Radiological Findings in Severe Pneumonia in Children 1-59 Months in a Children's Hospital, Khartoum, Sudan
Pediatrics & Therapeutics

Pediatrics & Therapeutics
Open Access

ISSN: 2161-0665

+44 20 3868 9735

Research Article - (2012) Volume 2, Issue 3

Radiological Findings in Severe Pneumonia in Children 1-59 Months in a Children's Hospital, Khartoum, Sudan

Karim Eldin Mohamed Ali Salih1*, Osman Abdel Wahb2 and Salah Ahmed Ibrahim3
1Paediatric Department, Gaafar Ibn Aouf Children’s Hospital, University of Juba, Sudan
2Radiology Department, Soba University Hospital, Khartoum University, Sudan
3Paediatric Department, Faculty of Medicine, Khartoum University, Sudan
*Corresponding Author: Karim Eldin Mohamed Ali Salih, Paediatric Department, University of Juba, P.O. Box: 321/1, Khartoum, Sudan Email:


Objective: This prospective hospital base study was conducted to examine the role of chest radiography in diagnosis of pneumonia in children and correlate the severity of the disease with radiological findings. Methods: A total of 156 cases aged 1-59 months admitted through the Emergency Room with severe pneumonia were enrolled over 24 hours/day admissions, once every two weeks Results: The enrolled groups were 61.5% female, 38.5% were male. The chest X-ray showed pneumonia in 83 (53.2%) cases with alveolar pneumonia accounting for 47 (30.12%), and non alveolar pneumonia for 36 (23.10%) cases. Factors that were found to have significant association with severe pneumonia included smoking associated diarrheal diseases, endemic diseases, malnutrition anaemia and breastfeeding < 18 months. (P. value < 0.04; < 0.001, <0.001, <0.001, <0.01 and <0.48, respectively). In conclusion chest X-ray is an important tool in diagnosing severe pneumonia, particularly in situations where other means of investigations are meager.

Keywords: Severe pneumonia; Chest XR; Alveolar pneumonia; Sudan


The estimation of annual death due to pneumonia, worldwide in children less than 5 years is more than 10 million, and most of these deaths occur among children in developing countries [1,2]. Also respiratory tract, mainly pneumonia caused by bacterial infection may account to 2 millions [3,4]. The Burden of pneumonia is poorly estimate, due to poor documented, which reflect difficulties for health planner to plan for prevention and selection of suitable treatment i.e. antibiotics [5].

Death due to pneumonia (bacteria) are more than that due to meningitis, however, surveillance for pneumonia is too difficult issue to be performed [6].

In order to make a definite diagnosis of clinical pneumonia you might need invasive procedure, which make more difficulties in identifying the causative organisms [7]. Blood culture is not acceptable way to identify bacterial pneumonia [8-10] and specimens from interstitial tissue is technically difficult and need experience personnel and it is risky procedure [9,11]. Therefore, chest X-ray can give useful information about the presence of pneumonia [12]. Due to the burden of pneumonia WHO established standard categorization for radiological pneumonia [13].

Patients and Methods

This is a prospective hospital-based which was done over study on a period of 2 years (from March 2009 to March 2011). The catchments area is approximately 5 million populations with more than 450 patients visiting the Emergency Room (ER) daily having different paediatrics problems. Children included were aged 1 – 59 months with the diagnosis of severe pneumonia according the WHO criteria for severe pneumonia [14,15]. They were admitted via ER to the tertiary hospital (Gaffar Ibn Aouf Children’s Hospital) in Khartoum. The sample of 156 patients was collected over whole 24 hours period on the unit causality duty day (which is every other Wednesday). A questionnaire was designed to include personal data, medical, nutritional and past history as well as clinical examination Investigations done included chest X-ray, TWCC, blood film for malaria and Widal test for typhoid fever. Routine management was timely initiated.

The chest X-rays were interpreted by a senior radiologist, one senior paediatrics chest physician and a general pediatrician. Informed verbal consent was obtained from parents or care providers.

Chest radiograph Interpretation was according to WHO classification:

1) Alveolar pneumonia: i.e. end point consolidation, which may be fluffy of part for whole lobe or enter lung often containing air bronchogram and or with plural effusion [16].

