The X-ray
is not as accurate as most people think. Many children (and also adults)
are diagnosed with “pneumonia” in ERs, Emergency Clinics, and even
physician’s offices when they really do not. The X-ray does not see
bacteria. It sees fluid, mucous, congestion, or any stuff. The mucous in
the chest could be allergy like asthma, bacterial pneumonia, viral
(pneumonia) infection like a bad chest cold or flu, fungal infection, or
even rarely cancer. The radiologist reads the X-ray as “pneumonia” but that
is the radiologist’s term for congestion. And the radiologist does not know
the patient so he will call it pneumonia if there is very little congestion
not wanting to miss it and get sued later. Some physicians will also over
call the diagnosis not wanting to get sued. Most patients with an asthmatic
attack or flu will have an abnormal X-ray. When there is what is called a
consolidation, where the whole lobe of the lung is a white out, then it is
most likely a bacterial pneumonia. But many X-rays have steaks or some
fluffiness that is called “pneumonia”.
I do not
take many X-rays since most cases it will not help us doctors. If there is
fever, cough, and I can hear what is called “rales” in the chest, then there
is most likely pneumonia and I will treat no matter what the X-ray shows.
And if there is a child that is not ill, has mild cough, mild fever, and
normal sounding chest with no labored breathing, then there is no bacterial
pneumonia and why take an X-ray that may show congestion. The X-ray
frequently lags behind the patient’s condition. So the X-ray may be normal
early on in pneumonia, and the abnormalities can persist in the X-ray for
months even though the patient is cured. X-rays can also cause cancer later
in life so why expose them unless needed. A history and physical is more
important.
So the
X-ray is not a microscope and does not see bacteria. For comparison; if
there is mucous in your nose that is clear allergy mucous or there could be
green infected mucous, when we X-ray your nose, it will show congestion but
we will not know if it is clear or infected boogers.
Dr. Knapp
See
summaries of Medical Studies and Articles written about this:
1. The
Journal of Pediatrics
The
cause and clinical manifestations of pneumonia were studied in 98 pediatric
outpatients. A viral diagnosis was established in 38 (39%) of the 98
patients, and a bacterial diagnosis in 19 (19%). Ten (53%) of the 19
patients with bacterial pneumonia had a concurrent viral infection. No
clinical, laboratory, or radiographic findings that would reliably
differentiate viral from bacterial infection were identified. This study
suggests that the clinical, laboratory, and radiographic findings in
patients with bacterial infection may be indistinguishable from findings in
patients with viral infection.
2. Radiologic Technology,
The chest
radiograph is a popular diagnostic toolin the care of patients
suspected of having pneumonia but hasa low diagnostic yield in
many cases. The clinical utility ofthe chest film could be
improved by careful clinical examinationof the patient before
obtaining the radiograph, especially inpediatric patients.
3.
Clinical Pediatrics
The chest
roentgenograms of 128 consecutive ambulatory children with radiologic
pneumonia were read independently and without clinical information by a
faculty general pediatrician (Ped), a pediatric radiologist (R-P) and a
general radiologist (R-G). Readings were compared with results of viral
titers and bacterial cultures. The three observers agreed on a correct
reading in only three children with viral and three with bacterial
pneumonia. Because of poor observer agreement and appreciable false-negative
errors when viral and bacterial readings were compared to titer increases
and positive bacterial cultures, respectively, we conclude that radiographic
findings are poor indicators of etiology diagnosis in ambulatory childhood
pneumonias and, of themselves, are an insufficient data base for making
therapeutic decisions.
4.
Archives of Argen Pediatrics
To
evaluate the accuracy of World Health Organization (WHO) method of
interpreting chest radiographs on identifying young children with bacterial
pneumonia, and to compare its accuracy with other method. Chest radiographs
from children aged under 5 years old hospitalized for pneumonia, with
microbiological evidence of bacterial or viral infection, were evaluated.
108 chest radiographs were evaluated (87 viral, 21 bacterial). There was a
specificity of 50-60% for diagnosing bacterial vs viral chest infections.
5.
Clinical Pediatrics
The
difficulty of diagnosing pneumonia by chest x-ray in children less than 4
years of age was studied by comparing the chest roentgenograms of 34 healthy
children with the chest roentgenograms of 34 children previously diagnosed
as having pneumonia. Review of these films without knowledge of the previous
interpretation and without clinical information disclosed variations
regarding the roentgenographic confirmation of pneumonia in 24 percent of
the cases and variations regarding the location of the lesion in about 50
percent of the cases.
6.
Pediatrics
The need
for follow-up roentgenograms documenting complete clearing of pulmonary
infiltrates in the pediatric patient with acute pneumonia was studied
prospectively. Seventy of 129 children enrolled in the study had a repeat
roentgenogram within three to four weeks after initial diagnosis. Twenty
percent of this group had residual pulmonary infiltrates. Of the two thirds
of those who returned for a second follow-up roetgenogram, the
infiltratrates had cleared completely within three months. Routine repeat
chest roentgenograms may not be necessary unless there is clinical evidence
of persistent respiratory difficulty or failure to thrive.
7.
Pediatric Pulmonology
This
study assessed the clinical value of routine follow-up chest radiographs in
hospitalized children with community-acquired pneumonia. …… In
conclusion, routine follow-up chest radiographs are not needed in childhood
community-acquired pneumonia if the child has a clinically uneventful
recovery.
8. Acta
Pediatrica
To
evaluate the value of radiographic follow-up of community-acquired pneumonia
in children who are previously healthy. ….. Such patients may have some
benefit from control radiographs, but only in terms of detecting the chronic
disease at an earlier stage, not in altering the clinical course. Such
modest benefits must be weighed against the consequences of providing
follow-up to a large number of healthy children, and making lots of abnormal
findings with no clinical significance. CONCLUSION: Control radiographs are
not very valuable in children who are otherwise healthy.
