neumonia necrotizante

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Diapositiva 1

Neumona necrotizanteDra. Astrid Pezoa F.Residente de pediatra 2 ao 2014Rotacin Enfermedades respiratorias del nio UCP. Universidad Catlica

BitcoraMotivacinDefinicin.Epidemiologa.EtiologaFisiopatologaCuadro clnico.Diagnstico.Tratamiento.PronsticoConclusiones.

MotivacinDanilo, 6 aos, sin antecedentes de importancia.Cuadro de 6 das de evolucin de fiebre, CEG y sntomas respiratorios altosGB 32000, PCR 441. Ag neumococo (+)

Motivacin

Motivacin

DefinicinForma grave de enfermedad pulmonar asociada a la formacin de abscesos y cavitaciones dentro del parnquima pulmonar, presentando o no compromiso pleural.Complicacin de la neumona asociada a la destruccin del tejido pulmonar y a la aparicin de focos de necrosis en zonas de condensacin.Necrotizing pneumonia , D.A. Spencer, M.F. Thomas, Paediatric Respiratory Reviews 15 (2014) 240245 Norte A, et al. Pneumonia Necrotizante: uma complicao rara, Acta Med Port 2012 Jan-Feb;25(1):51-55

Revision gigi6EpidemiologaNeumonaPrincipal causa individual de mortalidad infantil infecciosa en todo el mundo. 2010: 1,39 millones de nios menores de cinco aos, seguido por las patologas perinatales y SDA.

Necrotizing pneumonia , D.A. Spencer, M.F. Thomas, Paediatric Respiratory Reviews 15 (2014) 240245 Norte A, et al. Pneumonia Necrotizante: uma complicao rara, Acta Med Port 2012 Jan-Feb;25(1):51-55Rev neumologaRevisn Gigi7Epidemiologa

Necrotizing pneumonia in children. Report of 41 cases between 2006 and 2011 in a french tertiary care center. C lematre C. The Pediatric Infectious Disease Journal Volume32,Number10,October2013Reporte de 41 casos8

Necrotising pneumonia is an increasingly detected complication of pneumonia in children, Sawicki G. Eur Respir J 2008; 31: 12851291.Children hospital boston9Etiologa

Necrotizing pneumonia , D.A. Spencer, M.F. Thomas, Paediatric Respiratory Reviews 15 (2014) 240245 Revision gigi10EtiologaCausas no infecciosas

Necrotizing pneumonia , D.A. Spencer, M.F. Thomas, Paediatric Respiratory Reviews 15 (2014) 240245 Revision gigi11Etiologa

Necrotizing pneumonia in children. Report of 41 cases between 2006 and 2011 in a french tertiary care center. C lematre C. The Pediatric Infectious Disease Journal Volume32,Number10,October2013Reporte de 41 casos12FisiopatologaProceso inflamatorio -> Dao del parnquima. Microtrombos y oclusin vascular. Necrosis liquificante o colicuativa. Absceso pulmonar y/o Gangrena. Insuficiencia respiratoria.

Necrotizing pneumonia , D.A. Spencer, M.F. Thomas, Paediatric Respiratory Reviews 15 (2014) 240245 Norte A, et al. Pneumonia Necrotizante: uma complicao rara, Acta Med Port 2012 Jan-Feb;25(1):51-55Enfermedad pneumoccicaPrincipal patgeno causante de neumona. No siempre se logra identificar. Prevenar: EE.UU, 2000- 2001: serotipos 4, 6B, 9 V, 14, 18C, 19F y 23F Reduccin inicial de la incidencia. Serotipo 19A.Prevenar 13: 3, 5, 6A, 7F, 19A Synflorix : 1, 5 , 7F.