2) Non alveolar (i.e. other consolidation or infiltrate) [16].

The presence of other infiltrates as defined above in the absence of plural effusion as well as other non end point (i. e. linear, interstitial, pre-bronchial thickening, multiple areas of atelectases [16].

When more than one radiological signs were present condition is designed as severe radiological pneumonia.


One hundred and fifty six children aged 1-59 months with severe pneumonia (Based on WHO definition) were enrolled in this study.

Table 1 shows gender and age distribution, 60 (38.5%) cases were males and 96 (61.5%) were females. Those children of history of diarrhea, smoking at home and receiving breastfeeding less than 18 months showed significant association with severe pneumonia (P < 0.0001; P < 0.04 and P < 0.048) respectively (Table 2). All children with severe pneumonia presented with fever (100%), followed by shortness of breath (88.5%) , cough (81.4%) and running nose (78.2%) , while grunting in two third of the cases (Table 3) . X-ray finding of pneumonia were present in 83 (53.2%) children with alveolar pneumonia accounting for 47 (30.12%), and non alveolar pneumonia for 36 (23.10%) cases, while X-ray showed normal findings in 46.8% (Table 4). It was observed that 29 (34.9%) chest X-ray showed severe radiological pneumonia. The severity of the disease has significant association with many factors e.g. hospital stay more than 4 days (P <0.001), presence of severe malnutrition (P <0.001), presence of other illnesses like typhoid and malaria (P < 0.01) and anemia (Hb less than 10 grams based on WHO definition) (Table 5).

Characteristic Number of children Percentage
Age (in months)
< 12
12 – 24
25 – 36
> 36
Total 156 100%

Table 1: Gender and age distribution of children in the study (n=156).

Risk factors N (%) Chi-square (X2) P. value
Age (in month):
< 36
=> 36
36 (43.4)
47 (56.6)
4.2 0.240
- Female
- Male
47 (56.6)
36 (43.4)
1.3 0.246
Father’s education:
- Post primary
- Illiterate
73 (88.0)
10 (12.0)
3.8 0.143
Mother’s education:
- Post primary
- Illiterate
45 (54.2)
38 (45.8)
2.2 0.318
Father’s occupation:
- Skilled and professional
- Unskilled
61 (73.5)
22 (26.5)
1.4 0.49
Mother’s occupation:
- Skilled and professional
- Unskilled
45 (54.2)
38 (45.8)
3.2 0.201
Number of sibling:
< 4
> 4
62 (74.7 )
21 (25.3 )
0.014 0.704
- Yes
- No
67 (80.7)
16 (19.3)
3.9 0.04
History of diarrhea:
- Yes
- No
52 (62.7)
31 (37.3)
19 0.0001
Method of cooking:
- Gas.
- Wood and Coal
66 (79.5)
17 (20.5)
0.17 0.679
- Yes
- No
71 (85.5)
12 (14.5)
0.031 0.57
< 18 months
18 -24
59 (71.1)
18 (19.9)
6.07 0.048

Table 2: Possible risk factors contributing to pneumonia (n = 83).

Symptoms Number of cases Percentage
Fever 156 100
Cough 127 81.4
Running nose 122 78.2
Shortness of breath 138 88.5
Grunting 101 64.7

Table 3: Presenting symptoms of pneumonia (n= 156).

Finding Number of cases Percentage
Alveolar 47 30.1
Non alveolar 36 23.1
Normal 73 46.8

Table 4: Radiological findings (n= 156).

Factors for severity N (%) Chi-square (X2) P. value
Oxygen therapy more than 24 hours 29 (100) 5.7 0.22
Hospital stay more than 4 days 29 (100) 20 0.0001
More than one antibiotic:
- Yes
- No
- Missed
20 (69.0 )
7 (24.1)
2 ( 6.9)
3.9 0.142
Association with other diseases:
- Yes
- No
20 (69.0)
9 (31.0)
3.5 0.01
Association with anemia:
- Yes
- No
15 (51.8)
14 (48.2)
4.26 0.039
Association with malnutrition:
- Yes
- No
12 (41.4)
17 (58.6)
20.1 0.0001

Table 5: Factors associated with X-ray severity of the disease (n = 29).


