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Imaging Examinations of Complicated Pneumonias in Children

ORIGINAL PAPER

IMAGING EXAMINATIONS OF COMPLICATED PNEUMONIAS IN CHILDREN

Antonella Cheşcă1, Carmen Oţelea2, Domnica Săvescu3, M. A. Moga1, S. Toma1, Daniela Diaconescu1

Summary

Introduction: Within the context of a growing pulmonary pathology occurrence in young age ranges, this study is aimed at delivering complicated pneumonia cases in children. On the list of cases presenting this kind of pathology, we noticed a variability, concerning the time of the patients and the determinant factors in leading to the complicated inflammatory pulmonary pathology. As a result, we took into account elements related to the statute and the individual condition for the condition itself and its own complications.

Methods; The analysis is retrospective, the conditions of complicated pneumonias in children, being analyzed during the period 2004-2009. We reviewed the patients hospitalized within Brasov Children Clinical Clinic. For learning the complicated pneumonias in children, we used perish imaging method. The typical pulmonary radiography was used alongside the computer-tomography and, w hen applicable, with the echography. We reviewed 27 situations of complicated pneumonia in children, aged between 2 mondis and 8 years. On the list of cases included within the analysis, we found the increase of the incidence of this pathology in men, 17 males being identified as having complicated pneumonia.

Results: On the grounds of the imaging investigations that people made, we founded an increasing incidence of the issues of the pneumonias in children, caused by the overseas systems aspirated within the respiratory tracts. We also seen a high occurrence of complicated pneumonias, triggered by pulmonary abscesses and purulent pericarditis, one of the investigated circumstances. We also found problems of the pneumonias with pneumato- cyst. Furthermore, we found an instance of pulmonary aspergillum that was supplementary to an immune system deficit but also two cases of branch- pulmonary malformations.

Conclusions: The results of the analysis, through the imaging method, disclose different facets of the difficulties of pneumonia in children that are made by their determinant

Rétotalé

Examinations imagistiques des pneumonies compliquées chez les enfants

Introduction: A reason de l'incidence de la pathologie pulmonaire aux ges jeunes, cette étude vise la présentation des cas de pneumonie compliquée aux enfants. Parmi les cas investigués avec ce type de pathologie, on a observé une variabilité, concernant l'ge et les facteurs déterminants dans la production de la pathologie pulmonaire de type inflammatoire, compliqué. Dans ce contexte, on considère les aspects concernant le statut et le landscape individuel d'installation de la maladie et ses complications. Méthodes: L'étude est rétrospective, les cas de pneumonie compliqués aux enfants, étant investigués durant la période 2004- 2009. On the investigué les patients hospitalisés dans l'Hôpital Clinique d'Enfants de BraÅŸov. Pour étudier les pneumonies compliquésera aux enfants, over a étudié la méthode imagistique. La radiographie pulmonaire standard a été complétée par la computer tomographie et peut-être par une écographie. Over a investigué 27 cas de pneumonies aux enfants, gés entre 2 mois et 8 années. Parmi les cas inclus dans l'étude, on a observé une enhancement de l'incidence de cette pathologie aux personnes de genre masculin et on a trouvé 17 cas de pneumonies compliquéha sido, aux garçons.

Résultats: Les investigations imagistiques ont relevé une incidence des cas de difficulties des pneumonies aux enfants causésera par la présence des corps étrangers aspirés dans les tracts respiratoires. Les complications des pneumonies avec des abcès pulmonaires et de péricaidite purulente ont été très fréquentes parmi les cas étudiés. On the trouvé des issues des pneumonies avec pneumatocèle pulmonaire. On a remarqué un cas d'aspergillose pulmonaire secondaire à un déficit immun mais aussi deux cas qui présentaient des malformations broncho-pulmonaires. Conclusions: Les résultats de l'étude, effectuée par la méthode

They mostly appear in the upper part of the backside or on the throat, on the abdominal and on proximal portions of the extremities, being multiple in 5-10 % of the cases. (Nieto et al, 2001).

From the histological perspective, ipomas are made up of mature adypocite, lowing really small form and size variations. The nucleus of this type of skin cells is eccentric, being relatively homogeneous in the majority of the adypocites in the lipoma structure.

