Symptoms and signs of community-acquired pneumonia in children
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ORIGINAL PAPER
Symptoms and signs of community-acquired
pneumonia in children
Taina Juvén, Olli Ruuskanen and Jussi Mertsola
Department of Pediatrics, Turku University Hospital, Turku, Finland.
Scand J Prim Health Care 2003;21:52–56. ISSN 0281-3432 those with bacterial pneumonia were younger (means 2.8 vs 4.1
years) and more often had acute otitis media (41% vs 18%), dyspnea
Objecti7e – The aim of this investigation was to identify the clinical (48% vs 25%) and rhonchi on auscultation (47% vs 26%). Thoracic
symptoms and signs of pneumonia in hospitalised patients with pain, headache and decreased breathing sounds were more common
confirmed aetiologic diagnosis and to study whether it is possible to in patients with bacterial pneumonia.
differentiate viral from bacterial pneumonia by these means. Conclusions – Although the clinical findings in viral pneumonia
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Design – A 3-year prospective study. showed some differences from those in bacterial pneumonia, they
Setting – Turku University Hospital, Turku, Finland. were largely overlapping. This similarity and the frequent occurrence
Patients – 254 children with radiologically confirmed community-ac- of mixed infections make it impossible to differentiate between viral
quired pneumonia. and bacterial pneumonia simply by clinical symptoms and signs.
Main outcome measures – Data on symptoms and signs were
collected from the hospital records of patient files. A standardised Key words: pneumonia, viral infection, bacterial infection.
case record form was used.
Results – Eleven percent of the patients presented the illness without Jussi Mertsola, Department of Pediatrics, Turku Uni7ersity Hospi-
any respiratory symptoms. Patients with viral pneumonia versus tal, PL 52, FIN-20521 Turku, Finland. E-mail: jussi.mertsola@tyks.fi
Acute lower respiratory tract infections cause consid- through the nostrils with a disposable mucus extractor
For personal use only.
erable morbidity and mortality, particularly in chil- for virus antigen detection, virus culture, as well as
dren in developing countries. Although the mortality rhinovirus and Mycoplasma pneumoniae PCR. The
in childhood pneumonia is low in developed countries, follow-up appointment was 3 to 4 weeks after dis-
the morbidity is high and it is estimated that 2.5 charge, when another blood sample for viral and
million cases of childhood community-acquired pneu- bacterial serology and a chest radiograph were taken.
monia occur in Europe annually (1). The chest radiographs were re-evaluated by three
The aetiology of childhood pneumonia is difficult to paediatric radiologists. Forty-two patients were ex-
establish because a great number of bacteria and cluded: 9 because their disease did not meet the criteria
viruses can cause pneumonia and many of them can for acute pneumonia in the chest radiograph and 33
be detected by methods available only in research because no convalescent serum sample was obtained.
laboratories (1). Another problem is that most pub- The mean age of the patients was 3.8 years (median
lished data on symptoms and signs in patients with 2.4 years). Thirty-seven patients were 0–11 months of
childhood community-acquired pneumonia have been age, 71 were 12–23 months of age, 84 were 2–4 years
obtained in patients suffering from acute lower res- of age and 62 were 5 years of age or older. Fifty-six
piratory tract infection in developing countries (2–4). percent were males and 44% females. Four patients
We have recently studied pneumonia in 254 children had more than one episode of pneumonia requiring
and a possible aetiologic agent was found in 85% of hospitalisation during the 3 years.
cases (5). In this paper, we report the symptoms and A role of 17 microbes (10 viruses and 7 bacteria) was
signs of pneumonia in these patients with confirmed studied. The details of the methods and microbiologic
laboratory diagnosis.
New serological and other microbiological meth-
ods are now available and provide an opportunity
PATIENTS AND METHODS to study childhood pneumonia in a new way.
From 1993 to 1995, 296 children with community-ac-
Pneumonia in children is often the combination
quired pneumonia were enrolled in the study at the
of a viral and a bacterial disease.
Department of Pediatrics, Turku University Hospital,
It is not possible to differentiate bacterial from
Turku, Finland. On admission, a chest radiograph and
viral pneumonia simply by means of symptoms
a blood sample for blood culture and serologic studies
and signs of the patient.
were taken. A nasopharyngeal sample was aspirated
Scand J Prim Health Care 2003; 21Symptoms and signs of community-acquired pneumonia in children 53
findings have been reported earlier (5). A potential tients had typical pneumonic rales/crackles on auscul-
aetiology was found in 85% of the patients: 62% of tation. Decreased breathing sounds were found in 15%
these had evidence of viral, 53% of bacterial and 30% of patients, wheezing in 20% and rhonchi in 33% of the
of mixed viral-bacterial infection. Altogether, 81 pa- patients. Auscultation was normal in 28% of the
tients (32%) had evidence of a pure viral and 57 (22%) patients (Table I). Acute otitis media was diagnosed in
of a pure bacterial infection. Streptococcus pneumoniae 30% of the patients.
