DR K TAMILSELVAN

Pneumonia

Pneumonia

It is a condition which denotes inflammation of the lung parenchyma. Pneumonia is a serious lung infection that causes the air sacs in the lungs to fill with fluid or pus

An acute inflammation of the lungs, usually caused by inhaled pneumococci of the species diplococcus pneumonia. The alveoli and bronchioles of the lungs become plugged with a fibrosis exudates.

Anatomical Classification of Pneumonia

    Lobar Pneumonia

Due to virulent organisms such as pneumococci (Type-3), Friedlander’s (klebsiella), Staph aureus. Segmental: Due to organisms of low virulence.

Certain types of pneumococci.

Streptococci, H. influenzae, Vincent’s spirochetes, fusiform bacilli.

    Lobular Pneumonia (Bronchopneumonia if bilateral)

Occurs in elderly patients and babies, debilitated patients. Organisms are: H. influenzae, pneumococci, streptococci, tuberculosis.

Pneumonia 1

Etiological Classification

1. Infective

i. Bacterial: Pneumococcal, Klebsiella (Friedlander’s), Influenzas, Neisseria meningitis, Mycobacterium tuberculosis, Brucella, Salmonella, Staph aureus, Legionella pneumophila

ii. Viruses and small bacteria: Influenzae and para influenzae, measles and chickenpox, adenoviruses, respiratory syncytial ‘ viruses, chlamydia, Mycoplasma, pneumoniae.

iii. Rickettsia: Coxiella burnet (Q fever), Typhus,

iv. Yeasts and fungi: Actinomycosis, Candida, histoplasmosis, aspergillus, Cryptococcus neoformans.

v. Protozoa and parasites:  Pneumocystis carinii, amoebae, toxoplasma.

   2. Allergic

(i) Collagen vascular disease (PAN),

(ii) Steven Johnson syndrome.

   3.Chemical Agents

(i) Irritant gases: Ammonia, Sulphur dioxide, chlorine,

(ii) Irritant liquids: Lipoid pneumonia.

    4. Physical Agents

Irradiation.

Clinical classification of Pneumonia

Community Acquired Pneumonia (CAP)

Nosocomial (Hospital acquired)

In immunosuppressed patients

Causes of Pneumonia

Pneumonia can be caused by bacteria, viruses, or fungi

     Primary:  4 Is

                   Infection

Bacterial: Pneumococcus, staphylo, etc.

                   Influenza (Viral), respiratory syncytial

Rickettsia: Q fever

Mycoplasma: M. pneumoniae

Yeast and fungi: Candida, actino, histoplasma.

Protozoa and parasites : Toxoplasma, amoeba.

                    Immunological

Polyarteritis.

                     Irritation

Gas: Chlorine, ammonia, SO2

Liquids: Vomit, lipid pneumonia Irradiation.

Secondary : In association with

         Aspiration from nasopharynx

         Bronchiectasis

         Carcinoma of lung

         Depression of defenses (3S)

              Systemic disease

              Steroids

              Suppressive (immune) drugs

Symptoms of Pneumonia

Symptoms can range from mild to severe
Cough with or without mucus
Fever
Chills
Trouble breathing
Sharp pain in your chest or belly when you breathe or cough
Fatigue
Loss of appetite
Nausea, vomiting, or diarrhea
A bluish tint to your lips or fingernails

Special features of Pneumonia

Pneumococcal   : Lobar consolidation. Can result in most severe pneumonia. Good resolution.

Staphylococci       : Abscess formation.

Human influenza  : Principally in patients with underlying chest disorder (e.g. COPD).

Legionella spp.     : Important cause of CAP and nosocomial pneumonia.

Often severe illness.

Klebsiella             :  Blood tinged sputum. Patchy consolidation.
Tuberculous        : Usually apical No response to antibiotics.
Viral                    :  More symptoms than signs.

Failure to improve on therapy

       Antibiotic resistance

       Bronchial obstruction, bronchiectasis

       Complications: Abscess, empyema

       Diagnostic error example pulmonary embolism, bronchial Carcinoma, fibrosing alveolitis

       Endocarditis and other metastatic complications.

       Faulty (inadequate) dosage

       General factors

       Hypoxia, dehydration,

       Immunocompromised patient

Recurrent pneumonia

1. Respiratory disease

Bronchial obstruction

Intraluminal: Foreign body

Intramural: Growth, stenosis

Extramural: Compression by lymph nodes

Local bronchopulmonary disease

Localized bronchiectasis

Carnified lung due to chronic pneumonia

Generalized Bronchiectasis, cystic fibrosis, chronic bronchitis

2. Non-respiratory disease

Recurrent aspiration : Alcoholics, epileptics

Immune deficiency states

Predisposing Factors of Pneumonia

Altered consciousness due to alcoholism, cranial trauma, seizures, General anesthesia, drug overdose, cerebrovascular disease.

Old age: Depresses cough and glottic reflexes.

Pain from trauma.

Thoracic/upper abdomen surgery. Impede effective coughing and lead to aspiration.

Neuro muscular disease.

Weakness from malnutrition.

Kyphoscoliosis.

Severe obstructive lung disease.

Endotracheal tube/tracheostomy.

Impairment of muco-ciliary transport – Smoking, alcohol, old age, viral infection.

Acquired immunodeficiency syndrome (AIDS)

Impairment of alveolar macrophage function due to: smoking, starvation, anaemia, pulmonary edema, viral respiratory infection also predispose to pneumonia.

Types of pneumonia

Airspace pneumonia – example :  pneumococcal  pneumonia.

Nonsegmental consolidation with positive air bronchogram.