We frequently face the zoiemuclear vacuole which should not be considered as easy test elements for the level of the lipoblastic activity (Enzinger et mi. , 1995).

Other secondary changes are also often and they may determine identification problems. The traumatism of any lipoma ¡brmation includes necrosis emphasis points in tie up adypocite, presented by foam macrophage nests allocated in the zBiercellular spaces or around the lypocites. These macrophages must be differentiated from the lipoblasts which may have riyperchromatic nuclei, usually bigger in size.

The studies show that despite their close resemblance to the normal adipose tissue, the majority of the lipomas feature anomalies of the karyotype, usually regarding chromosome 12 (William, 2006).

Although considered as the most commune harmless formation, the cause of lipoma is not completely grasped, yet its incident propensity is inherited. A little lesion may effect the introduction of such creation.

Lipoma is diagnosed by its simple isppearance, yet the doctor may want to extirpate it to be sure that is not malignant. Lipomas are classified in solitary, predominant in women, and multiple which can be frequent in men (Becker Jilrgen et al, 2005).

Singular lipoma might occur with the same frequency both in men and in women. Multiple lipomas occur more frequently in men. Generally, lipoma does not require a specific treatment. As lipoma is not really a cancers tumor and it cannot become cancer, it isn't necessary to remove it. So far there is no treatment to avoid the occurrence of lipoma or even to prevent their expansion.

Material and methods

To compare the morphological areas of the white adipose cells, we needed such sample cells from various types of human tissue and organs.

This review shows the case of male patient aged 41 years old who came to the cosmetic surgery service with lipoma in the right deltoid region.

By taking intraoperatory biopsy, we extirpated a half-moon form 42 cm long, 27 cm large and 10-15 mm variably solid fragment, with smooth surface and bosselated appearance.

The pathologic anatomy prognosis of lipoma was set up by the information of the lesion composed of adipose muscle with adult adypocites, crossed by fine conjunctive septa.

In this review we used the traditional histological method, by hematoxylin - eosine staining (H-E), Truck Gieson, Gomori argentic impregnation and cytochemical dyes to emphasize the lipids, the sudanophilia method with Sudan III.

Until the control and staining of the permanent preparations through the classical laboratory technique that targeted at the steps of sample taking, fixation, addition, sectioning, staining, assembling, labeling and keeping in histological products catalogue, the taken examples were stored in formalin 10%.

The used classical and cytochemical histological methods allowed the observation of the white adypocites, of the conjunctive septa and of other structures of the lipoma and of the white adipose muscle by biopsies extracted from other parts of the human body, such as the tegument, the adjacent section of the appendix and the adrenal of the individual.

causes. From this point of view, the presence of the overseas bodies within the respiratory system together with other styles of malformations, among which we discuss the bronchogenic cyst, play a major role in the incident of complicated pneumonia in children. The analysis that people made revealed difficulties of the pneumonia in children, brought on by purulent pleurisy, pulmonary abscess, purulent pericarditis and pneumatocyst and bronchopleural fistula.

Key words: child, pneumonia, complications, standard pulmonary radiography, computed-tomography

Introduction

GÅ£m A he pathology of the second-rate respiratory tracts comprises different kinds of pneumonias.

Among the diversity of the infectious pneumatic syndromes, the pneumonias explain inflammatory type procedures of the distal pulmonary parenchyma [14, 15]. These may be triggered both by infectious type factors and also by non-infectious factors, as the inflammation of the pulmonary parenchyma, implying the respiratory bronchiole, alveolar areas and the interstitial [13, 14]. We consider that the process depends upon the invasion of the above mentioned structures, that stand for the result of the invasion of the anatomic buildings, mainly of infectious type agent [3, 10].

The exactness of diagnosing the kind of pneumonia may be determined by the connection of certain complementary medical information [6, 7]. These may suggest the condition of event of the problem that determines the condition, the agent type and types, that causes the illness, the type of clinical symptoms, the damaged anatomic structure, the device of causing the disease, alongside the individual status and condition of the disease incident [2, 4].

Being a frequent pathology type for all your age range, pneumonias imply a rapid and conect establishment of the analysis for the intended purpose of determining the satisfactory treatment for recovery. From this perspective, the imaging examinations play an exceptionally important role.

The risk of event of the infection is determined by the sponsor organism or on its dwelling [1].

