Pneumonia
Done By Ruba Loulou
Supervised By Dr Rafiq Abou-Shaaban
Table of Content
1. General 4
2. Pneumonia: 5
2.1 Epidemiology 5
2.2 Definitions 5
2.2.1 Common symptoms of pneumonia 5
2.3 Pathogenesis 7
2.4 Causes of pneumonia 8
2.5 Diagnosis: 9
2.6 Clinical presentation 11
2.6.1 Bacterial Pneumonia 11
2.6.1.1 Gram-positive bacteria: 12
2.6.1.2 Enteric Gram-Negative Bacteria: 13
2.6.1.3 Nonenteric Gram-Negative Bacteria: 13
2.6.1.4 Legionella Pneumophilia: 13
2.6.2 Anaerobic Pneumonia: 14
2.6.3 Tuberculosis: 15
2.6.4 Mycoplasma Pneumonia: 16
2.6.5 psittacosis 16
2.6.6 Viral Pneumonia: 17
2.6.7 Pneumonia is special clinical circumstances: 18
2.6.7.1 Pneumonia in the HIV-infected patient: 18
2.6.7.2 Pneumonia in the Neutropenic Host: 19
2.6.8 Nosocomial Pneumonia: 19
2.6.9 Fungal Pneumonia 20
2.6.9.1 Histoplasmosis 20
2.6.9.2 Coccidioidomycosis 21
2.6.9.3 Blastomycosis 21
2.6.10 Aspiration pneumonia 22
2.6.10.1 Chemical pneumonitis 22
2.6.10.2 Bacterial aspiration 23
2.6.10.3 Mechanical obstruction 23
2.6.11 Pneumocystis Pneumonia 23
2.7 Treating Pneumonia 25
2.7.1 Empirical treatments: 25
2.7.1.1 Symptomatic treatment: 26
2.7.1.2 Empiric treatment for hospitalized patients 27
2.7.2 Preventing pneumonia is possible: 27
2.7.3 Preventing pneumococcal infection: 28
2.7.4 Management of pneumonia: 28
2.7.5 Common pathogens and treatment 29
2.7.6 Drug of choice: 31
2.7.7 Medication: 32
2.8 Pediatric pneumonia: 41
2.8.1 Background 41
2.8.2 Pathophysiology 41
2.8.3 Clinical 42
2.8.4 Treatment 47
2.8.5 Follow-up 48
2.9 Pneumonia clinical cases 50
Pneumonia Case #1 50
2.9.2 Pneumonia Case #2 52
2.9.3 pneumonia Case #3 54
2.9.4 pneumonia Case #4 56
2.9.5 pneumonia Case #5 57
3 references: 60
1. General
Lower respiratory tract infection is divided into:
· Tracheobronchitis: Acute or acute exacerbation of chronic bronchitis.
· Pneumonia: which is described in details through out the present report.
2. Pneumonia:
2.1 Epidemiology
Prior to the antibiotic era, pneumonia was referred to as “the captain of the men of death” and bore a mortality rate in excess of 50%. While the availability of antimicrobial therapy has significantly improved the outcome in this disease, pneumonia remains the most common infectious cause of death in the United States. Pneumonia occurs throughout the year, with the relative prevalence of disease resulting from different etiologic agents varying with the seasons. It occurs in persons of all ages, although the clinical manifestations are most sever in the very young, the elderly, and the chronically ill.
2.2 Definitions
Pneumonia is an inflammation of the bronchial tubes and tiny air sacs (alveoli) in your lungs. Pneumonia affects your lungs in two ways. Lobar pneumonia affects a section (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) affects patches throughout both lungs.
Bacteria and viruses are the most common causes of pneumonia.
The infection typically follows a cold or flu but may begin as a primary infection in your lungs. Instead of recovering within a few days to a week, your symptoms quickly worsen.
2.2.1 Common symptoms of pneumonia
The common symptoms of pneumonia are fever, shaking chills, pleuritic (lung) pain, cough, and sputum production. In some cases, the resulting
Sputum may be minimal and off-white in color. Sometimes the patient produces abundant amounts of yellow, green, or brown sputum.
In viral pneumonia, you may have a dry, hacking cough with headache, fever, and muscle pain and fatigue. Occasionally, a bacterial infection follows viral pneumonia.
Telltale symptoms of bacterial pneumonia are high fever and a cough that produces thick, rusty-colored, greenish or yellowish sputum. You may also have shaking chills and stabbing chest pains when you breathe.
Pneumonia tends to occur in older adults. It can be serious, or even fatal, if you have heart or lung disease or condition that compromise your body's natural defenses. Poor nutrition, chronic bronchitis, emphysema, cancer, alcoholism and AIDS make you more vulnerable to serious pneumonia.
