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Friedländer's pneumonia with multiple lung abscesses: Recovery following the use of streptomycin and aureomycin
FRIEDLANDER'S PNEUMONIA WITH MULTIPLE LUNG ABSCESSES: R E C O V E R Y F O L L O W I N G T H E U S E OF S T R E P T O M Y C I N AND AUREOMYCIN SEYMOUR GRVBER, M.D., RICHARD D. TVRIN, M.D., S. DAVID STERNBERG, M.D., AND HENRY RASCOFF, M.D. BROOKLYN, N. Y .
M O N I A caused by the F r i e d l ~ n d e r ' s bacillus (Klebsiella pneumoniae) p Nis E Uconsidered to be uncommon in childhood. Bullowa 1 reports an incidence of 1.1 p e r cent cases of this t y p e in a series of 4,416 cases of pneumonia. Julianelle, 2 in a n extensive s t u d y of this disease, notes a similar rate of occurrence with a m o r t a l i t y ranging f r o m 71 to 97 per cent. Miller, Orris, and Taus 3 in 1947 found only four previous reports of F r i e d l ~ n d e r ' s pneumonia in children p r i o r to a case which they report. Grotts, 4 however, cites Kliewe as having observed an outbreak of pneumonia due to K. pneumoniae in 1930. Thus it is obvious t h a t the previously reported cases in childhood are few enough to be enumerated easily. The course of this disease m a y lead to early death, to chronic s u p p u r a t i v e p u l m o n a r y disease, or to recovery in a relatively small percentage of cases. The diagnosis is made by finding the characteristic organism in the secretions of the throat or b r o n c h o p u l m o n a r y tree2, ~ The characteristic roentgen picture is that of diffuse p a t c h y consolidations which coalesce. I n these areas thin-walled cavities and abscesses without walls m a y form. P r i o r to the advent of streptomycin as a therepeutic agent, there was no specific effective t r e a t m e n t f o r this f o r m of pneumonia, and the m o r t a l i t y was v e r y high. Since the use of streptomycin there have been a few reports of cases treated a n d cured in adults. 5, 6, 7 The first ease treated in infancy was t h a t of Miller and co-workers. 3 Their ease was that of a newborn i n f a n t who r a n a s t o r m y course with no response to sulfadiazine and penicillin therapy, but who had a r a p i d recovery when streptomycin was started. The infant developed p u l m o n a r y cavitations but was discharged at 3 months of age as clinically cured despite the persistanee of " c a v i t i e s " in follow-up roentgenograms. More recently Grotts 4 presented seven cases of p n e u m o n i a in which F r i e d l g n d e r ' s bacillus was ,isolated as the sole or p r e d o m i n a n t organism. His patients ranged f r o m 3 weeks to 13 months of age. All but one had an insidious onset. All failed to respond to penicillin a n d / o r sulfadiazine. Five of the seven patients showed m a r k e d pallor or eyanosis. All had a cough, and all had some vomiting or diarrhea. There was no u n i f o r m i t y of the t e m p e r a t u r e curve or leucocyte count. All but two had roentgen findings of pneumonia, but none had the typical picture of abscesses and cysts. These patients showed r a p i d i m p r o v e m e n t with streptomycin therapy. We are presenting another case to emphasize the value of streptomycin, and also because we believe it is the first ease reported in childhood in which aureomycin was also used and in which the cavitations disappeared and the lung fields became clear, CASE REPORT
M. W., a 131~-month-o14 Negro male infant, was admitted to the Beth-E1 Hospital with a chief complaint of high fever and cough. Ten days p r i o r to From the Department of Pediatrics, Beth-E1 Hospital, Brooklyn. 237
238
TIIE
JOURNAL
OF P E D I A T R I C S
admission the i n f a n t ' s t e m p e r a t u r e , was 104 ~ F. A serous discharge was noted coming f r o m the right external auditory canal and the family doctor administered an intramuscular injection of 300,000 units of penicillin. Although the i n f a n t seemed better, the t e m p e r a t u r e remained at about 101 ~ F., and after four days penicillin via the oral route was started. There was no improvement. On the day p r i o r to admission the t e m p e r a t u r e rose to 103.2 ~ F. An otolaryngologist felt t h a t there was insufficient evidence of ear pathology to account for the prolonged fever. The i n f a n t was referred to one of us (S. G.) and was hospitalized because of findings of a massive pneumonia. Physical examination revealed a well-developed, and well-nourished, irritable, dyspneic male infant, with t e m p e r a t u r e of 102.8 ~ F., who exhibited a marked pallor and had a hacking cough. The anterior fontanel was patent with a diameter of 1 centimeter. The t y m p a n i c membranes were slightly inflamed. The tonsils were enlarged and the oral mucosa a p p e a r e d pale and boggy. Percussion of the lungs revealed dullness over the right lung area anteriorly and posteriorly and a]so over the left lung posteriorly. The breath sounds were m a r k e d l y diminished throughout the chest. Showers of rs were heard on auscultation. The remainder of the physical examination was negative.
