1

Pneumonias
1. General characteristics. Schneider . 195. Inflammatory process of infectious origin affecting the pulmonary parenchyma. 2. Morphologic types - Lobar Causative organism: Most frequently S. pneumoniae. Characteristics Predominantly intra alveolar exudates resulting in consolidation. May involve entire lobe. - Bronchopneumonia Causative organism Many, including S. aureus, H. influenzae, K. pneumoniae, and S. pyogenes. Characteristics Acute inflammatory infiltrates extending from bronchioles into adjacent alveoli. - Interstitial Causative organism Most frequently viruses or mycoplasma pneumoniae. Characteristics Diffuse, patchy inflammation localized to interstitial areas of alveolar walls. Distribution involving one or more lobes. 3. Etiologic types a) Hospital acquired gram-negative pneumonias. Caused by many gram-negative organisms, including Klebsiella, pseudomonas aeruginosa, and escherichia coli. Endotoxins produced by these organisms play an important role in the infection. BSR. 61. Nosocomial infections: can cause bacteremia, which frequently results in shock. High mortality rate ( 40 60% ) because many of these organisms are resistant to antibiotics. b) Mycoplasma pneumonia ( primary atypical pneumonia ) The most common nonbacterial form of pneumonia. It usually occurs in children and young adults. From 5 15 years of age. It may occur in epidemics. Has a more insidious onset than bacterial pneumonias and usually follows a mild, self limited course. Characterized by an inflammatory reaction confined to the interstitium, with no exudate in alveolar spaces, and by intra alveolar hyaline membranes. Diagnosed by sputum cultures, requiring several weeks of incubation, and by complement fixing antibodies and nonspecific cold agglutinins reactive to RBC. BRS. 48. Attaches to mucosal cells by the P 1 protein ( an adhesion virulence factor ) Releases hydrogen peroxide, damaging epithelial cells, and producing a long lasting, hacking cough.

2 Laboratory diagnosis 1. Serology or polymerase chain reaction ( PCR ) , very sensitive. Cold agglutinins ( autoantibodies agglutinating RBC at 4 Centigrade degrees ) may be present after 1 2 weeks of clinical disease. Titers greater than 1:32 are considered positive. These immunoglobulins are IgM. 2. Mycoplasma culture - Requires special mycoplasma or PPLO culture medium. - Is slow. Tiny colonies with a fried egg appearance grow in 2 to 3 weeks. - Giemsa stain on cultured organisms reveals small, pleomorphic bacteria. - Grown on Eatons agar. c) Pneumocystis carinii pneumonia Most common opportunistic infection in AIDS. d) Q fever Most common rickettsial pneumonia. Caused by coxiella burnetii. May infect persons working with infected cattle or sheep, who inhale dust particles containing the organism, or those who drink unpasteurized milk from infected animals. BSR. 118. Coxiella burnetii is usually transmitted by dust particles, but can be transmitted by ticks. Absence of rash. e) Ornithosis Caused by an organism of the genus chlamydia, transmitted by inhalation of dried excreta of infected birds. Streptococcus pneumoniae. BRS. 46. - Is part of the normal oropharyngeal flora in 40 70% of human beings. - Is a gram positive, lancet shaped diplococcus. - Is sensitive to the quinine derivative ethyl hydrocuprine ( optochin ) Clinical disease 1. Pneumonia seldom occurs as a primary infection. 2. Pathogenicity is associated with disturbances of normal defense barriers of the respiratory tract. 3. Infants, elderly, immunosuppressed persons, chronic alcoholics, malnourished persons, Pts with CP disease, are most vulnerable. 4. In 50 70% of untreated cases, recovery is associated with the appearance of an anticapsular antibody. 5. Two thirds of deaths occur in the first 5 days of clinical disease. 6. Otitis media and septicemia occur in infants older than 2 months of age. 7. S. pneumoniae is a leading cause of bacterial meningitis, mainly in infants and the aged. First aid. 204: 6 months 6 years. 60 years and +. 8. Schneider. 196. Empyema. Schneider. 196. Bacterial pneumonias Streptococcus pneumoniae Most common in elderly or debilitated patients. May lead to empyema.

