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Pleural Effusion Increases Serum Procalcitonin Values in Children with Community-acquired Pneumonia

Fonseca, Taiane S. MD; Gendrel, Dominique MD, PhD; Ruuskanen, Olli MD, PhD; Nascimento-Carvalho, Cristiana M. MD, PhD

The Pediatric Infectious Disease Journal: August 2015 - Volume 34 - Issue 8 - p 914–915
doi: 10.1097/INF.0000000000000763
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Postgraduate Program in Health Sciences, Federal University of Bahia School of Medicine, Salvador, Brazil

Department of Pediatrics, Saint-Vincent-de-Paul and Necker-Enfants-Malades Hospital, AP–HP, Université Paris-Descartes, Paris, France

Department of Pediatrics, University of Turku, Turku, Finland

Postgraduate Program in Health Sciences, Federal University of Bahia School of Medicine, Salvador, Brazil, Department of Pediatrics, Federal University of Bahia School of Medicine, Salvador, Brazil

This study was supported by the Bahia State Agency for Research Funding (FAPESB; grant number 52/2004) and the Brazilian Council for Scientific and Technological Development (CNPq; grant number 303551/2011–9) in Brazil and the Pediatric Research Foundation, in Finland. C.M.N.-C. is an investigator at the Brazilian Council for Scientific and Technological Development (CNPq). The authors have no other conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.pidj.com).

Address for Correspondence: Taiane S. Fonseca, MD; E-mail: taianesf@hotmail.com.

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To the Editors:

Community-acquired pneumonia (CAP) remains one of the most important causes of morbidity and mortality in children younger than 5 years. Pleural effusion (PE) is the most frequent complication of CAP, and its incidence has been rising recently.1 PE has been classically associated with bacterial infection.2 Those patients are usually excluded from longitudinal studies because they show a delayed response to antibiotics.3 Procalcitonin (PCT) is an inflammatory biomarker that has been studied in children with CAP to support bacterial etiology and to guide the length of antibiotic use.3,4 No study has compared PCT serum values in children with CAP with or without PE.

This was a prospective study conducted at the Emergency Room of the Federal University of Bahia Hospital. Children younger than 5 years diagnosed with CAP admitted in a 21-month period were evaluated. On admission, clinical and radiologic data were collected as were aspirates and blood to investigate etiologic agents and serum PCT values. All chest radiographs were read by a pediatric radiologist blinded to patient’s clinical data. Eleven viruses and 8 bacteria were investigated. PCT concentration was measured by an immunoluminometric assay (LUMItest PCT, BRAHMS Diagnostica, Berlin, Germany), and the detection limit was 0.02 ng/mL. The study was conducted in accordance with the principles of the Helsinki Declaration, and it was approved by the Ethics Committee of the Federal University of Bahia.

From 128 CAP patients included in this evaluation, 75 (59%) were boys. The median (interquartile range) age was 17 (9; 27) months. PE was detected in 13 (10.2%) cases. The median (interquartile range) PCT serum concentration on admission was 1.68 (1.19; 6.56) ng/mL in those with PE compared with 0.69 (0.12; 2.53) ng/mL in those without PE (P = 0.021; Mann–Whitney U test). In the PE group, evidence of viral (46.2%), bacterial (30.8%) and mixed viral–bacterial (23.0%) infections were detected, of which 30.8% were caused by pneumococci (7.7% invasive disease all with positive blood culture) and 7.7% by Mycoplasma pneumoniae. In the CAP group, viral (47%), bacterial (19.1%) and mixed viral–bacterial (33.9%) were detected, of which 26.1% were pneumococcal [7.8% invasive disease with positive blood culture (6.1%) and positive blood PCR (1.7%)] and 8.7% were because of M. pneumoniae. PCT serum level on admission ≥1.0 ng/mL was associated with PE (85% vs. 44%; P = 0.005, χ2 test) for which the area under the ROC curve for PE was 0.7, sensitivity was 85% (95% confidence interval: 58–97%) and the negative predictive value was 97% (95% confidence interval: 90–99%). The diagnostic criteria for PE and for the etiology in each case are presented in Table (Supplemental Digital Content 1, http://links.lww.com/INF/C143).

Our findings show that serum PCT values are higher in children with CAP and PE than in children with CAP without PE. Interestingly, the frequency of the etiologic groups and of pneumococcal infection was similar among cases with or without PE.

One study concluded that serum PCT concentration ≥3 ng/mL is suggestive of pneumococcal etiology, and it is the best predictor of response to beta-lactam treatment.3 Another investigation found that it is possible to reduce unnecessary antibiotic therapy using antibiotic therapy only for cases with PCT levels ≥0.25 ng/mL.4 Both studies excluded children with CAP and PE from their study groups.

The relationship between pleural inflammation and biomarkers has not been well established in children. One study5 suggested that pleural inflammation associated with CAP is a continuous process, and inflammatory cytokines are significantly higher according to the stage of disease in the evaluated children. In the study of Lahti et al,6 C-reactive protein values were higher among children with PE than among those with uncomplicated CAP.

It is important to stress that some bacterial infection may not have been detected by the tests employed in this investigation, either in cases with PE or in cases without PE.

Taiane S. Fonseca, MD

Postgraduate Program in Health Sciences

Federal University of Bahia School of

Medicine

Salvador, Brazil

Dominique Gendrel, MD, PhD

Department of Pediatrics

Saint-Vincent-de-Paul and Necker-Enfants-

Malades Hospital

AP–HP, Université Paris-Descartes

Paris, France

Olli Ruuskanen, MD, PhD

Department of Pediatrics

University of Turku

Turku, Finland

Cristiana M. Nascimento-Carvalho, MD, PhD

Postgraduate Program in Health Sciences

Federal University of Bahia School of

Medicine

Salvador, Brazil

Department of Pediatrics

Federal University of Bahia School of

Medicine

Salvador, Brazil

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REFERENCES

1. Yu D, Buchvald F, Brandt B, et al. Seventeen-year study shows rise in parapneumonic effusion and empyema with higher treatment failure after chest tube drainage. Acta Paediatr. 2014;103:93–99
2. Michelow IC, Olsen K, Lozano J, et al. Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children. Pediatrics. 2004;113:701–707
3. Cohen JF, Leis A, Lecarpentier T, et al. Procalcitonin predicts response to beta-lactam treatment in hospitalized children with community-acquired pneumonia. PLoS One. 2012;7:e36927
4. Esposito S, Tagliabue C, Picciolli I, et al. Procalcitonin measurements for guiding antibiotic treatment in pediatric pneumonia. Respir Med. 2011;105:1939–1945
5. Chiu CY, Wong KS, Huang JL, et al. Proinflammatory cytokines, fibrinolytic system enzymes, and biochemical indices in children with infectious para-pneumonic effusions. Pediatr Infect Dis J. 2008;27:699–703
6. Lahti E, Peltola V, Virkki R, et al. Development of parapneumonic empyema in children. Acta Paediatr. 2007;96:1686–1692

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