RECURRENT/

PERSISTENT
PNEUMONIA
DR.ISHITHA PANDEY
DNB .
SENIOR RESIDENT
DEPARTMENT OF PEDIATRICS
PIMS ,LUCKNOW.
 Plan of
today’s talk

• Why are we discussing these two

entities here together??
• Why the two definitions are different?
 Definition
RECURRENT PNEUMONIA is defined as:
2 or more episodes in a year
or
3 or more episodes ever
With
radiographic clearing between occurrences

PERSISTENT PNEUMONIA is defined as persistence of symptoms and

radiological changes for 4 weeks or more despite treatment.

Nelson, textbook of pediatrics, 21st edition

• Slowly resolving pneumonia
• Signs & symptoms fever, cough, dyspnea, and
leukocytosis improving, while radiographic
evidence of infection persist.
• Chronic Pneumonia
• Symptoms of infection do not remit and
• x-ray findings persist longer than one month
Difficulties in Clinical settings

• May be difficult to know if no skiagrams of the

“defervescence” available

• At times persistent infections may present as

recurrent infections because of inadequate or
inappropriate therapy.

• Persistent What ? - ??symptoms /??shadows/ both

Problems with X-rays

• Radiograph may have been over-read for

minor abnormalities
• Expiratory chest films particularly under
penetrated
• Difference in exposure can affect perception
regarding clearance
• Actual film not available
PATHOLOGY OF
RECURRENT/PERSISTENT PNUEMONIA

Usually result from deficiencies in the local pulmonary or

systemic host defenses or from underlying disorders that
modify the lung defences

It is not a diagnosis but a clinical situation

Paed Respir Reviews 2012

 Predominantly three clinical types

• Recurrent Pulmonary Infilterates with interval

clearing
• Persistent or recurrent radiological findings with
persistent s/s
• Persistent radiological findings without clinical
evidence all the time
 Predominantly three clinical types

• Recurrent Pulmonary Infilterates with interval

clearing
Classification of recurrent pneumonia
Recurrent
Pneumoni
a

Same Lobe Different

(Localized) Lobe
CAUSES OF RECURRENT PNEUMONIA IN
SAME LOBE
1) Localised airway obstruction
a)Intraluminal obstruction
b)Extraluminal compression
2) Structural abnormalities of airways or lung parenchyma
3) Right middle lobe syndrome
 CAUSES OF RECURRENT PNEUMONIA IN
SAME LOBE
1)Localised airway obstruction
• Inhaled FB
a) Intraluminal obstruction
• Endobronchial granuloma
b)Extraluminal compression (tuberculosis)

2)Structural abnormalities • Endobronchial tumor

• Hemangioma
3)Right middle lobe syndrome • Lipoma
• Adenoma
• Papilloma
 CAUSES OF RECURRENT PNEUMONIA IN
SAME LOBE
• Lymphadenopathy:
1) Localised airway obstruction Infectious (TB, histoplasmosis,
coccidioidomycosis, blastomycosis)
a) Intraluminal obstruction
b)Extraluminal compression Non-infectious (Hodgkins,
sarcoidosis)
2) Structural abnormalities
• Vascular rings and slings
3) Right middle lobe syndrome • Esophageal FB
• Cardiomegaly
• Inflammatory pseudotumour
 CAUSES OF RECURRENT PNEUMONIA IN
SAME LOBE
1) Localised airway obstruction
• Bronchial stenosis
a) Intraluminal obstruction • Segmental bronchomalacia
• Bronchogenic cyst
b)Extraluminal compression • CPAM
• Congenital lobar emphysema
2) Structural abnormalities
• Tracheal bronchus
3)Right middle lobe syndrome • Pulmonary sequestration
• Congenital pulmonary cysts
• Pulmonary hypoplasia
 CAUSES OF RECURRENT PNEUMONIA IN
SAME LOBE
1)Localised airway obstruction
• Recurrent right middle lobe pneumonia
a) Intraluminal obstruction and atelectasis

b)Extraluminal compression • Predisposing factors:

• Narrow diameter of bronchus
2) Structural abnormalities • Acute angle of origin
• Relative anatomical isolation from
3) Right middle lobe syndrome
other lobes
-Poor collateral ventilation
• Proximity to hilar lymph nodes
CAUSES OF RECURRENT PNEUMONIA IN
DIFFERENT LOBE
1) Recurrent aspirations
2) Structural abnormalities
3) Defects in clearance of airway secretions
4) Systemic immunodeficiency
5) Allergic lung disease
6) Congenital heart disease
7) Asthma
CAUSES OF RECURRENT PNEUMONIA IN
DIFFERENT LOBE FROM ABOVE:
• Impaired swallowing (CNS
disorders, neuromuscular
1) Recurrent aspirations*
disorders, cricopharyngeal
2) Structural abnormalities incoordination)
• Laryngeal/submucosal clefts,
3) Defects in clearance of airway secretions cleft
palate, Pierre Robin syndrome
4) Systemic immunodeficiency • Esophageal obstruction or
dysmotility (webs, stricture,
5) Allergic lung disease achalasia)
• TEF
6) Congenital heart disease
7) Asthma FROM BELOW:
• GERD
• TEF
Owayed AF, Campbell DM, Wang EE. Underlying causes of recurrent pneumonia in children. Arch
Pediatr Adolesc Med. 2000 Feb;154(2):190-4. doi: 10.1001/archpedi.154.2.190. PMID: 10665608.
CAUSES OF RECURRENT PNEUMONIA IN
DIFFERENT LOBE
1) Recurrent aspirations • Tracheobronchomegaly
• Generalised
2) Structural abnormalities bronchomalacia
(Williams-Campbell
3) Defects in clearance of airway secretions syndrome)
4) Systemic immunodeficiency
5) Allergic lung disease
6) Congenital heart disease
7) Asthma
CAUSES OF RECURRENT PNEUMONIA IN
DIFFERENT LOBE
1) Recurrent aspirations
2) Structural abnormalities
• Cystic fibrosis
3) Defects in clearance of airway secretions
• Primary ciliary
4) Systemic immunodeficiency dyskinesia

