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An 8-year-old boy was admitted with a 5-day history of cough, shortness of breath and fever. A round opacification on his chest X-ray was reported as a round pneumonia by a consultant radiologist. He was treated with oxygen and intravenous antibiotics. He is clinically improved and medically fit for discharge. You have been asked to arrange a follow-up chest X-ray and wonder as to the value of this additional exposure to radiation.
Structured clinical question
Is follow-up X-ray required in a child with clinical and radiological findings in keeping with round pneumonia?
We performed an online search using PubMed and Medline (1946–present) in July 2017. The key terms used were ‘round pneumonia’ or ‘round opacification’. We limited the search to include articles written in English and those relating to children. Our searches of these databases yielded 67 and 39 results, respectively. On review of titles and abstracts, we identified five relevant articles. In addition, we identified a further abstract of relevance to this review. All the included articles are shown in table 1. The level of evidence was graded according to the Oxford levels of evidence.1
It is widely accepted that routine follow-up chest X-ray is not indicated in children with uncomplicated pneumonia who have responded well to appropriate antibiotic therapy.2–5 Guidance on the value of follow-up chest radiography in children with round pneumonia is less definitive. Some articles and reviews recommend that children with round pneumonia should have a repeat X-ray in approximately 8 weeks.6–8
Our current practice to perform follow-up X-ray in children with round pneumonia is likely to be an extension from adult practice, where lung cancer is common.9 By contrast, round pneumonia is a well known entity within paediatrics. The physiological reasons for this are well understood.10 Children have poorly developed pathways of collateral ventilation, more closely apposed connective tissue septae and smaller alveoli than adults. The result is more compact areas of pulmonary consolidation.11
An article in 2004 on the best practice for management of paediatric community-acquired pneumonia recommends repeat chest X-ray in cases of round pneumonia.7 This article cites two papers as justification for this recommendation; the first is a paper in the British Medical Journalby Gibson, referenced above, which does not specifically mention round pneumonia. The second paper is based on a questionnaire sent out to consultants asking when they would repeat chest X-ray.12 The 2011 British Thoracic Society guidelines on the management of paediatric community-acquired pneumonia also suggest considering performing follow-up chest X-ray in those with round pneumonia.6 However, no evidence is cited to support this recommendation.
There is a paucity of literature relating to follow-up X-ray in round pneumonia, and none of the abstracts we identified directly answer the question posed above. The case reports describe children who had a round opacification on chest X-ray, presenting with typical features of pneumonia and responded well to antibiotic therapy.13–15 In all cases, when the X-ray was repeated there was full resolution of the pneumonia. The case report by Bentur et al highlights the importance of considering an alternative diagnosis for a round opacification on chest X-ray when symptoms are persistent despite appropriate treatment.13 The case-controlled clinical series by Fretzayas et al demonstrated full resolution of round pneumonia on all follow-up X-rays and showed that no cases of round pneumonia were reported incorrectly.16 A retrospective review of 109 chest X-rays showed that radiological diagnosis of round pneumonia is accurate and that the X-ray changes resolve with patients improving condition.10
These studies would suggest that a follow-up chest X-ray is of limited value, if at all, in children with round pneumonia who are responding well clinically to appropriate treatment.
Clinical bottom line
A child presenting with features of lower respiratory tract infection—fever, cough, increased work of breathing—who is found to have a round opacification on chest X-ray (reported by a radiologist as a round pneumonia) should be treated with appropriate antibiotics (Grade C).
A child with round pneumonia who is responding appropriately to antibiotic therapy does not require follow-up chest X-ray (Grade C).
Contributors The initial concept for this clinical question was devised by AT and he oversaw the project. AT approached PMC and BMcN to undertake the literature review and commence the process of writing the paper. MS kindly offered his expert opinion of the finished article and gave constructive criticism.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
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