F i g . 1 . - - A d m i s s i o n r o e n t g e n o g r a m s h o w i n g m u l t i p l e a b s c e s s e s of t h e r i g h t u p p e r p a r i e t a l p l e u r a l e f f u s i o n , a n d c o n s o l i d a t i o n of t h e r i g h t u p p e r lobe.
lobe, r i g h t
The admission blood count revealed 40 per cent hemoglobin and 2.75 million red blood cells; 13,000 white blood cells with 60 per cent polymorphonuclears, one per cent eosinophiles, 37 per cent ]ymphocytes, and 2 per cent m o n o e y t e s . Urinalyses were negative. The infant received penicillin and sulfadiazine, and the t e m p e r a t u r e dropped to 100 ~ for t w e n t y - f o u r hours; then it rose again to 103.6 ~ F. A throat culture taken on admission was reported at this time as showing a p u r e culture of the F r i e d l ~ n d e r ' s bacillus (K. pneumoniae). Cultures of the nose and blood were negative. A roentgen0gram of the chest showed multiple
GRUBER ET
AL, :
239
I~RIEDLANDER~S P N E U M O N I A
abscesses of the right upper lobe, right parietal pleural effusion, and consolidation of the right upper lobe (Fig. 1). The infant was then started on streptomycin therapy because of these laboratory findings; the dosage was 800 rag. daily. Aureomycin therapy, in a dosage of 600 rag. daily, was started twenty-four hours later. The temperature dropped to a normal range within twenty-four hours after streptomycin therapy was started and remained normal for the rest of the hospital stay. The child was transfused with compatible whole blood. The hemoglobin rose to 82 per cent and the red cell count to 4.3 million. The nose and throat cultures were negative for Friedl~Lnder's bacillus twenty-four hours after streptomycin was started, and remained so for the duration of the hospital stay.
Fig.
2.--Final
roentgenogram
taken
twenty-seven days pathology.
later showing
r e s o l u t i o n of t h e
hmg
There was complete resolution of all abnormal physical findings by tile seventh day of streptomycin therapy and the sixth day of aureomycin therapy. The child at this time appeared perfectly well, but serial roentgenograIns indicated the continuing gravity of the patient's condition, showing at first increasing numbers of small abscess cavities and then a confluence of the cavities in the right lung. Therapy was continued and finally on the twentyninth hospital day a roentgenogram revealed clearing of the lung pathology (Fig. 2.). The infant was discharged after thirty-two days of hospitalization. DISCUSSION
The discovery of the newer antibiotics has been an added impetus for more accurate bacteriological diagnosis of disease processes in order that the correct therapeutic agent may be employed. More cases of pneumonia in infancy and childhood due to K. pneu~monia,r will probably be found as a result of this trend, and more exact and effective treatment will ensue. Streptomycin, at present, appears to be the drug of choice in this disease. Aureomycin, however, has been shown experimentally and clinically to be effective in infections
240
THE JOURNAL OF PEDIATRICS
caused by K. pneumoniae, s Aureomycin, if found to be as effective, may replace streptomycin because it is less toxic. The role that aureomycin played in the cure of our patient is difficult to evaluate because of the combined therapy employed. We do feel, however, that this antibiotic aided in the sterilization and closure of the cavities, a result which Miller and co-workers 3 did not achieve with streptomycin alone. Surgical intervention was considered when the clinical condition of our patient improved, but the roentgen picture showed an enlarging cavity with fluid level and pleural effusion. It was deferred because of the remarkable well-being of the infant, and the final result obtained justified that decision. SUIV~IV~AI~Y