3 Staphylococcus aureus Often a complication of influenza or viral pneumonias or a result of blood borne infection in IV drug users. Seen principally in debilitated hospitalized patients, the elderly, and those with chronic lung disease. Abscess formation frequent. May lead to empyema or to other infectious complications, including bacterial endocarditis, brain, and kidney abscesses. Streptococcus pyogenes. Group A Often a complication of influenza or measles. May lead to lung abscess. Klebsiella pneumoniae Most frequent in debilitated hospitalized Pts, and diabetic or alcoholic Pts. High mortality in elderly Pts. Considerable alveolar wall damage, leading to necrosis, sometimes with abscess formation. Kaplan. Microbiology. 558. K. pneumoniae. Pneumonia: most often in older males. Most commonly in Pts with either chronic lung disease or alcoholics, or diabetics. ( not the most common cause of pneumonia in alcoholics. S. pneumoniae is ) Haemophilus influenzae Usually seen in infants and children, but may occur in debilitated adults, most often those with chronic obstructive pulmonary disease. Meningitis in infants and children. Legionella pneumophila Infection from inhalation of aerosol from contaminated stored water, most often in air conditioning systems. Viral pneumonias - The most common pneumonias of childhood. - Caused most commonly by influenza and parainfluenza viruses, adenoviruses, and respiratory syncytial virus. May also arise after childhood exanthems. Measles produces giant cell pneumonia, marked by numerous giant cells and often complicated by tracheobronchitis. Simple. 210. Viral illnesses in children: 1. RSV. BRS. 160. Localized virus infections that are most often confined to the upper respiratory tract, ( bad colds in adults ) but can involve the lower respiratory tract. ( pneumonia in children ) Major cause of serious bronchiolitis and pneumonia in infants. May be treated with ribavirin if severe. 2. Parainfluenza. BRS. 160 Caused by parainfluenza type 1 virus. Cause a variety of upper and lower respiratory tract illnesses, usually in the fall and winter. Cause croup ( parainfluenza type 2 ) in infants. 3. Rhinovirus

4 Most frequent cause of common cold. More than 100 serotypes. Cause localized upper respiratory tract infections. 4. Adenovirus NMS, review, 387 428, q 17, test V. vignette. An afebrile 12-week-old infant presents with bilateral conjunctivitis, cough, tachypnea, inspiratory rales, y scattered expiratory wheezing. A CBC reveals eosinophilia. The chest X ray shows hyperinflation y patchy interstitial infiltrates bilaterally. Which is the most likely Dx ? A. Respiratory syncytial viral pneumonia B. Bronchiolitis C. Chlamydial pneumonia D. Cystic fibrosis E. The larval phase of ascariasis The answer is C. Chlamydial pneumonia in infants presents at 3 to 16 weeks of age. Typically, the infants appear quite well, are afebrile, but have been ill with tachypnea y a repetitive staccato cough. Rales, y sometimes wheezing, can be heard. Conjunctivitis is present in approximately 50% of Pts. Hyperinflation y patchy infiltrates are seen on chest x ray, y eosinophilia is apparent on CBC. RSV infection may present with temperature instability, respiratory distress, apnea, clear nasal discharge, y poor feeding. Bronchiolitis causes inflammation of the bronchioles with narrowing of the bronchial diameter. It manifests with low-grade fever, tachypnea, nasal flaring, rales, y expiratory wheezing. Chest X ray shows hyperinflation or atelectasis without infiltration. Cystic fibrosis commonly presents as respiratory insufficiency with cough, dyspnea, bronchiectasis, y pulmonary fibrosis. The child also shows signs of malabsorption y failure to thrive. The larval stage of ascariasis is asymptomatic. However, if a large parasite load penetrates the lungs, it may manifest with cough, hematemesis, eosinophilia, y pulmonary infiltrates. NMS, 344, q 38. Test IV. A lung abscess is due to aspiration of infected material from the oropharynx. This condition occurs in Pts who are unconscious or obtunded from alcohol. Poor dental hygiene is invariably present. The basilar segments of the right lower lobe are the classic location for aspiration in the upright or sitting position. The posterior segment of the upper lobe is involved if aspiration occurs when the Pt is lying on the right side. The superior segment of the lower lobe is involved if the Pt aspirates in the supine position. Q book, test 2, 99, q 47. The superior part of the right lower lobe is a common location for aspiration pneumonia.