Chest X-ray is a useful investigation in diagnosing severe pneumonia whereby reducing the burden of severe pneumonia. In this study the chest radiology showed signs of alveolar and non alveolar pneumonia (based on WHO criteria) in 83 (53.2%) cases which is less than that seen in Northern Territory endogenous children in Australia [14]. The high rate of positive X-ray findings in that population is higher than in our study because they include all hospitalized children, moreover, due to good facilities, easy transportation many patients they report to hospital, this differ from our situation, where some patients receiving antibiotics at home, were reluctant to report to hospital. The lack of expert facilities made our rate of positive X-ray findings less than that in Australia. However, our findings are more or less similar to the Spanish study where chest X-ray proved pneumonia in 62.1% of cases [17]. But our findings in X-ray are more than that in Fiji where pneumonia was proved in 34% of the children [18].

Diarrheal disease and gastroenteritis and severe malnutrition had strong association with the severity of the disease in this research, which in concordance with other studies done in Middle-east [14,19,20]. The diarrhoeal disease will lead to deficiency of vitamin A and zinc with subsequent deficiency in mucosal defense against organisms as a result of this immunodeficiency infection will develop [21-24]. Therefore, diarrhoeal disease and malnutrition with trace elements and anaemia will predispose to severe infection of pneumonia. Those children with hospital stay more than 4 days associated with severe disease in this study and this in agreement with other studies [25]. Smoking and incomplete breastfeeding which is significant in this study agreed with other studies [26,27]. The symptomatology in severe pneumonia is also in agreement with previous study in Sudanese children [28].


Achievement of goal number four of the UN Millennium Development as far as acute lower respiratory tract infection should be obtained [29]. Chest X-ray is an important tool in diagnosing severe pneumonia. It also helps in deciding the severity of the disease. It is highly recommended for diagnosis of pneumonia particularly in lowincome countries where other tools of investigations are meager.