Against the different types of aggressions that cause installing the pneumonia, we used a security device system of the respiratory system.

Among the defense lines against bacteria, the first place is taken by the mucociliary clearance. This is formed out of skin cells that are given with cilia, which hinder the respiratory tracts, of secretory cells seromucous glands and mucus [3], The efficiency of the mucociliary clearance is totally dependent on keeping a normal quantity and viscosity of the bronchial mucus. The coordinated modality of producing the cilia activity is also very important 13, 10].

imagistique, relèvent des aspects divers des difficulties de la pneumonie aux enfants, qui sont produites par les triggers déterminantes de ceux-ci. De ce point de vue, la présence de corps étrangers dans les tracts respiratoires mais aussi de certains types des malformations, dont on the mentionné le kyste bronchogène, ont un rôle important dans l'apparition des cas de pneumonie compliquée aux enfants. L'étude a relevé des difficulties de la pneumonie aux enfants, causées par la pleurésie purulente, l'abcès pulmonaire, la suppuration pulmonaire, la péricardite purulente, la pneumatocèle et la fistule broncho-pleurale. Mots-clés: enfant, pneumonie, problems, radiographie pulmonaire standard, tomographie computérisée

The rapidity and the exactness of the professional medical and para- professional medical diagnosis facilitate the enough treatment recommendation for the intended purpose of the rapid recovery.

The imaging examinations play a major role in the speedy and conect diagnosis of the pathology of the kid and of the adult, regarding the complicated pneumonias in children [9, 12], As the clinical medical diagnosis of the serious pneumopathy in children is seldom atypical, frequently taking place standard non-respiratory symptoms as irritability, different general state, abdominal discomfort, cephalgia, thoracic pains and non-suggestive physical exam, pulmonary radiography is considered a basic medical diagnosis method.

Pulmonary pathology is regular in children, showing diverse causes. Caused by amnesia, by the target clinical evaluation, completed by paraclinical investigations, pneumonias allow the institution of the enough treatment, for the procedure and the therapeutic of the disease.

The pulmonary radiography must show the next: if the love is viral or bacterial; if associated with an underlying pathology; which will be the causes that driven the persistence and the development of the symptoms; the way in which of assessing the difficulties.

The factors behind the advancement of the pneumonia are symbolized by the intensifying lesion of the pulmonary sequestration type, congenital cystic adenomatoid malformation, bronchogenic cyst, bronchogenic obstruction by the international physiques aspirated within the respiratory tract, gastroesophageal reflux, systemic diseases, immunodeficiency syndromes, other styles of problems [14, 15].

The issues of pneumonia are dependant on purulent pleurisy, by pulmonary abscess, pulmonary suppuration, purulent pericarditis, pneumatocyst, bronchopleural fistula.

The thoracic Ultrasonography provides us the possibility of differentiating the pleural series and the easy pericardial ones, as transudate, of the septal ones, encysted or with fiber content ones, as exudades, that are different in terms of restorative abort and also in conditions of prognosis [8, 11].

The thoracic computed-tomography examination provides us supplementary data, emphasizing lesions that were registered before the occurrence of the pneumonia or complications that appear during the advancement of the condition [2, 5].

Material and Methods

This study implies the research of the situations of [pneumonia and its own complication forms. For this function we iiased the imaging method. Taking on a typical radiological examination, the typical pulmonary radio- Eiaphy was completed by the computed-tomography evaluation and by the Ultrasonography. Using these imaging methods, we investigated situations of complicated pneumonias in children, found at the children who have been Hospitalized within Brasov Children Clinical Medical center during the period 2004 - 2009 for the children aged between 2 weeks and 8 years. The investigated conditions revealed the frequency of the condition in males, the children from the rural environment being symbolized by 17 circumstances.

Results

The standard pulmonary radiographics as well as ttihe computed-topographies supply the reliability of the identification.

We identified 8 children delivering foreign body. Tispirated within the respiratory tracts, 2 children showing ¡bronchopulmonary malformations, 4 pulmonary abscesses, 2 :. ases of multiple phonemic pulmonary abscesses in staphylococci as osteomyelitis, 4 purulent pleurisies, 1 purulent pericarditis, 5 children delivering pneumatocyst and a case showing pulmonary aspergilla extra to an immune system deficit. The cases that were found by the imaging examinations, through the computed-tomography and the standard pulmonary radiography receive within the following images, numbered from figure 1 to figure 7.