5) Allergic lung disease

6) Congenital heart disease
7) Asthma
CAUSES OF RECURRENT PNEUMONIA IN
DIFFERENT LOBE Primary:
• Antibody deficiency
1) Recurrent aspirations (agammaglobulinemia, CVID, IgG
def)
2) Structural abnormalities • CMI deficiency
• Complement deficiency
3) Defects in clearance of airway secretions • Phagocytic defect

4) Systemic immunodeficiency Secondary:

• Infections, HIV
5) Allergic lung disease
• Iatrogenic (steroids,
6) Congenital heart disease immunosuppressive drugs, post
RT, post-transplant)
7) Asthma • Malignancy (leukemia, lymphoma)
• Diabetes, Malnutrition
• Acquired hyposplenism (sickle cell
anemia, trauma)
CAUSES OF RECURRENT PNEUMONIA IN
DIFFERENT LOBE
1) Recurrent aspirations
2) Structural abnormalities
3) Defects in clearance of airway secretions
4) Systemic immunodeficiency
• Allergic bronchopulmonary
5) Allergic lung disease aspergillosis
• Hypersensitivity pneumonitis
6) Congenital heart disease
7) Asthma
CAUSES OF RECURRENT PNEUMONIA IN
DIFFERENT LOBE
1) Recurrent aspirations
2) Structural abnormalities
3) Defects in clearance of airway secretions
4) Systemic immunodeficiency
5) Allergic lung disease ACHD with
increased
6) Congenital heart disease pulmonary blood
flow
7) Asthma
 CAUSES OF RECURRENT PNEUMONIA IN
DIFFERENT LOBE

1) Recurrent aspirations
2) Structural abnormalities
3) Defects in clearance of airway secretions
4) Systemic immunodeficiency
5) Allergic lung disease
6) Congenital heart disease
7) Asthma– mcc of recurrent/persistent infiltrates*

*Lederman H: The clinical presentation of immunodeficiencies. Clinical focus on primary

immunodeficiencies,2002.
The Initial approach to additional investigations may be
guided by the localization of the recurrent pneumonias

History

Physical
examinati
on

Investigatio
ns

Final
Diagnosis
 History
History Explore the following What do they imply

Detailed cough history, pattern, GERD/asthma/reactive

relation to food or exercise, exposure airway disease/ pneumonia
History of to colds and color of sputum if
present productive.
illness Foreign body inhalation
Paroxysmal cough
Frequent loose and offensive bowel Cystic fibrosis
motions with failure to thrive

•Term or preterm? chronic lung disease / BPD

Birth history •Required ventilation?
•Delay in passage of meconium CF
 History
History Explore the following What do they imply
• Age at infections • Congenital malformations
• Pattern of previous infections • Post-viral illness ?Reactive airway
disease
• SPUR(Severe, Persistent, unusual, • Immunodeficiency
recurrent)
• History of persistent diarrhea,
Past medical
cutaneous infections/abscess/boils • Primary ciliary dyskinesia
history
etc.
• Other associated conditions like • Pulmonary T.B
persistent nasal discharge/
dextrocardia
• History of exposure to chronic
cough
• Family history of Chronic coughs. • T.B
Family and • Family history of immunodeficiency • Immunodeficiency
Social history • History of exposure to • Reactive airway disease or asthma
environmental tobacco smoking
GENERAL PHYSICAL WHAT TO LOOK FOR
EXAMINATION
GROWTH Height, Weight, BMI

ENT EXAMINATION Recurrent Otitis media and effusion (Immunodeficiency)

Nasal polyp (Cystic fibrosis), sinusitis, rhinitis(Allergic
disorders), cleft palate
CLUBBING Indicates chronic hypoxia or Suppuration
(Cystic fibrosis, bronchiolitis obliterans, bronchiectasis)

LYMPHOID ORGANS Absent tonsils: hypo/agammaglobinemia

Generalised lymphadenopathy (HIV, TB, histiocytosis)

HEAD & NECK Ear, nose, conjunctiva, allergic shiners, Dennie morgan
folds, allergic salute (Allergic Disorders)
Oral cavity (candidiasis)
MORPHOLOGICAL FEATURES "fish mouth" with hypertelorism (DiGeorge’s
syndrome)
Telangi-ectasia of eyes/ears (Ataxia telangiectasia)
SKIN Pustules, rash, features of atopic dermatitis
 Griscelli
Wiscott Aldrich
Syndrome
Syndrome

SCID with
Ataxia Telengiectasia disseminated BCG Courtesy
Dr SK Kabra
disease
SYNOPSIS
SYNOPSIS
 Take home message
 Review all old x-rays

 Review history

 See if patient fits into definition of “persistent/recurrent pneumonia”

 Assess if it is a single lobe or multiple lobe involvement

 Look for extra pulmonary features