Radiological Findings
in Children with Acute Pneumonia: Age More Important Than Infectious Agent
Purpose: To evaluate
whether radiological findings and healing time in children with pneumonia
are correlated to etiologic agent. A
total of 346 children with radiologically verified acute pneumonia, and with
accomplished serological tests for bacteria and viruses, were included in
the study. Five etiological groups were analysed: children with bacterial
etiology only, with viral etiology only, with mixed bacterial and viral
etiology, with Mycoplasma only, and children with no etiology. The chest
films of each etiological group were analysed and the findings were
correlated to the children's age. The radiological findings did not differ
between the etiological groups. Radiological findings correlated
significantly with the patient's age.
Result: Conclusions about the etiology could not be drawn from the chest
X-ray findings.
Here is a newsymail I
sent out in Sept2011
2011 October 1 issue of Clinical
Infectious Diseases will present
this information and recommendations.
The Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases
Society of America (IDSA) convened an expert panel to review the management
of Community acquired Pneumonia (CAP). The PubMed database was reviewed
through May 2010. The expert panel included clinicians and investigators who
represented community pediatrics, public health, critical care, emergency
medicine, hospitalist medicine, infectious diseases, pulmonology, and
surgery. The first-ever guidelines on the diagnosis and treatment of CAP
in infants and children, from PIDS and IDSA, emphasize the importance of
immunizations (Prevnar), including a yearly influenza vaccine, to protect
children from life-threatening pneumonia. A 13-member panel, led by John S.
Bradley, MD, with the Department of Pediatrics, University of California San
Diego School of Medicine and Rady Children's Hospital of San Diego, in
California, authored the new guidelines published online August 30 and to
appear in the print October 1 issue of Clinical Infectious Diseases.
The document presents 92 specific recommendations in all, each with varying
levels of evidence.
Recommendations for Diagnosis
"Diagnostic methods and treatments that work well in adults may be too risky
and not have the desired result in children," Regarding diagnosis, the
guidelines state that blood cultures should not be routinely performed in
nontoxic, fully immunized children with CAP treated in the outpatient
setting. "In these cases, there is no need to perform unnecessary medical
interventions such as using x-rays (which expose the child to radiation
needlessly) or prescribing antibiotics (which kill bacteria, not viruses,
and may foster drug-resistant bacteria)," the written release states. The
guidelines also recommend that infants 3 to 6 months old with suspected
bacterial pneumonia be hospitalized.
Amoxicillin Sufficient for First-Line Therapy In addition, amoxicillin
should be used as first-line therapy for bacterial pneumonia, but more
powerful antibiotics are not needed. Methicillin-resistant
Staphylococcus aureus should be considered as a cause of
pneumonia if first-line treatment is unsuccessful. According to the
guidelines, overtreatment is a critical concern. Most cases of pneumonia in
preschool-aged children are of viral origin and will therefore not develop
into life-threatening bacterial pneumonia.
"With these guidelines, we are hopeful that the standard and quality of
care children receive for community-acquired pneumonia will be
consistent from doctor to doctor — providing much better treatment
outcomes," Dr. Bradley indicates. "Pneumonia is one of the most common
reasons for hospitalization for children in the United States, and
there's a huge variation in the care that's delivered to children,"
"Often the care of children is not evidence based and result in both
over- and undertreatment of children and less than ideal outcomes.”
It is interesting that they do not recommend x-rays. When you take an x-ray
the cloudy area that one sees is called pneumonia but in fact is just
“congestion”. It is mucous. The mucous can be sterile as in allergies and
asthma, it can be viral with a chest cold, or bacterial as with bronchitis
or pneumonia. The x-ray does not tell you which but is reported
“pneumonia”. Then the doctor faced with a x-ray report of pneumonia has to
treat it as if it is bacterial pneumonia so that he does not “miss”
pneumonia and get sued if the patient later comes in the secondary bacterial
pneumonia after the chest cold. We have discussed in previous articles
about the chest viral cold with fever and cough at the beginning is usually
viral and a recurrence of fever and lethargy after the fifth day is
secondary bacterial infection. That is when we need to see the patient.
But many people are treated for pneumonia who have a viral chest cold or
allergy. Everyone who is coughing and goes into the walk-in emergency
clinics gets a chest x-ray and many get treated for their “pneumonia”. I
don’t take a lot of x-rays for this reason. It does not affect your medical
decision that much.
While we are talking about false diagnosis with tests, let’s talk about
strep tests. 10% of strep cultures and rapid tests are negative when there
actually is strep throat. And 5% of the population carries strep around in
their throat all year. They are carriers. So you can have a strep throat
and a negative test and not get treated. Then you can have a viral/allergy
sore throat and positive test and get treated for a strep that has been in
there all year and had nothing to do with the sore throat. That is why your
friend says their child had a strep throat and did not even run fever. Or
the doctor started antibiotics for “strep throat” and the patient was not
well in a few days so they changed antibiotics. There are no strep
resistant to Amoxicillin. When they changed antibiotics then the viral sore
throat finally went away and it seems like it was from the changing of the
antibiotic.
Also think of Urinary tract infections. Most girls below 5 yrs. old who
have burning do not have an infection but just irritation. There is what is
called asymptomatic bactiuria. There are bacteria in many females bladder
and it is in there all year. It does not harm them and does not need to be
treated. But the child gets irritation from a bubble bath and the culture
comes out “positive”. Those may have been bacteria that were in there all
month. They still get treated to be on the safe side. (no bubbles and use
Dove soap in the bath.)
What I am saying is that it is not exact and gets confusing as to what is
real or not. A lot of clinical judgment, experience, and common sense goes
a long way.