Discussion and Conclusion

The study uncovered the living of certain types of pneumonia that acquired worse because of the pulmonary abscess that alongside the pulmonary gangrene and the bronchiectasis constitute the category of the pulmonary suppurations.

In children, we found as causes of the difficulties of pneumonia, the existence of foreign body within the respiratory tracts but also of certain types of malformations as the bronchogenic cyst.

The pulmonary abscess identifies a process of parenchymal necrosis. With this context, a neoformat cavity delivering purulent content is made. Irrespectively of the diffuse type suppurations, as the truth of the pulmonary gangrene, the pulmonary abscess represents a type of parenchymal suppuration that is usually located at the level of a pulmonary section.

The recognition of the pulmonary abscess may be performed at the amount of a short parenchyma, that was affected by the pre-existent anguish. By explanation, the pulmonary abscess signifies a problem of the severe bacterial pneumonia, by contamination with the anaerobe bacterial agents. The pulmonary abscess constitutes a sophisticated progressive level of the aspiration pneumonia. This may appear as a result to the alteration of the immunity mechanisms and of the contaminated inoculum size. The inflammatory process that is specific to the pneumatic condensation is seen as a a tendency give attention to necrosis and soft-mindedness, delivering an important exudate structure. From the anatomic-pathologic viewpoint, the bronchial epithelium is infiltrated and delivering an edema and the bronchial lumen is partly obstructed and included in purulent secretions. The wall of the pulmonary abscess is constituted of fibrin debris, pus, fibrin or purulent alveolus and granulates cells areas.

The radiological aspect within the initial point out is of rounded consolidation that can determine the bulging of the fissure.

The computed-tomography discloses a consolidation that presents a hypodense centre that is charged with contrast only peripherically.

In advancement there are recorded gas bulls at the level of the central area, the vox vomica identifying a hydro-air

image aspect, presenting a thick wall and a horizontal level, consequently to the evacuation by the bronchia. Sometimes the abscess can break within the pleural cavity creating the purulent pleurisy.

The computed-tomography may disclose information regarding the differentiation of the peripheral pulmonary abscess, sub-pleural of a possible pleural empyema located at the thoracic level, which presents a hydro-air level, by bronchopleural fistula. The computed-tomography assessment allows also the reference to the anatomic sub-layer of the extra pulmonary abscesses.

The Pneumatocyst are air bulls that occur in the development of the bacterial pneumopathies, especially staphylococcal ones, as a result to the occlusive effect of the exudate and of thickening of the mucous, identifying the result of "air trapping". These lower spontaneously in a number of weeks or days. A reducible complication that might look is represented by the pneumothorax produced by the

rupture of the tensioned pneumatocyst, which determines ¡pleural drainage.

The bronchopulmonary malformations arise within the 1. imaging evaluation as consolidations or cystic images, -hich persist after the treatment and after the disappearance 2 or the inflammatory symptoms. The treatment is made up in the operative abort.

The cavitary necrosis is a pneumatic problem in s'hich the area dominated by necrosis includes a varying 4 amount of cavities with liquid or air. The Pathologic Agencies involved are the staphylococcus and the streptococcus. The 5. pulmonary radiography is not suggestive, the computed- Tomography exam with contrast compound, being the ^ - election exploration. The occurrence system comprises m the creation of some thrombosis in the vascularization Cif the alveoli, which lead to the apparition of the necrosis and at the forming of certain cavities. Primarily the cavities g contain liquid that may be evacuated by bronchia, the place or the liquid being considered by air. Even if the imaging aspect is 9. impressive, the majority of the circumstances heal without the specific ^ ¿equelae. Very few cases need operative interventions.

Pneumonia in children is repeated, even if the majority of the n. oases heal swiftly without sequelae. However there are 12.

situations when the advancement is dragging on, difficult and ^ proclaimed by issues. This difficult development is given by ihe aggressiveness of the pathogen germ, of the protection 14. capacity of the organism or pre-existent pulmonary lesions.

Archives of the Balkan Medical Union

The imaging investigations and the right operative abort ^ given in enforced situations, adapted to each circumstance, by multi- iisciplinary co-operation, determine the best ends up with solving the detailed pathology.

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