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PECARN Pie: Pneumonia - Radiographic Signs and Biomarkers

Todd Florin, MD, Julia Magana, MD, and Jason Woods, MD
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Jason and Julia, co-chairs of dissemination for PECARN, discuss the diagnosis of pneumonia with Dr. Todd Florin, Associate Professor of Pediatric Emergency Medicine at Northwestern University Feinberg School of Medicine.

  • Community-acquired pneumonia (CAP) is a syndromic diagnosis, meaning that it is made based on a combination of clinical signs and symptoms and/or radiographic findings. 

  • The strongest predictors of radiographic CAP are hypoxia and work of breathing. There is data to suggest that the negative predictive value of a normal chest x-ray is high and that very few children with a normal chest x-ray will later go on to develop a radiographic pneumonia.

  • Differentiating between bacterial and viral pneumonia remains a major challenge. For the most part, radiographic findings cannot be used to define the etiology of an individual case pneumonia. 

    • However, pneumonia associated with a moderate to large pleural effusion is more likely to be due to  bacterial pneumonia. 

  • Elevations in procalcitonin are not specific and cannot be used to definitively say whether a child has a bacterial pneumonia. 

  • There is data to suggest that when procalcitonin is very low, less than 0.1 to less than 0.25, the risk for a typical bacterial pneumonia is low. 

    • An important caveat to note is that atypical pathogens, namely mycoplasma, generally do not incite an elevation in procalcitonin. 

  • The Catalyzing Ambulatory Research in Pneumonia Etiology and Diagnostic Innovations in Emergency Medicine (CARPE DIEM) study found that white blood cell count, C-reactive protein and procalcitonin were all not statistically associated with increasing disease severity, as one went from mild to moderate to severe. 

  • Proadrenalmedullin is a vasodilatory peptide that has been studied more extensively in sepsis but also in adult pneumonia. The CARPE DIEM study found proadrenalmedullin was the most strongly associated marker of the group with disease severity. 

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Hippo Peds RAP September 2021 Written Summary 240 KB - PDF

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