Case 1: Recurrent pneumonia in a 24-month-old boy

A 24-month-old boy was admitted to hospital with his fifth episode of pneumonia. On admission, his perinatal, growth and developmental histories were unremarkable, and his vaccinations were complete for his age. His family history revealed a father with atopy, and his history revealed eczema and occult Streptococcus pneumoniae bacteremia at nine months of age. Radiologically confirmed pneumonia had occurred in the right lower, right middle, right lower and right upper lobes at 11, 14, 18 and 22 months, respectively, with the final case of pneumonia being complicated by a 30 min atypical febrile seizure. Investigations during the hospitalization, including a complete blood count, complement and immunoglobulin levels, echocardiogram, sweat chloride test and antibody responses to vaccinations, were normal. His medications included fluticasone (250 μg twice daily) and salbutamol (two puffs four times per day as needed) started at 14 months of age, penicillin V prophylaxis (125 mg twice daily) started at 18 months of age and montelukast (4 mg at bedtime) started at 23 months of age. At 24 months of age, a chest x-ray confirmed right middle lobe pneumonia. Further questioning revealed that for a few weeks, the patient had days when he would wake up with unexplained sleepiness and no desire to play. A physical examination was positive for fever, cough and crackles in the right middle lobe. During his admission, an empirical treatment was initiated, and the response suggested the underlying diagnosis. On further examination of his history, five clear episodes of hypertonicity, hypersalivation and altered mental status for up to 30 s followed by deep somnolence were reported, and seizures were suspected. It was postulated that the recurrent pneumonias were due to aspiration secondary to seizure activity. Two electroencephalograms (EEGs), one routine and one sleep-deprived, were performed and did not show epileptiform activity. No formal evaluation of aspiration was performed in the present case. A computed tomography scan of the head and a lumbar puncture were normal. Despite the negative EEGs, the patient was started empirically on phenytoin in consultation with a neurologist, given the strong suspicion of seizures. Soon after starting this medication, the patient developed frank absence seizures and was then switched to clobazam. On clobazam, while tapering and stopping inhaled corticosteroids and prophylactic antibiotics, the child had no additional episodes suggestive of seizures or lower respiratory tract infections. Clobazam was finally discontinued at 4.5 years of age and the patient, now six years old, remains well and symptom-free. The diagnosis of recurrent pneumonia in children requires evaluation for an underlying cause (1). Importantly, a complete review of all chest radiographs is mandatory to establish the nature of the findings because many parenchymal anomalies may not represent recurrent bacterial pneumonia. Predisposing factors to recurrent lung parenchymal opacities include untreated asthma and repeated viral respiratory illnesses. Common causes of recurrent bacterial respiratory tract infections include reactive airway disease or asthma, gastrointestinal disorders (including gastrooesophageal reflux disease), cystic fibrosis, neuromuscular disease, congenital or acquired immunodeficiency, congenital heart disease, primary ciliary diskynesia and anatomical anomalies involving the lungs and/or airways that lead to partial obstruction and decreased clearance of secretions. A retained foreign body and chronic aspiration with or without neurological disorder are other important causes (1,2). Pulmonary aspiration has long been recognized as a complication of generalized seizures. However, given that partial complex seizures at such a young age are rarely described, this diagnosis was considered unlikely in the initial workup of this patient’s recurrent pneumonias. Indeed, there was initially no evidence of a possible seizure disorder other than the history of two typical febrile seizures. Only when other more common causes of multilobar pneumonia were excluded and other clues pointing to the possibility of epilepsy became apparent (ie, the atypical febrile seizure, the history of absence and the repeated days of somnolence/fatigue) was the decision made to treat the patient empirically for a partial complex seizure disorder. While not definitive, the child’s history, response to treatment, subsequent course and exclusion of other conditions suggested aspiration events secondary to seizures. The present case highlights the importance of maintaining a broad differential diagnosis in the work-up of recurrent pneumonia. The differential diagnosis of recurrent lung infections/recurrent airspace disease is broad. The presence of a seizure disorder with pulmonary aspiration should be considered, even in the developmentally normal child, if other common causes have been ruled out. Partial complex seizure disorders are rare in children younger than six years of age and the EEG can be normal between episodes.

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