A case of pneumonia due to the Friedl~nder's bacillus (K. pneumoniae) in a 13-month-old boy is presented. There was an impressive response to streptomycin and aureomycin therapy with sterilization and closure of all cavities. Streptomycin is considered the drug of choice at present for such infections, but it is suggested that aureomycin may replace streptomycin therapy in infections due to K. pneumoniae. EEFERENCES 1. Perlman, E., and Bullowa, J. G. M.: P r i m a r y Bacillus Friedl~nder (Klebsiella Pneumoniae) Pneumonia, Arch. Int. Med. 15: 907~ 1941. 2. Julianelle, L . A . : The Pneumonia of Friedl~nder's Bacillus, Ann. Int. Med. 15: 190, 1941. 3. Miller, B. W., Orris, H. W., and Taus~ H. H.: Friedliinder~s Pneumonia in Infancy, J. PEDIAT. 31: 521, 1947. 4. Grotts, B . F . : Pneumonia in I n f a n c y Caused by Friedl~nder's Bacillus, J. FEDIAT. 34: 174, 1949. 5. Bishop, C. A , and Rasmussen, E u t h : Klebsiella Pneumonia Treated With Streptomycin~ J. A. M. A. 131: 821, 1946. 6. tterrell, W. E , and Nichols, D . R . : The Clinical Use of Streptomycin: A study of Forty-five Cases, Proe. Staff Meet., Mayo Clin. 20: 449, I945. 7. Learner, ~.~ and Minniek, W. R. : Fried]~nder's Pneumonia Treated "With Streptomycin; Report of a Case With Prompt Recovery, Ann. Int. Med. 25: 516, 1946. 8. Long, P. H , Schoenbach, E. B., Bliss, E. A., Chandler, C. A., and Bryer, M. S.: The Present Status of Polymyxin, Chloromycetin and Aureomycin: Experimental and Clinical: An address presented by P e r r i n H. Long before the American Pharmaceutical M a n u f a c t u r e r ' s Association, Dec. 7, 1948.
M O N I A caused by the F r i e d l ~ n d e r ' s bacillus (Klebsiella pneumoniae) p Nis E Uconsidered to be uncommon in childhood. Bullowa 1 reports an incidence of 1.1 p e r cent cases of this t y p e in a series of 4,416 cases of pneumonia. Julianelle, 2 in a n extensive s t u d y of this disease, notes a similar rate of occurrence with a m o r t a l i t y ranging f r o m 71 to 97 per cent. Miller, Orris, and Taus 3 in 1947 found only four previous reports of F r i e d l ~ n d e r ' s pneumonia in children p r i o r to a case which they report. Grotts, 4 however, cites Kliewe as having observed an outbreak of pneumonia due to K. pneumoniae in 1930. Thus it is obvious t h a t the previously reported cases in childhood are few enough to be enumerated easily. The course of this disease m a y lead to early death, to chronic s u p p u r a t i v e p u l m o n a r y disease, or to recovery in a relatively small percentage of cases. The diagnosis is made by finding the characteristic organism in the secretions of the throat or b r o n c h o p u l m o n a r y tree2, ~ The characteristic roentgen picture is that of diffuse p a t c h y consolidations which coalesce. I n these areas thin-walled cavities and abscesses without walls m a y form. P r i o r to the advent of streptomycin as a therepeutic agent, there was no specific effective t r e a t m e n t f o r this f o r m of pneumonia, and the m o r t a l i t y was v e r y high. Since the use of streptomycin there have been a few reports of cases treated a n d cured in adults. 5, 6, 7 The first ease treated in infancy was t h a t of Miller and co-workers. 3 Their ease was that of a newborn i n f a n t who r a n a s t o r m y course with no response to sulfadiazine and penicillin therapy, but who had a r a p i d recovery when streptomycin was started. The infant developed p u l m o n a r y cavitations but was discharged at 3 months of age as clinically cured despite the persistanee of " c a v i t i e s " in follow-up roentgenograms. More recently Grotts 4 presented seven cases of p n e u m o n i a in which F r i e d l g n d e r ' s bacillus was ,isolated as the sole or p r e d o m i n a n t organism. His patients ranged f r o m 3 weeks to 13 months of age. All but one had an insidious onset. All failed to respond to penicillin a n d / o r sulfadiazine. Five of the seven patients showed m a r k e d pallor or eyanosis. All had a cough, and all had some vomiting or diarrhea. There was no u n i f o r m i t y of the t e m p e r a t u r e curve or leucocyte count. All but two had roentgen findings of pneumonia, but none had the typical picture of abscesses and cysts. These patients showed r a p i d i m p r o v e m e n t with streptomycin therapy. We are presenting another case to emphasize the value of streptomycin, and also because we believe it is the first ease reported in childhood in which aureomycin was also used and in which the cavitations disappeared and the lung fields became clear, CASE REPORT
