With this observational retrospective study, we wanted to investigate the potential diagnostic and prognostic value of LUS in a cohort of 100 CAP patients treated with a macrolide+beta-lactam/cephalosporin combination or with monotherapy (amoxicillin or cephalosporin). The most important limitations of our study are its retrospective nature and the impossibility to stratify patients in the non-mycoplasma group based on the specific etiology, due to the unavailability of some microbiological and virological tests which would be required (some of which are not routinely performed in our hospital). Other important limitations are represented by the low number of Mycoplasma-positive patients and the absence of a centralized review of lung ultrasound images. In addition, the operators who performed the ultrasound examination were not blind to the clinical conditions of the patient during the examination.
There are two main indications for LUS use in pediatric CAP: diagnosis of disease and monitoring of its evolution.19 The diagnostic precision of LUS in demonstrating an involvement of lung parenchyma was confirmed by the Urbankowska study, 10 which found a sensitivity of 93.4%, a specificity of 100% and a positive predictive value of 100%. In addition, studies have shown that LUS has greater accuracy, compared to conventional chest X-ray, in identifying pleural effusions in complicated cases of pneumonia.²⁰
In daily practice, LUS is frequently used as a diagnostic tool in children with CAP, but few authors have questioned the validity of its use for differential diagnosis. In a study by Voiko, 11 LUS was performed on admission on 147 patients with CAP and a second US examination was performed after discharge on most of them. From this study, it emerges how LUS can give additional information about the etiology of pneumonia in children, helping to differentiate between viral and bacterial CAPs. Moreover, the study found a statistically significant difference in the number (p <0. 001) and size (p <0. 001) of lung lesions in viral versus bacterial CAP, with bacterial pneumonia showing a faster regression of consolidations compared to viral pneumonia (96. 6% vs 33. 3%).
The aim of our study instead, was to establish whether LUS could be used as a reliable tool to differentiate between Mycoplasma-induced pneumonia from CAP caused by other agents.
We also took into account clinical signs and symptoms on admission, in order to evaluate whether it is possible, based merely on clinical features, to distinguish Mycoplasma pneumonia from bacterial or viral forms, assessing for each item whether there is a difference between the two groups.
Statistical analysis shows that there is no significant difference in clinical features on admission in the two groups (Fig. 3), with the most frequent symptoms, fever and cough, being evenly distributed between the two. Reduced breath sounds were detected more frequently among patients diagnosed with Mycoplasma pneumonia (63% Mycoplasma-CAP vs 37% non-Mycoplasma-CAP), even though the positive predictive value was not particularly high (PPV 63%).
Contrarily, in Vojko's study, 11 this latter finding was prevalent among patients with typical bacterial CAP (32% bacterial CAP vs 20% atypical CAP). However, it should be noted that this outcome could be influenced by bacterial superinfections, which are always a possibility in Mycoplasma CAP. ²¹ Furthermore, this latter study, in agreement with ours, shows that wheezing, a sign that is commonly considered a hallmark of viral CAPs, is not in fact a sensitive indicator of the etiology of pneumonia, whereas a study by Qian, showed a correlation between wheezing and infections by Mycoplasma pneumonia. ²²
Our data show that LUS alone, cannot discriminate between different etiologies of CAP in children. We have found that patients with CAP caused by Mycoplasma or other infectious agents, frequently have the same pattern of parenchymal involvement: a single consolidation (75% Mycoplasma-CAP and 78% non-Mycoplasma CAP) and interstitial disease (33% Mycoplasma-CAP and 30% non-Mycoplasma-CAP). In addition, the size of consolidation foci was not significantly different in the two groups, with a large lesion present in 78% of cases in both groups (Tab. 1). This finding disagrees with previous studies, which showed how large alveolar infiltrates are a feature of typical bacterial CAPs, while in CAPs caused by atypical pathogens, lesions are smaller and more commonly multiple (65% vs 10% in our study) and are associated with interstitial infiltrates (50%).
Regarding the influence of age on the size of lesions, we have not found a significant association between the two variables (Tab. 6). As discussed before. while lesion size appeared to increase with age in Mycoplasma CAP (Fig. 4), and to decrease with age in non-Mycoplasma forms (Fig. 5), p-value was not significant in either case.
Patients were discharged after an average of 4,1 days and a third LUS (eot-LUS) was performed approximately one week after discharge on 62 patients. In this last examination a regression of consolidations was observed in 11% of Mycoplasma positive patients and in 89% of cases non-Mycoplasma CAP. Complete resolution was instead detected in 49% of Mycoplasma CAP patients and 51% of non-Mycoplasma CAP underwent complete resolution. These data show a difference in healing times (p = 0. 04) which turned out to be shorter in Mycoplasma CAP, leading to a reduction in the length of hospitalization (Tab. 3). This finding is in contrast with Vojko's 2019 study, in which a slower regression of consolidations was observed in patients with CAP Mycoplasma (50% of patients showed lesion regression and 14. 3% underwent complete resolution), but in accordance with the Bruns’ study in which chest radiography showed a faster resolution of consolidations in CAP from Mycoplasma compared to pneumococcal pneumonia. ²³
The i-LUS, performed 3-4 days after antibiotic treatment, showed disease progression in 4%, stationarity in 3%, regression of consolidations in 86% of cases and complete remission in 7% of cases. In this regard, LUS did not demonstrate a statistically significant difference in the echographic appearance of pulmonary lesions in the two groups, but, nevertheless, proved itself to be an effective mean of monitoring the effects of therapy.
Our study suggests, in accordance with 2018 Balk’s meta-analysis, ²⁴ that LUS should be the preferred imaging technique for the diagnosis and follow-up of pneumonia in children.
From the collected data and subsequent statistical analysis, it is clear that ultrasounds examination alone does not allow for a differential etiological diagnosis of CAP, for which serology and/or PCR remain the most accurate tools. However, it often orients and supports the diagnostic suspicion by identifying the presence of pneumonia, allowing in the vast majority of cases to avoid radiographic examination. Its role in follow-up as a reliable and safe tool compared to radiological imaging remains confirmed.