Auscultation of the lungs may reveal localized rales, wheezing, and decreased air entry in the affected area. However, auscultatory findings may not be reliable in children. When a group of pediatricians was asked to examine children with lower respiratory tract symptoms, there was only fair agreement about most auscultatory findings.28 In younger children, decreased breath sounds, rather than rales, are often heard, since the involved areas tend to be ventilated poorly. Observable findings, such as respiratory rate and work of breathing, are more reliable. 25 Signs of increased work of breathing may include retractions, chest indrawing in infants, or paradoxical (seesaw) breathing. Grunting respirations are frequently present, particularly in infants with pneumonia. 29 Abdominal distention and pain may be present secondary to a paralytic ileus or diaphragmatic irritation in lower-lobe pneumonias. 30
The clinical presentation may be suggestive of the etiologic agent. Two classic presentations have been described for pneumonia: typical pneumonia and atypical pneumonia. Typical pneumonia is characterized by abrupt onset of fever, chills, pleuritic chest pain, and productive cough. Associated physical examination findings include high-grade fever, localized findings on chest examination, and a toxic appearance. Atypical pneumonia is characterized by gradual onset (over days) of headache, malaise, nonproductive cough, and low-grade fever. Associated physical examination findings may include wheezing, prolonged expiration, rhinitis, conjunctivitis, pharyngitis, and rash. The typical pattern is generally thought to be associated with a bacterial pathogen, and the atypical pattern is thought to be more characteristic of a viral infection; however, significant overlap exists, and identification of a causal agent based on clinical presentation is not always reliable. 31
Typical clinical presentations have been described for some specific pathogens. Pneumonia due to S. aureus is notorious for being particularly rapid in the progression of clinical findings. Patients with B. pertussis pneumonia typically develop prodromal symptoms, including mild cough, conjunctivitis, and coryza, that lasts 1 to 2 weeks. A severe, paroxysmal cough often associated with emesis and dehydration, because coughing prevents eating and drinking, is characteristic of the catarrhal phase of pertussis infections. The inspiratory whoop is generally present only in older children. A history of maternal pelvic or conjunctival chlamydial infection is present in up to 50 percent of cases in which the infant develops C. trachomatis pneumonia. An infant with a chlamydial infection is usually afebrile, has a distinct staccato cough (i.e., short, abrupt onset), and diffuse rales on auscultation. Such infants rarely appear systemically ill. Chlamydial pneumonia in adolescents is usually insidious in onset and often includes complaints of sore throat and dysphagia. Mycoplasmal infections generally present with the gradual onset of malaise, fever, and headache. A hacking, nonproductive cough usually begins 3 to 5 days after the onset of illness and is present in up to 98 percent of children. Mycoplasmal infection may produce pharyngitis, and rales are present in approximately 75 percent of patients. A variable rash, which may be papular, vesicular, urticarial, or erythema-multiforme-like, is present in about 10 percent of patients with M. pneumoniae.
The age of the patient may also affect the clinical presentation. Pneumonia often occurs in association with a sepsis syndrome in neonates. 1 22 Infants frequently lack the classic symptoms and present with a variety of nonspecific findings. Nonspecific symptoms and signs of pneumonia in infants include fever without a localizing source, apnea, poor feeding, abdominal pain, vomiting or diarrhea, hypothermia, grunting, bradycardia, lethargy, and shock. Sputum production is uncommon in nontracheostomized children less than 8 years of age.
The severity of pneumonia may be judged by clinical features. More severe pneumonia is associated with deterioration of the patient's mental status, the use of accessory muscles, and the presence of retractions, nasal flaring, splinting, and cyanosis. Infants with poor feeding and lethargy may have more severe disease. A patient with a history of immunosuppressive therapy, a history of primary immune deficiencies, or a history suggestive of an immune deficiency may have more severe pneumonia, often caused by unusual pathogens. Children with underlying illnesses, such as congenital heart disease, chronic pulmonary disease, or sickle cell disease, are often more severely compromised by pneumonia.
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