Interstitial pneumonia example : mycoplasma and viral pneumonia; inflammation only involves interstation, hence reticular appearance

Bronchopneumonia: – Inflammation of terminal and respiratory bronchioles. Hence segmental infiltration without air bronchogram.

Clinical Features of Pneumonia

Fever, Tachypnoea, Pleuritic pain.

Cough with expectoration (rusty in pneumococcal pneumonia).

Signs of consolidation i.e., dull percussion note, increased VF and VR, bronchial breathing.

Investigations of Pneumonia

Chest X-ray images showing examples of normal lung (left), bacterial pneumonia (Centre), and viral pneumonia (right).

Sputum Gram stain and culture.

Serology for mycoplasma, chlamydia, legionella, viruses.

Chest X-ray: may show consolidation and parapneumonic effusion.

CT scan if X-ray is equivocal.

Complication of Pneumonia

1. Pulmonary

Delayed resolution, bronchiectasis, lung abscess.

2.  Pleural

Pleural effusion, Empyema, Pyopneumothorax.

3. Cardiovascular

Endocarditis, pericarditis, pericardial effusion, peripheral circulatory failure.

4. Neurological

Meningism, pneumococcal meningitis, cerebral abscess.

5. Nonspecific

Herpes labialis, septicemia (and shock) cardiac arrhythmias, cardiac failure, deep vein thrombosis.

Risk factors of Pneumonia

People at higher risk of developing pneumonia include:
Infants and young children
Adults 65 or older
People who have other health problems

Staphylococcal Pneumonia

Patchy bronchopneumonia progressing over few hours to Pleural effusion and Pyopneumothorax.

Extensive, often bilateral involvement.

Multiple, thin walled cavities widely distributed.

Klebsiella Pneumonia

Occurs in debilitated immunosuppressed or diabetic children.

Patients may often have existing lung abscess or bronchiectasis.

Can involve upper lobes, also may be bilateral.

X-ray shows dense infiltrates with bulging fissures.

Currant jelly sputum in older children.

Toxic looks disproportionate to fever.

Empyema is quite common.

Mycoplasma pneumonia

Gradual onset of symptoms; intense headache

Cough is a prominent finding and sore throat is constant; scanty sputum.

Symptoms are more severe in comparison to scanty physical signs.

Normal total leukocyte and differential leukocyte count.

Patchy infiltration in the lungs but no pleural reaction.

Hemolysis use to cold hemagglutinin (IgM) may occur.

Treatment is with tetracycline or erythromycin 500 mg qid for 10 days.

Legionella pneumonia

Bilateral patchy infiltration

Toxic look, hemoptysis

Confusion, high fever

Treated with erythromycin 500 mg qid along with rifampicin 600 mg.

Pneumocystis pneumonia

Fever, dry cough, tachypnea

Ground glass opacity of lung (interstitial pneumonia)

Often bilateral, paucity of signs

   Treatment with TMP-SMX

Viral pneumonia

Minimum symptoms, ache and pain

Bilateral involvement, florid signs

Influenza virus mostly the causative agent.

Acyclovir 200 mg 5 times daily x 5 days for influenza, and vidarabine 10 mg/kg x 5 day for varicella pneumonia.

Chemotherapy of Pneumonia

It is usually given by antibacterial drugs for fourteen days. Radiological clearance takes about 4 weeks.

Antibiotic regimen: Ampicillin 500 mg 6 hourly, Amoxycillin 500 mg tid, Cephalosporin 500 mg 6 hourly, cefadroxil 50  mg bid, Ciprofloxacin 500 mg bid, IV cefoperazone, IV cefotaxime l gm bid, Inj. cloxacillin 500 mg 6 hourly for S aureus

Jaundice in pneumonia

Hemolysis in mycoplasma pneumonia

Lung cancer with hepatic metastasis

Septicemia

Legionella infection

Drug induced

Hepatitis in pneumococcal infection.

Causes of Delayed Resolution

Pleural infection.

Tuberculosis.

Malignancy (bronchial obstruction by tumor).

HIV disease, immunocompromised.

Pneumonia, diagnosis and treatment

The Eosinophilic Pneumonias

1.Etiology known

a. Allergic bronchopulmonary aspergillosis

b. Parasitic infestations :-microfilaria.

c. Drug reactions

2.Idiopathic

a. Loeffler’s syndrome

b. Chronic eosinophilic pneumonia

c. Allergic granulomatosis of Churg and Strauss

d. Hypereosinophilic syndrome.

Recurrent pneumonia at same site

Foreign body

Bronchial obstruction by neoplasm – benign/malignant

Bronchiectasis

Lung sequestration

Bad prognosis in pneumonia

Old age

Hypotension, tachypnoea

Very high leukocytosis/leucopenia

Hypoxemia

Extensive involvement.

 Hypersensitivity Pneumonitis

Clinical features, diagnosis

Sudden chill, fever, cough, dyspnea on exposure to offending agent.

Bilateral basal crepitations but no rhonchi.

X-ray: nodular opacities sparing apices of lungs.

Restrictive pattern in PFT and 4-diffusion capacity.

AB G shows hypoxemia.

Antibody against precipitating agent in serum.

Treatment of Pneumonia 

Treatment depends on the type and severity of the pneumonia
Bacterial pneumonia is usually treated with antibiotics.
Viral pneumonia a doctor may prescribe antiviral medications if influenza is the cause.
Fungal pneumonia is usually treated with antifungal medications

Subacute hypersensitivity pneumonitis occurs in 15% that gradually progress to lung fibrosis and respiratory insufficiency.

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A light on Practice of Medicine (The information provided is for informational and educational purposes only and should not be considered professional advice)

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DR K TAMILSELVAN