In this study, we evaluated the prevalence of CHD in patients aged 0 to 18 years with recurrent or persistent pneumonia. In our study group, 67.6% of the patients were male. The fact that the number of male patients was higher than that of female patients in our study is compatible with other studies in the literature [5, 6, 9–21].
Growth retardation was observed in 18% in our study. In a retrospective study published in 2012, Türel et al. [15] found growth retardation in 60.6% of patients with RP. In the same study, it was reported that the most common underlying diseases causing growth retardation in the patient group were neuromotor developmental delay and cystic fibrosis, and these two etiologies accounted for 31.8% of the patient group. The inclusion criteria may explain the difference between the studies. In our study, developmental delay may be lower than in the literature because patients with known diseases were included in the exclusion criteria.
Regarding symptoms and physical examination findings, cough was present in 98% of our patients. The second most common complaint was fever, with a rate of 83.3%. In a retrospective study by Hossain et al. [18], including 30 children, cough was present in all patients, while fever was found in 86.6%. When interpreted together with previous studies, cough is the most common complaint. Fever is the second most common complaint, although its frequency varies in patient populations. Pathologic cardiac murmur was heard in 13.7% of our patients. There is no review of cardiac murmur in patients with RP or PP in the literature. Although there is no study on recurrent or persistent pneumonia, the frequency of murmur was found to be 10.7% in a study by Sadoh et al. [22] in Nigeria to determine the frequency of CHD in 121 children with pneumonia. In our study, cardiac murmurs were heard in all patients in whom CHD was thought to be involved in the etiology (8 patients), indicating the importance of cardiac auscultation in evaluating the etiology of recurrent or persistent pneumonia.
When the lung imaging findings of our patients were analyzed, bilateral infiltration was observed in 44 (43.1%) and hilar lymphadenopathy in 28 (27.5%). In a study by Türel et al., bronchopneumonic infiltration was found in 72.7% of the patients [15]. While broncho-pneumonic infiltration was observed in 26.6% of the patients in the study by Hossain N et al. [18], infiltration was found in 29% and consolidation areas in 44% of the patient group in the study by Bolursaz et al. [6]. There are differences in the frequency of lung imaging findings between the studies. Consolidation areas are more frequent in patient groups with frequent aspiration syndromes, whereas infiltration is more frequent in patients with recurrent pneumonia attacks due to community-acquired pneumonia or an underlying disease. In our study, the exclusion of patients with a previously known diagnosis and the fact that some patients were referred to us for etiologic investigation of RP when they were healthy explains the difference in radiologic findings.
There are not enough studies in the literature on the frequency of CHD in patients with RP and PP. It is possible to obtain data from studies on the underlying disease in recurrent and persistent pneumonia. While congenital heart diseases were listed in detail in some of the studies on etiology, only the number of CHD was given in others. When CHD was found, the studies recorded it as the etiologic cause. However, it is known that not all congenital heart diseases increase the frequency of pneumonia. In our study, patients with CHD were evaluated separately, and patients for whom CHD was thought to be the main cause of recurrent pneumonia were evaluated separately. Congenital heart disease (CHD) affects approximately 0.8–1.2% of live births worldwide (23,24). The rate of CHD detected in etiologic studies on recurrent or persistent pneumonia is higher than the rate of CHD in all live births. Among the studies on recurrent and persistent pneumonia in the literature, 19.7% in Türel Ö. et al. [15], 29.3% in CabezueloHG et al. [19], 2% in MontellaS et al. [25], 20.6% in Al-JanabiMK et al. [21], 2.1% in PatriaF et al. [20] reported CHD, but no details of the defects were mentioned.
Hossainn et al. [18] reported a CHD rate of 16.6%, Saadk et al. [16] reported a rate of 10.4%, and the most common cardiac defect was VSD. In the study by Çelebi S et al. [1] published in Turkey, 17.2% CHD was found, 43% of these patients had VSD, and 31% had ASD. In the study by Ciftci E et al. [14], CHD was detected in 9% of patients, and half of those with CHD were VSD patients. In our study, CHD was detected in 21.5% of patients. Eight of these patients had isolated ASD, and five had isolated VSD. Previous studies have shown a high rate of VSD. Although the frequency of isolated ASD and VSD seems to be low in our study if VSDs and ASDs accompanying other cardiac pathologies are added, it can be said that 11 patients had ASD and nine patients had VSD. In light of these data, the results are consistent with the literature.
When our patient group was evaluated in terms of PP, all patients met the criteria for RP, and 55 patients met the criteria for PP. The number of male patients was 35, and the number of female patients was 20. The high rate of male patients in the patient group is consistent with the literature [4, 6, 10, 16–18]. There are studies on the etiology of intractable pneumonia with few cases. In a study conducted by Saad et al. [16] with 27 patients, the most common etiologic causes were aspiration at 26%, pulmonary tuberculosis at 22%, CHD at 14.8%, immunodeficiency at 14.8%, and no etiology was found in 11% of the patient group. In the study of Bolursaz MR et al. [6], pulmonary tuberculosis was the etiologic cause in 30.69% of the patients, aspiration syndromes in 20.7%, and CHD in 4.9%. [4] aspiration was reported as the etiologic cause in 29% of patients, tuberculosis in 19%, immunodeficiency in 7%, and CHD in 4.8%. In our study, the etiology could be determined in 70.1% of patients meeting the criteria for PP. The most common cause was asthma, with 21.8%. Aspiration syndromes were seen in 3.6% and gastroesophageal reflux in 7.3%. Respiratory tract anomalies were found in 7.3% of patients, while tuberculosis, which has been reported with high rates in other studies, was found in only 1.82%. CHD was the etiologic cause in 10.9% of the patients. Since the number of patients was small, the comparative results of 5 studies, including our study, do not give close values [4, 6, 16, 17]. Regional conditions may explain the high rate of tuberculosis in other studies in the literature. The reason for the low rate of aspiration syndromes in our study is that patients with neurologic sequelae and underlying diseases that may cause aspiration were not included in the study.
In conclusion, asthma was the most common diagnosis in our study regarding the etiology of Recurrent Pneumonia. Asthma was also found to be the most common underlying disease in the etiology of Persistent Pneumonia. Congenital heart disease was the second most common etiology in both recurrent and persistent pneumonia. The rate of CHD in patients with recurrent and persistent pneumonia is higher than in the general population. In our study, patients with CHD were compared with other patients. Hearing a murmur on physical examination was found to be a significant finding in terms of CHD. Among the patients with recurrent pneumonia, those with CHD had lower body weights than those without CHD. The proportion of male patients was higher in the patient population; however, when we compared those with and without CHD according to gender, it was observed that the rate of CHD in girls with recurrent pneumonia was higher than the rate of CHD in boys with RP. Many studies on etiology have made superficial investigations of CHD and did not present detailed data. In the literature, a study specifically on CHD in patients with Recurrent and Persistent Pneumonia, examining gender, growth retardation, symptoms, and complaints has not been published before.
Limitations of the study
The retrospective nature of the study is one of the important limitations. Since long-term follow-up of the patients was not performed, changes in the frequency and severity of pneumonia after treatment of CHDs, which are thought to play a role in the etiology, could not be evaluated. In addition, regional etiologic differences could not be determined because the study was single-centered.