M. W., a 131~-month-o14 Negro male infant, was admitted to the Beth-E1 Hospital with a chief complaint of high fever and cough. Ten days p r i o r to From the Department of Pediatrics, Beth-E1 Hospital, Brooklyn. 237
238
TIIE
JOURNAL
OF P E D I A T R I C S
admission the i n f a n t ' s t e m p e r a t u r e , was 104 ~ F. A serous discharge was noted coming f r o m the right external auditory canal and the family doctor administered an intramuscular injection of 300,000 units of penicillin. Although the i n f a n t seemed better, the t e m p e r a t u r e remained at about 101 ~ F., and after four days penicillin via the oral route was started. There was no improvement. On the day p r i o r to admission the t e m p e r a t u r e rose to 103.2 ~ F. An otolaryngologist felt t h a t there was insufficient evidence of ear pathology to account for the prolonged fever. The i n f a n t was referred to one of us (S. G.) and was hospitalized because of findings of a massive pneumonia. Physical examination revealed a well-developed, and well-nourished, irritable, dyspneic male infant, with t e m p e r a t u r e of 102.8 ~ F., who exhibited a marked pallor and had a hacking cough. The anterior fontanel was patent with a diameter of 1 centimeter. The t y m p a n i c membranes were slightly inflamed. The tonsils were enlarged and the oral mucosa a p p e a r e d pale and boggy. Percussion of the lungs revealed dullness over the right lung area anteriorly and posteriorly and a]so over the left lung posteriorly. The breath sounds were m a r k e d l y diminished throughout the chest. Showers of rs were heard on auscultation. The remainder of the physical examination was negative.
F i g . 1 . - - A d m i s s i o n r o e n t g e n o g r a m s h o w i n g m u l t i p l e a b s c e s s e s of t h e r i g h t u p p e r p a r i e t a l p l e u r a l e f f u s i o n , a n d c o n s o l i d a t i o n of t h e r i g h t u p p e r lobe.
lobe, r i g h t
The admission blood count revealed 40 per cent hemoglobin and 2.75 million red blood cells; 13,000 white blood cells with 60 per cent polymorphonuclears, one per cent eosinophiles, 37 per cent ]ymphocytes, and 2 per cent m o n o e y t e s . Urinalyses were negative. The infant received penicillin and sulfadiazine, and the t e m p e r a t u r e dropped to 100 ~ for t w e n t y - f o u r hours; then it rose again to 103.6 ~ F. A throat culture taken on admission was reported at this time as showing a p u r e culture of the F r i e d l ~ n d e r ' s bacillus (K. pneumoniae). Cultures of the nose and blood were negative. A roentgen0gram of the chest showed multiple
GRUBER ET
AL, :
239
I~RIEDLANDER~S P N E U M O N I A
abscesses of the right upper lobe, right parietal pleural effusion, and consolidation of the right upper lobe (Fig. 1). The infant was then started on streptomycin therapy because of these laboratory findings; the dosage was 800 rag. daily. Aureomycin therapy, in a dosage of 600 rag. daily, was started twenty-four hours later. The temperature dropped to a normal range within twenty-four hours after streptomycin therapy was started and remained normal for the rest of the hospital stay. The child was transfused with compatible whole blood. The hemoglobin rose to 82 per cent and the red cell count to 4.3 million. The nose and throat cultures were negative for Friedl~Lnder's bacillus twenty-four hours after streptomycin was started, and remained so for the duration of the hospital stay.
