Boehringer Ingelheim Pharma GmbH & Co. KG, Germany) at a dose of 0.3 ml every six hours were applied, as well as a corticosteroid budesonide (Pulmicort Turbuhaler®, 500 μg/ dose, AstraZeneca, Sweden) at a dose of 1 ml twice a day. Since the child's health condition was getting worse, he was transferred to the Institute for further diagnostic and treatment.
On admission he was conscious and alert, pale, subfebrile with rectal temperature of 37.5 degrees Celsius, tachypneic with the respiratory rate (RR) of forty breaths per minute, oxygen saturation of 96% on room air, heart rate of 140 beats per minute and the normal body weight of 10.85 kg (75 th percentile). On examination beside stuff y nose and hyperemic pharynx, lung auscultation revealed diminished breath sounds with early inspiratory crackles. All other physical fi ndings were normal. Th e initial analysis showed signifi cantly raised level of infl ammatory marker CRP 249 mg/L, whereas complete blood count was within the reference range. First chest Xray performed on admission showed denser condensations of the both sides of the lung parenchyma -paracardially in the upper and middle pulmonary fi eld and hilobasal on the right side, as well as in the middle and lower pulmonary fi eld on the left side (see picture no. 1). Aft er admission, a double antibiotic www.hophonline.org Picture 1. Pneumonia intravenous therapy with cephalosporin of the third generation of ceft azidime (Forcas®, GlaxoSmithKline Manufacturing s.p.a., Italy) at a dose of 500 mg was included every eight hours, together with clindamycin (Clindamy-cin®, HemofarmAD, Serbia) at a dose of 100 mg every six hours. Th e inhalations with Berodual® and Pulmicort® continued with the gradual prolongation of the intervals between the inhalations. In spite of the applied thera-Volume 7 • Number 1 • April 2020 • HOPH py fever lasted for ten days followed by night sweats. On the 14 th day of hospitalization, when the patient was clinically stable the intravenous antibiotic therapy was switched to oral -cefi xime suspension (Pancef®, Alkaloid AD Skopje, North Macedonia) at a dose of 4 ml once per day. Further clinical course showed the improvement of the fi nding at ausculta-tion of the lungs, which was normal. Th e chest X-ray on the 20 th day of treatment revealed a newly discovered, clearly outlined half-spherical shadow of about 21 mm on the right side of in the upper mediastinum next to the heart shadow along with the small stain condensations of the lung parenchyma (picture no. 2). Th e clinical course indicated recovery (the child was not febrile any more, the parameters of infection decreased, auscultation fi ndings were without pathological sound phenomena), but meanwhile an infl ammatory change discovered by chance was located. Th e ultrasound of the lungs was done fi rst, and because the fi ndings were not clear, the X-ray scans of the lungs and the heart were done additionally. A pulmonologist was consulted and because of the evaluation of the suspected change, a CT scan of the lungs with contrast was carried out as well.
In the upper lung lobus paracardially, on the right and next to the pericardium, a round, relatively clearly outlined hypodense lesion with the dimensions of 26 x 25 x 25 mm (AP x LL x CC) was noticed (picture no. 3). Following administration of the contrast agent, it showed primarily at the edge but partly at the center as well, and according to its CT characteristics indicated abscess (picture no. 4). Th e smaller zones of lung parenchyma condensation on the right with the distinctive hypodense zones were recoreded. A thorough diagnostic evaluation of the lesion etiology included bronchoscopy and the examination of broncholates (bacteriological, cytopathological, mycological micro bacteria testing), gastric lavages and the diagnostic testing for tuberculosis (QuantiFERON test and PPD probe). On 22 nd day of hospitalization a triple intravenous antibiotic therapy with vancomycin, meropenem and metronidazole over a period of at least three weeks and in accordance with the handbook for treating abscess was involved. Th is therapy covered Gram positive and Gram-negative aerobes and anaerobes. Prior to the enhanced antibiotic therapy, hemoculture and blood tested for viruses (the most common cause of pneumonia) had been taken indicating slightly higher IgM of antibodies of Mycoplasma pneumonia and when the results arrived clarithromycin suspension was included into the therapy. Because the assessment of the immunology status was necessary, an immunologist was consulted and the immunology examination was carried out, www.hophonline.org Bajić DD et al: Lung Abscess as a Complication of Pneumonia in 19-month Old Child together with immunophenotyping of lymphocytes and determining the subclass of IgG antibodies. Th e results showed that the absolute number of B lymphocytes was decreased to the referent range according to age, while the absolute number of T lymphocytes and NK cells as the ratio of CD4 : CD8 were normal. ELISA test for Toxoplasma gondii (IgM and IgG negative) was carried out diff erentially as well as the test of indirect hemagglutination for echinococcosis which was also negative. During the hospitalization, US of the lungs and CT of the chest were performed a number of times, justifying the applied therapy, with the gradual regression of the abscess. Having been implemented for three weeks, the applied therapy was suspended and replaced with ampicillin sulbactam (Ampisulcillin® 1000 mg + 500 mg, ZDRAVLJE AD Leskovac, Serbia) at a dose of 500 mg every eight hours parenterally and ciprofl oxacin (Marocen®100 mg/10 ml, Hemofarm AD, Serbia) at a dose of 100 mg three times a day during the period of seven days.