  1. Babamy C (2002) The state of tire world’s children 2003. Geneva: United Nations Children’s Fund.
  2. Ahmad OB, Lopez AD, Inoue M (2000) The decline in child mortality: a reappraisal. Bull World Health Organ 78: 1175-1191.
  3. Williams BG, Gouws E, Boschi-Pinto C, Bryce J, Dye C (2002) Estimates of w orld-wide distribution of child deaths from acute respiratory infections. Lancet Infect Dis 2: 25-32.
  4. Shann F (1986) Etiology of severe pneumonia in children in developing countries. Pediatr Infect Dis 5: 247-252.
  5. Black S, Shinefield H, Fireman B, Lewis E, Ray P, et al. (2000) Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Northern California Kaiser Permanente Vaccine Study Center Group. Pediatr Infect Dis J 19: 187-195.
  6. Centers for Disease Control and Prevention (CDC) (2009) Pediatric bacterial meningitis surveillance - African region, 2002--2008. MMWR Morb Mortal Wkly Rep 58: 493-497.
  7. Campos JM (1998) Haemophilus. In: Murday PR (editor) Manual of clinical microbiology. (7thedn) Washington. PC: ASM Prices, p604.
  8. Karim Eldin MA (2004) Spectrum of some serious infections caused by Haemophlus Inflenzae type b in children between 2 -59 months in Omdurman Children’s Emergency Hospital, Omdurman, Sudan, Thesis submitted for Clinical MD in Paediatric and Child Health, University of Khartoum, p75.
  9. Levine OS, Liu G, Garman RL, Dowell SF, Yu S, et al. (2000) Haemophilus influenzae type b and Streptococcus pneumoniae as causes of pneumonia among children in Beijing, China. Emerg Infect Dis 6: 165-170.
  10. Bonadio WA (1988) Bacteremia in febrile children with lobar pneumonia and leukocytosis. Pediatr Emerg Care 4: 241-242.
  11. Dworicin PH (1996) Lower respiratory tract infections. In: Dworicin PH (editor). The National Medical Series for Independent study (pediatrics), 3rd ed. Philadelphia: Williams and Wilkins p297.
  12. Vuori-Holopainen E, Peltola H (2001) Reappraisal of lung tap: review of an old method for better etiologic diagnosis of childhood pneumonia. Clin Infect Dis 32: 715-726.
  13. World Health Organization (2001) Pneumonia vaccine trial investigators Group Standardization on Interpretation of chest radiographs for the diagnosis of pneumonia in children. Geneva.
  14. O'Grady KA, Taylor-Thomson DM, Chang AB, Torzillo PJ, Morris PS, et al. (2010) Rates of radiologically confirmed pneumonia as defined by the World Health Organization in Northern Territory Indigenous children. Med J Aust 192: 592-595.
  15. Gove S (1997) Integrated management of childhood illness by outpatient health workers: technical basis and overview. The WHO Working Group on Guidelines for Integrated Management of the Sick Child. Bull World Health Organ 75 Suppl 1: 7-24.
  16. WHO standardization of interpretation of chest radiographs for the diagnosis of pneumonia: WHO pneumonia vaccine trial investigator’s Group. 2001; Geneva: WHO, WHO/V & B/01.35.
  17. Gustavo C, Eider O, Edurado GP, Agustin N, Emilio PT (2009) Incidence of hospitalization due to pneumonia in children aged less than 5 years. Open Infect Dis J 3: 27-30.
  18. Magree HC, Russell FM, Sa'aga R, Greenwood P, Tikoduadua L, et al. (2005) Chest X-ray-confirmed pneumonia in children in Fiji. Bull World Health Organ 83: 427-433.
  19. Forman MR, Guptill KS, Chang DN, Sarov B, Berendes HW, et al. (1990) Undernutrition among Bedouin Arab infants: the Bedouin Infant Feeding Study. Am J Clin Nutr 51: 343-349.
  20. Scrimshaw NS, SanGiovanni JP (1997) Synergism of nutrition, infection, and immunity: an overview. Am J Clin Nutr 66: 464S-477S.
  21. Alvarez JO, Salazar-Lindo E, Kohatsu J, Miranda P, Stephensen CB (1995) Urinary excretion of retinol in children with acute diarrhea. Am J Clin Nutr 61: 1273-1276.
  22. Mitra AK, Alvarez JO, Wahed MA, Fuchs GJ, Stephensen CB (1998) Predictors of serum retinol in children with shigellosis. Am J Clin Nutr 68: 1088-1094.
  23. Roth DE, Caulfield LE, Ezzati M, Black RE (2008) Acute lower respiratory infections in childhood: opportunities for reducing the global burden through nutritional interventions. Bull World Health Organ 86: 356-364.
  24. Roth DE, Caulfield LE, Ezzati M, Black RE (2008) Acute lower respiratory infections in childhood: opportunities for reducing the global burden through nutritional interventions. Bull World Health Organ 86: 356-364.
  25. Levy A, Fraser D, Vardi H, Dagan R (1998) Hospitalizations for infectious diseases in Jewish and Bedouin children in southern Israel. Eur J Epidemiol 14: 179-186.
  26. Sopori M (2002) Effects of cigarette smoke on the immune system. Nat Rev Immunol 2: 372-377.
  27. Lennart B, Olcen P (1999) International Epidemiological Association. Protective effect 0f breastfeeding.
  28. Karim Eldin MA (2004) Spectrum of some serious infections caused by Haemophlus Inflenzae type b in children between 2 -59 months in Omdurman Children’s Emergency Hospital, Omdurman, Sudan, Thesis submitted for Clinical MD in Paediatric and Child Health, University of Khartoum, p67.
  29. O’Brien KL, Wolfson LJ, Watt JP, Henkle E, Deloria-Knoll M, et al. (2009) for the Hib and Pneumococcal Global Burden of Disease Study Team. Lancet 374: 893–902.
Citation: Ali Salih KEM, Wahb OA, Ibrahim SA (2012) Radiological Findings in Severe Pneumonia in Children 1-59 Months in a Children’s Hospital, Khartoum, Sudan. Pediatr Therapeut 2:117.

Copyright: © 2012 Ali Salih KEM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.