Chapter 187

Each year, a large number of children are evaluated by their primary care physicians for recurrent infections, an especially common event in early childhood.1 The overwhelming majority of such cases are benign, and an extrinsic cause of recurrent infection is identified. Examples of extrinsic causes include heightened exposure to pathogens in a daycare setting, carriage of a pathogenic organism such as Staphylococcus aureus in the context of recurrent infection with this organism, or recurrent upper respiratory tract infections in the context of parental smoking. However, concern about an intrinsic pathologic underpinning is heightened on the basis of frequency of infections, their severity, and the nature of the offending organism. The coexistence of multisystem disease, autoimmunity, or lymphoreticular malignancy should also prompt evaluation for immunodeficiency. A family history of recurrent infections raises the index of suspicion.

One helpful clue to the presence of a host abnormality is a high frequency of infections. Examples include two or more systemic bacterial infections at any time (such as sepsis, deep-seated abscesses, or meningitis), three or more bacterial infections (eg, draining otitis media), or six to eight or more upper respiratory tract infections in 1 year.2 The last finding should be modified by the fact that many children, especially toddlers, suffer from recurrent upper respiratory tract infection from repeat exposure to respiratory (usually viral) pathogens, especially during the first year of daycare attendance.

Recurrent infections with a particular organism also point to abnormalities of the host. A case in point is meningococcemia, in which a second episode of this disease raises the prevalence of a terminal complement pathway abnormality in afflicted individuals from ⩽1% to 30 to 40%. Other examples include Staphylococcus aureus infections in children with chronic granulomatous disease (CGD) or leukocyte adhesion deficiency (LAD).

The severity of the recurrent infection is reflective of the seriousness of the underlying disorder. The compromised child may fail to recover completely between infections. Failure to thrive, weight loss, and growth retardation are grave manifestations of immunodeficiency and call for immediate investigation. The need for surgical intervention provides yet another measure of the severity of the underlying infection. Such interventions may include myringotomy tube placement for chronic otitis media, sinus surgery for chronic sinusitis, lobectomy for chronic right middle lobe pneumonia, and drainage of superficial and deep abscesses.

The availability of effective antibiotic therapy may modulate the presentation, but in general the clinical picture may slowly but progressively worsen over a protracted period of time.

The nature of sites affected by the recurrent infections also provides valuable clues to the problem at hand. Humoral immunodeficiency, cystic fibrosis, and immotile cilia syndrome result in recurrent severe sinopulmonary infections including chronic sinusitis, pneumonia, and bronchiectasis. Humoral immunodeficiency may also result in chronic diarrhea as a consequence of infestations with pathogens such as Giardia lamblia. Recurrent infections affecting one particular site (eg, one specific lung lobe or one ear) may ...

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