All intravenous therapy was suspended during the last week of hospitalization and the patient was switched to amoxicillin plus clavulanic acid suspension (Panklav forte® 250 mg + 62.5 mg/5 ml Hemofarm AD, Serbia) at a dose of 1.6 ml three times a day. Th e applied therapy resulted with the improved health condition of the patient and fi ndings on the lungs, while the characteristic of abscess cleared up almost completely (pictures no. 5 and 6.). Th e patient was regularly monitored by the pulmonologist and immunologist, while US of the lungs was occasionally applied and it was normal.

DISCUSSION
Lung abscess is a tick-walled cavity in the pulmonary parenchyma that contains purulent material and is initiated or complicated by infectious organisms [7]. Lung abscess is classifi ed as primary or secondary depending on underlying conditions. Primary lung abscess occurs in the absence of a specifi c lung disease, while secondary lung abscess occurs in the presence of predisposing structural or functional lung diseases including congenital lung disorders, ciliary dyskinesia and cystic fi brosis, systemic diseases such as neuro-developmental abnormalities and congenital immunodefi ciencies that may lead to aspiration or infection [8].
Th e introduction of microbials into clinical practice has improved the prognosis of lung abscess, but the literature from 1969 to 2005 reported mortality rates ranging from 2.0% -38.2% [9]. Pediatric lung abscess can occur at any age and morbidity is lower than that in adults [7]. Th e clinical signs and therapy of lung abscess were described for the fi rst time by Hippocrates. In pre-antibiotic era, one third of patients with lung abscess would die, the other third of patients would fully recover, and the rest would survive with sequels such as chronic lung abscess, pleural empyema or bronchiectasis [10]. In pre-antibiotic era, lung abscess was caused by one type of bacteria, and today almost in all cases is caused bypolymicrobial fl ora [11]. From anaerobic bacteria in lung abscess predominant bacteria isolates are gram-negative Bacteroidesfragilis, Fusobacteriumcapsulatum and Necrophorum, grampositive anaerobic Peptostreptococcus and Microaerophilic streptococci. From aerobic Picture 5. CT scan after therapy Picture 6. Regression of abscess Volume 7 • Number 1 • April 2020 • HOPH od is a "backup" method in particular cases that are not clear and where better magnifying power is necessary to enable a clear detection of the changes.
In the cases where a concrete microbiological fl ora has not been isolated, which is considered as a primary causative agent for the development of abscess, empiric therapy has to be conducted in such a way to cover the most dangerous and/or the most frequent causative agents. In our case were chosen backup antibiotics of which some can go through hematoencephalic barrier, while others cover Gram-positive and Gram-negative aerobic and anaerobic. Meropenem, vancomycin and metronidazole were the proper choice because their targeted use in the period of three weeks resulted with the regression of abscess almost completely. According to the recommendations of the guidelines, antibiotic therapy should last until the visible clinical and radiological signs of the abscess regression appear [17]. Th e child has been controlled on a regular basis since the treatment by the pulmonologist and immunologist. Th e child does not have any diffi culties and his body mass index has increased.

CONCLUSION
Lung abscess is a rare complication of pneumonia in infancy, and its atypical clinical picture is a proof that in spite of the standard antibiotic therapy (treatment), the response of the organism is always individual. Radiological diagnostic was used to control and monitor the course of abscess treatment, from its recognition to regression. Th e combination of antibiotics that led to recovery included meropenem, vancomycin and metronidazole. bacteria predominant bacteria isolates in lung abscess are Staphylococcus aureus (including methicillin resistant Staphylococcus aureus MRSA). Streptococcus pyogenes and pneumonia, Klebsiella pneumonia, Pseudomonas aeruginosa, Hemophilus infl uenza (type B), Acinetobacterspp, Escherichia coli, and Legionella [12].
Th e duration of antibiotic therapy depends on the clinical and radiographic response of the patient [13]. According to the guidelines, intravenous therapy should be applied for at least three weeks, and then it should be switched to the oral form in such a way that the complete duration of the treatment is not beyond six weeks [14]. Th e chosen antibiotics have to cover a wide specter of Gram-positive and Gram-negative bacteria [15]. Th e differential diagnosis is particularly signifi cant because of a non-specifi c clinical picture with relatively common signs and symptoms of the disease such as non-productive cough, fever and night sweat. Th e additional diagnostic should confi rm or reject the following entities: excavating bronchial carcinoma (squamouscell or microcellular), excavating tuberculosis, localized pleural empyema, infected emphysematous bullae, cavitary pneumoconiosis, hiatus hernia, pulmonary hematoma, hydatid cyst or lungs, cavitary infarcts of lungs, Wegener's granulomatosis [13].
Diagnostic bronchoscopy is a part of diagnostic protocol for taking the material for microbiological examination and to confi rm intrabronchial cause of abscess -tumor or foreign body [16]. Bronchoscopy should be an integral part of the algorithm for diagnostic and therapy of lung abscess [13]. Th e examination of bronchial aspirate culture, broncholavage and gastric lavage showed that the microbiological cultures were without bacterial increase. Th e cytopathological analysis showed the presence of mucus, rare cylindrical cells and lipid laden macrophages in broncholavage. While making a diagnosis, besides the clinical picture which is the starting point, imaging methods and the response of the organism to the applied therapy are also crucial. If the lung diseases are suspected, the fi rst step is a chest X-ray, which is still in practice as the most common diagnostic method although it belongs to ionizing radiation. Computerized tomography is more advanced in the diagnostic algorithm and CT scans will not be used for detecting every case of pneumonia. Th is meth-