pneumonia was diagnosed in 93 patients (37%), RSV
in 73 (29%), rhinovirus in 58 (24%), parainfluenza Symptoms and signs in patients with 6iral or
viruses 1, 2 or 3 in 25 (10%), Haemophilus influenzae bacterial pneumonia
in 22 (9%), adenovirus in 19 (7%) and Mycoplasma No significant differences occurred in the presence of
pneumoniae in 18 patients (7%) (5). fever, cough, toxic appearance, rhinorrhea, abdominal
A standardised case record form was used: data on pain, vomiting or diarrhoea in patients with viral
26 items were collected from the hospital records of infection when compared to those with bacterial or
the patient files, including date of birth, gender, date mixed viral-bacterial associated pneumonia. In pa-
of infection, aetiology of the disease, presenting signs tients with viral disease, dyspnea was a more common
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and physical examination findings. Clinical history symptom (p= 0.01), whereas those with bacterial
was taken by the paediatrician in charge and who did pneumonia more often had thoracic pain (p= 0.064)
the clinical evaluation of the patients. The highest and headache (p= 0.058) (Table II). In patients with
breath rate was recorded on admission by the paedia- viral, bacterial or mixed viral-bacterial infection, the
trician and on the ward by a paediatric nurse using the mean durations of symptoms before admission to
observation counting method (60 sec). hospital were 6.9, 7.5 and 8.0 days, and fever lasting
2.6, 3.4 or 3.7 days, respectively.
Statistical analysis Patients with pure viral or mixed viral-bacterial
The Pearson chi-square test was used to compare infection had higher breath rates than those with pure
proportions between the groups. bacterial pneumonia (45/min and 43/min versus 37/
For personal use only.
min) (p= 0.005). Decreased breathing sounds oc-
curred more often in children with bacteria-
RESULTS associated infection (p= 0.046) and rhonchi in pa-
General tients with viral disease (p= 0.006), but no other
The most common symptoms were fever in 96%, statistically significant differences were found on aus-
cough in 76%, rhinorrhea in 48%, dyspnea in 37% and cultation of the lungs (Table II).
malaise/lethargy in 31% of the patients (Table I). The Of patients with acute otitis media (30% of total),
mean duration of symptoms before hospitalisation 18% had evidence of bacterial, 35% of mixed and 41%
was 7.0 days (median 5.0 days) and of fever 3.0 days of viral pneumonia.
(median 2.0 days). The mean of the highest tempera-
ture measured was 39.3°C (median 39.5°C). Symptoms and signs in patients of different ages
Breath rate was ] 40/min in 51% and ]50/min in Fever, cough and malaise/lethargy were equally com-
30% of the patients. Twenty-four percent of the pa- mon in patients B 2 and ] 2 years of age. Younger
children (B 2 years) had dyspnea (pB 0.001) and
rhinorrhea (p= 0.003) more frequently, whereas older
Table I. Symptoms and respiratory findings (%) in 254 chil- ones (] 2 years) had thoracic (pB 0.001) or abdomi-
dren with community-acquired pneumonia. nal pain (pB 0.001) and headache (pB 0.001) more
Symptom % Finding % often (Table III). The duration of symptoms and fever
showed no significant differences between the age
Fever \37.5°C 96 Auscultation groups: The mean duration of symptoms was 6.9, 6.1
High fever (]39.0°C) 77 Rhonchi 33 and 8.2 days, and that of fever 3.1, 2.7 and 3.2 days
Cough 76 Normal 28 in age groupsB 2 years, 2 to 4 years and ] 5 years,
Rhinorrhoea 48 Rales/crackles 24
Dyspnea 37 Wheezing 20 respectively.
Malaise/lethargy 31 Decreased 15 Patients B 2 years of age had higher breath rates
Vomiting 29 sounds (mean 47/min, median 48/min) than older patients
Poor appetite 25 Breath rate (mean 39/min in children 2–4 years and 31/min in
Headache 15 ]40/min 51 (n= 188) those ] 5 years) (pB 0.001). In patients B 1 year of
Abdominal pain 13 ]50/min 30 (n= 188)
Thoracic pain 10 age, the mean breath rate was 50/min and the median
Diarrhoea 6 52/min. The younger the child the more usual were
wheezing and rhonchi on auscultation. Patients ]2
Scand J Prim Health Care 2003; 2154 T. Ju6én et al.
Table II. Symptoms and respiratory findings (%) in 215 patients with childhood community-acquired pneumonia with defined
aetiology.
Symptom or finding Bacterial infection Viral infection Viral-bacterial infection
(n=57) (n = 81) (n =77)
Fever \37.5°C 95 94 97
High fever (]39.0°C) 80 66 81
Cough 74 84 77
Rhinorrhoea 42 57 52
Vomiting 32 25 22
Headache 28 9 12
Malaise/lethargy 26 26 33
Dyspnea 25 481 35
Thoracic pain 21 5 7
Poor appetite 19 30 26
Abdominal pain 14 10 8
Diarrhoea 4 6 8
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Auscultation
Normal 37 20 23
Rhonchi 26 471 30
Rales/crackles 21 25 29
Wheezing 16 25 18
Decreased sounds 14 91 22
Breath rate
]40/min 37 (n=43) 62 (n= 56) 54 (n = 61)
]50/min 21 (n=43) 38 (n =56) 34 (n =61)
1
pB0.05, comparison between patients with bacterial (pure bacterial or mixed) infection and those with viral infection.