Fig.
2.--Final
roentgenogram
taken
twenty-seven days pathology.
later showing
r e s o l u t i o n of t h e
hmg
There was complete resolution of all abnormal physical findings by tile seventh day of streptomycin therapy and the sixth day of aureomycin therapy. The child at this time appeared perfectly well, but serial roentgenograIns indicated the continuing gravity of the patient's condition, showing at first increasing numbers of small abscess cavities and then a confluence of the cavities in the right lung. Therapy was continued and finally on the twentyninth hospital day a roentgenogram revealed clearing of the lung pathology (Fig. 2.). The infant was discharged after thirty-two days of hospitalization. DISCUSSION
The discovery of the newer antibiotics has been an added impetus for more accurate bacteriological diagnosis of disease processes in order that the correct therapeutic agent may be employed. More cases of pneumonia in infancy and childhood due to K. pneu~monia,r will probably be found as a result of this trend, and more exact and effective treatment will ensue. Streptomycin, at present, appears to be the drug of choice in this disease. Aureomycin, however, has been shown experimentally and clinically to be effective in infections
240
THE JOURNAL OF PEDIATRICS
caused by K. pneumoniae, s Aureomycin, if found to be as effective, may replace streptomycin because it is less toxic. The role that aureomycin played in the cure of our patient is difficult to evaluate because of the combined therapy employed. We do feel, however, that this antibiotic aided in the sterilization and closure of the cavities, a result which Miller and co-workers 3 did not achieve with streptomycin alone. Surgical intervention was considered when the clinical condition of our patient improved, but the roentgen picture showed an enlarging cavity with fluid level and pleural effusion. It was deferred because of the remarkable well-being of the infant, and the final result obtained justified that decision. SUIV~IV~AI~Y
A case of pneumonia due to the Friedl~nder's bacillus (K. pneumoniae) in a 13-month-old boy is presented. There was an impressive response to streptomycin and aureomycin therapy with sterilization and closure of all cavities. Streptomycin is considered the drug of choice at present for such infections, but it is suggested that aureomycin may replace streptomycin therapy in infections due to K. pneumoniae. EEFERENCES 1. Perlman, E., and Bullowa, J. G. M.: P r i m a r y Bacillus Friedl~nder (Klebsiella Pneumoniae) Pneumonia, Arch. Int. Med. 15: 907~ 1941. 2. Julianelle, L . A . : The Pneumonia of Friedl~nder's Bacillus, Ann. Int. Med. 15: 190, 1941. 3. Miller, B. W., Orris, H. W., and Taus~ H. H.: Friedliinder~s Pneumonia in Infancy, J. PEDIAT. 31: 521, 1947. 4. Grotts, B . F . : Pneumonia in I n f a n c y Caused by Friedl~nder's Bacillus, J. FEDIAT. 34: 174, 1949. 5. Bishop, C. A , and Rasmussen, E u t h : Klebsiella Pneumonia Treated With Streptomycin~ J. A. M. A. 131: 821, 1946. 6. tterrell, W. E , and Nichols, D . R . : The Clinical Use of Streptomycin: A study of Forty-five Cases, Proe. Staff Meet., Mayo Clin. 20: 449, I945. 7. Learner, ~.~ and Minniek, W. R. : Fried]~nder's Pneumonia Treated "With Streptomycin; Report of a Case With Prompt Recovery, Ann. Int. Med. 25: 516, 1946. 8. Long, P. H , Schoenbach, E. B., Bliss, E. A., Chandler, C. A., and Bryer, M. S.: The Present Status of Polymyxin, Chloromycetin and Aureomycin: Experimental and Clinical: An address presented by P e r r i n H. Long before the American Pharmaceutical M a n u f a c t u r e r ' s Association, Dec. 7, 1948.