Necrotizing pneumonia , D.A. Spencer, M.F. Thomas, Paediatric Respiratory Reviews 15 (2014) 240245

Neumococo 19A

Emergence of 19A as Virulent and Multidrug Resistant Pneumococcus in Massachusetts Following Universal Immunization of Infants With Pneumococcal Conjugate Vaccine. Pediatr Infect Dis J2007;26: 468 472

Neumococo 19A

Emergence of 19A as Virulent and Multidrug Resistant Pneumococcus in Massachusetts Following Universal Immunization of Infants With Pneumococcal Conjugate Vaccine. Pediatr Infect Dis J2007;26: 468 472

Enfermedad StafiloccicaMenor prevalencia que neumococo, pero mayor proporcin de complicaciones.

Mecanismos de resistencia:MRSALeucocidina Panton-Valentine (PVL).: Lisis de leucocitos ->poros ->liberacin de grnulos citotxicos. Factors Predicting Mortality in Necrotizing Community-Acquired Pneumonia Caused by Staphylococcus aureus, Gillet Y. Clinical Infectious Diseases 2007; 45:3152

Enfermedad StafiloccicaMRSAPresente desde la dcada 1950-1960.Genotipos ms comunes:EE.UU: USA 300 (ST8), USA 400 (ST1), USA 1000 (ST59).Europa: ST80.Asia: ST30.Sudamrica: ST5 (Argentina).

Factors Predicting Mortality in Necrotizing Community-Acquired Pneumonia Caused by Staphylococcus aureus, Gillet Y. Clinical Infectious Diseases 2007; 45:3152

MRSA1-5% de todas la neumonas por SA. Pacientes jvenes.Agente causal principal de neumona necrotizante en pases desarrollados.Sinergia con cepas positivas para PVL (Panton Valentine Leukocidin).

Factors Predicting Mortality in Necrotizing Community-Acquired Pneumonia Caused by Staphylococcus aureus, Gillet Y. Clinical Infectious Diseases 2007; 45:3152

MRSAAsociacin de previa exposicin a Influenza tipo A:Mayor expresin de proteasas por el MRSA.Mayor adherencia del MRSA.

Factors Predicting Mortality in Necrotizing Community-Acquired Pneumonia Caused by Staphylococcus aureus, Gillet Y. Clinical Infectious Diseases 2007; 45:3152

ppt20LPVPhillip Noel Panton y Francis Valentine la asocian con infeccin tejidos blandos en 1932En < 5% de cepas totales de S. Aureus.En el 85% de las neumonas necrosantes.Tasa de mortalidad variable desde 10-61%.

Staphylococcus aureus Panton-Valentine Leukocidin Causes Necrotizing Pneumonia, Labandeira-Rey M. Science 315, 11-30 (2007)ppt21

Staphylococcus aureus Panton-Valentine Leukocidin Causes Necrotizing Pneumonia, Labandeira-Rey M. Science 315, 11-30 (2007)Model for how PVL might mediate tissue necrosis. The two components of PVL, LukS-PV and LukF-PV are secreted fromS. aureusbefore they assemble into a pore-forming heptamer on PMN membranes. High PVL concentrations cause PMN lysis whereas low concentrations mediate a novel pathway of PMN apoptosis by directly binding to mitochondrial membranes.28Tissue necrosis could result from release of reactive oxygen species (ROS) from lysed PMNs. Alternately, release of granule contents from lysed PMNs could set in motion an inflammatory response, eventually resulting in tissue necrosis. It is unlikely that PVL has a direct necrotic effect on epithelial cells.22MRSA con PVL:Shock: 81%.SDR: 75%.Hemoptisis: 38%.Mortalidad: 75%.MRSA sin PVL:Shock: 53%.SDR: 53%.Hemoptisis: 3%.Mortalidad: 47%.Staphylococcus aureus Panton-Valentine Leukocidin Causes Necrotizing Pneumonia, Labandeira-Rey M. Science 315, 11-30 (2007)Enfermedad Stafiloccica

ppt23Cuadro clnicoDe das a semanas de evolucin.Fiebre, dificultad respiratoria, tos. Hemoptisis, shock, insuficiencia respiratoria rpidamente progresiva.Mala respuesta a tratamiento antibitico inicial. Necrotizing pneumonia , D.A. Spencer, M.F. Thomas, Paediatric Respiratory Reviews 15 (2014) 240245 Norte A, et al. Pneumonia Necrotizante: uma complicao rara, Acta Med Port 2012 Jan-Feb;25(1):51-55