For personal use only.
years of age had statistically more often normal pneumonia, 48% of patients B 2 years of age had
(p =0.007) or decreased breath sounds (p= 0.002) acute otitis media. In age groups 2–4 years and ]5
than younger patients (Table III). In addition to years, the frequencies of acute otitis media were 21%
and 10%, respectively.
Table III. Symptoms and respiratory findings (%) in 254 pa-
tients with community-acquired pneumonia according to age.
DISCUSSION
Symptom or finding Age
Although pneumonia is a respiratory infection, 24%
B2 years 2–4 years ]5 years of our patients were not reported to have cough, and
n=108 n =84 n= 62 11% presented with the illness without any respira-
tory symptoms. All of these patients without respira-
Fever \37.5 °C 94 98 97 tory symptoms had fever, half had malaise or were
Cough 77 71 81
Rhinorrhoea 581 41 39
lethargic, one-third had headache and one-third had
Dyspnea 531 29 19 vomiting. These results concur with our recent study,
Poor appetite 32 21 20 where only 55% of patients with bacteraemic pneu-
Malaise/lethargy 26 37 32 mococcal pneumonia had cough, 49% had nasal
Vomiting 22 36 31 symptoms and 11% had dyspnea (6).
Diarrhoea 7 5 7
Abdominal pain 51 21 29
Most published data on signs and symptoms in
Headache 31 16 37 patients with childhood pneumonia come from the
Thoracic pain 01 6 32 developing countries in patients suffering from acute
Auscultation lower respiratory tract infections (ALRI) (2– 4). The
Rhonchi 491 22 21 respiratory rate (breaths/min) thresholds for ALRI,
Wheezing 281 15 15 set by the World Health Organisation, are 60/min for
Rales/crackles 23 27 20 infants less than 2 months of age, 50/min for infants
Normal 191 33 36
from 2 to 12 months and 40/min for children aged
Decreased sounds 71 20 21
1 – 5 years (7,8). In countries where the mortality of
Breath rate childhood pneumonia is high and trained staff are
]40/min 711 (n=86) 48 (n= 61) 12 (n= 41)
]50/min 471 (n=86) 21 (n =61) 7 (n = 41)
lacking, the criteria of ALRI could be helpful (9,10).
In Western industrialised countries, however, it is
1
pB0.05 when compared to patients ]2 years. important to differentiate asthma and bronchiolitis
Scand J Prim Health Care 2003; 21Symptoms and signs of community-acquired pneumonia in children 55
from pneumonia. The sensitivity of tachypnea as an breathing sounds were heard significantly more often
indication of pneumonia is 50%– 81% and its specific- in patients with bacterial pneumonia than in those
ity 54%– 70% (7,11– 13). Only 30% of our patients with pure viral pneumonia (14% vs 9%).
with radiologically confirmed pneumonia had a breath It is important to emphasise the limitations of this
rate ] 50/min, and as defined by the age-related study. Although we used a wide panel of laboratory
criteria of ALRI the corresponding number was 56%. methods, the observations are only indirect evidence
Our results indicate that viruses, in particular, cause of the aetiology of pneumonia, because potentially
dyspnea and an increased rate of breathing (Table II). harmful trans-thoracic needle aspiration cannot be
The intention of our study was not to find symp- done directly from the infected lung. The other impor-
toms indicating pneumonia, but instead to analyse the tant limitation is that we only studied hospitalised
symptoms and signs of patients with radiologically patients, and the results cannot be generalised to
and aetiologically well-confirmed pneumonia. Accord- outpatients with pneumonia.
ing to Zukin, the best screen for pneumonia is the In summary, the diagnosis of pneumonia is difficult,
presence of fever (13). Some studies suggest that higher because patients with pneumonia may present without
and long-lasting fever is associated with bacterial any respiratory symptoms. Furthermore, it is not
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pneumonia infection (14– 16), especially in combina- uncommon that auscultation findings and breath rate
tion with abnormal laboratory tests. Recently, we are normal. Our results with modern diagnostic tech-
showed that serum C-reactive protein, procalcitonin niques support earlier findings that it is difficult to
and interleukin-6 have only limited value in differenti- differentiate between bacterial and viral infection in
ating between bacterial and viral pneumonia, because children suffering from community-acquired pneumo-
their values show a wide distribution (17). Fever was nia on the basis of symptoms, signs and clinical
a common finding in our patients (96%), but no findings only (24,25).
differences occurred in the highest temperature and
duration of fever between children with viral and those
with bacterial infection. Bacterial pneumonia is often ACKNOWLEDGEMENTS
For personal use only.
considered an acute and rapid febrile illness. It is This study was supported by the Academy of Finland,
interesting that the symptoms of our patients had the Finnish Anti-Tuberculosis Association Founda-
lasted for several days (mean 7.0 days) before admis- tion and the Väinö and Laina Kivi Foundation.
sion. Duration of the symptoms was not significantly
longer in patients with mixed viral-bacterial infection.
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