LaboratorioParmetros inflamatorios. Exmenes generales para evaluar repercusin. Cultivos: mal rendimiento: 45- 51% . Antgeno urinario de pneumococo. PCR bacteriana en el lquido pleural y la sangre. Necrotizing pneumonia , D.A. Spencer, M.F. Thomas, Paediatric Respiratory Reviews 15 (2014) 240245 Norte A, et al. Pneumonia Necrotizante: uma complicao rara, Acta Med Port 2012 Jan-Feb;25(1):51-55ImgenesConsolidacin neumnica ->necrosis-> gangrena.Rx de traxMasas nicas o cavitadas aisladas o en el seno de una consolidacin parenquimatosa.Bordes definidos.Nivel hidroareo.Consolidacin del parnquima adyacente.Signo de aire creciente (separacin de la porcin gangrenosa). Necrotizing pneumonia , D.A. Spencer, M.F. Thomas, Paediatric Respiratory Reviews 15 (2014) 240245 Norte A, et al. Pneumonia Necrotizante: uma complicao rara, Acta Med Port 2012 Jan-Feb;25(1):51-55 AJR:171, July 199

Necrotizing pneumonia , D.A. Spencer, M.F. Thomas, Paediatric Respiratory Reviews 15 (2014) 240245Necrosis masiva del pulmn, que se produce como complicacin severa de una infeccin parenquimatosa, se manifiesta con estado toxinfeccioso y fiebre prolongada, pudindose complicar con derrame pleural (40% de los casos). La leucocitosis y la ERS son elevadas, el germen mas frecuente el estreptococo pneumoniae y el tratamiento es medico27

Cavitary Necrosis Complicating Pneumonia in Children: Sequential Findings on Chest Radiography, Lane F. Donnelly, AJR:171, July 1998. Nuestro caso

Nuestro caso

ManejoAbordaje teraputico agresivo:Volumen. O2. AntibiticosTratamiento por al menos 6-8 semanas. Antibiticos de amplio espectro con cobertura anaerobia:

Cefalosporina de 3 o 4 asociado a un antiestafoloccico. Ceftriaxona-Clindamicina. -Curacin con ATBs IV: 80-90%.

Necrotizing pneumonia , D.A. Spencer, M.F. Thomas, Paediatric Respiratory Reviews 15 (2014) 240245 Norte A, et al. Pneumonia Necrotizante: uma complicao rara, Acta Med Port 2012 Jan-Feb;25(1):51-55Manejo QxLa intervencin quirrgica temprana reduce la estada hospitalaria. Mala respuesta a tratamiento. Abcesos. Fstula broncopleural. Surgical management of acute necrotizing, lung infections, Reimel B. Can Respir J Vol 13 No 7 October 2006Drenaje percutneo:Sntomas de gravedad luego de 2 semanas de tratamiento antibitico.Desplazamiento mediastnico.Dependencia ventilatoria.

Surgical management of acute necrotizing, lung infections, Reimel B. Can Respir J Vol 13 No 7 October 2006Drenaje percutneo:Tubo de drenaje intracavitario (guado por ecografa).Evita hasta en un 84% la ciruga en casos refractarios.Se deja por 7-8 das.Complicaciones: Obstruccin del catter (dolor torcico, neumotrax, hemotrax).

Surgical management of acute necrotizing, lung infections, Reimel B. Can Respir J Vol 13 No 7 October 2006VATSVideo toracoscopa asistida. Si se realiza precoz, 48 hrs, reduce los das de hospitalizacin y evita la reseccin pulmonar. An Early Thoracoscopic Approach in Necrotizing Pneumonia in Children, Kalfa N. Journal of laparoendoscopic & advanced surgical techniques, Volume 15, Number 1, 2005