If you're in one of these risk groups, get a one-time vaccination for pneumococcal pneumonia. This immunization prevents pneumonia caused by pneumococcal bacteria, but it doesn't protect you from all pneumonias. If you've had your spleen removed or an organ transplanted, you may need to be immunized every three to six years.
Fig. 1: Human Lungs
Though they fill most of the chest, the lungs perform their crucial task at an almost microscopic level. Starting at the trachea, or windpipe, the airs
Passages within the lung divide and redivide into ever-smaller branches, or bronchioles, finally terminating in 300 million minute air sacs called alveoli. It's within these capillary-laced sacs that the air we inhale meets our circulatory system, passing fresh oxygen to the blood and removing waste CO2.
2.3 Pathogenesis
Microorganisms gain access to the lower respiratory tract by three routes: They may be inhaled as aerosolized particles or may enter the lung via the bloodstream from an extrapulmonary site of infection; however, aspiration of oropharyngeal contents, a common occurrence in both healthy and ill persons during sleep, is the major mechanism by which pulmonary pathogens gain access to the normally sterile lower airways and alveoli.
When pulmonary defense mechanisms are functioning optimally, aspirated microorganisms are cleared from the region before infection can become established; however aspiration of potential pathogens from the oropharynx can result in pneumonia if lung defenses are impaired. Lung infection with viruses suppresses the antibacterial activity of the lung by impairing alveolar
Macrophage function and mucociliary clearance, thus setting the stage for secondary bacterial pneumonia.
In addition to myriad factors that promote the development of pneumonia by impairing lung defenses, characteristic of bacterial colonization of the upper airway can influence the development of lower respiratory tract infections.
The vast majority of pneumonia cases acquired in the community by otherwise healthy adults are due to one of two organisms: staphylococcus pneumonia (pneumococcus) and mycoplasma pneumonia.
Gram negative aerobic bacilli and S. aureus are also the leading causative agents in the hospital-acquired pneumonia.
A wider range of microorganisms and, unlike adults causes pneumonia in infants and children, nonbacterial pathogens predominate. Most pneumonia in the pediatric age group are due to viruses, mycoplasma pneumonia is an important pathogen in older children, and other nonbacterial pathogens such as Chlamydia trachomatous, cause of pneumonia during the first 3 months of life. Beyond the neonatal period, the pneumococcus is the major bacterial pathogen in childhood pneumonia followed by group A streptococcus and S. aureus. HI type B.
2.4 Causes of pneumonia
· Pneumonia due to G+ve aerobic bacteros:-Diplococcus Pneumonia.
-Staphylococcus Aureus.
-Streptococcus pyogenes.
-Bacillus Anthracis.
-Listeria Monocytogenes.
· Pneumonia due to Anaerobic Organisms:
-Bacteroides species.
-Microaerophilic and spirochetes.
-Clostridium Perfringens.
· Pneumonia due to Fungus Infections:
-Histoplasmosis.
-Coccidioidomycosis.
-Blastomycosis.
-Cryptococcosis.
-Actinomycosis.
-Nocardiosis.
-Aspergillosis.
-Candidiasis.(moniliasis).
-Phycomycosis.(mucormycosis).
-Geotrichosis.
-Sporotrichosis.
· Pneumonia due to Parasitic Infection. / · Pneumonia due to G-ve aerobic bacteros:-
-Pseudomonas Aeruginosa.
-Pseudomonas Pseudomallei.
-Klebsiella and Aerobacter Species.
-Escherichia Coli.
-Bcillus Proteus.
-Salmonella Species.
-Hemophilus Infleunzae.
-Hemophilus Pertussis.
-Bacterium Anitratum.
-Brucella Species.
· Pneumonia due to Mycobacteris:
-Mycobacterium tuberculosis.
-Anonymous Mycobacteria.
· Pneumonia due to Virus Infection:
-Mycoplasma and Rickettsiae.
· Pneumonia due to Protozoan Infection:
-Amoebiasis.
-Toxoplasmosis.
-Pneumocytis Carnini infection.
· Pneumonia due to Metazoan Infection:
-Nemanthelminth(round-worm) Infection.
-Phtyhelminth(flat-worm)Iinfection.
-Arthropod Infection.
(Ref *)
2.5 Diagnosis:
-History:
Occupational and social history should be carefully collected in order to determine whether there has been exposure to water-cooling facilities (Legionella), wild animals (anthrax or Q fever) or exposure to person with TB. Travel history is also important.
-Differential diagnosis of unilateral signs:
Acute bronchitis, effusion, pulmonary embolism, carcinoma, pulmonary edema.(Ref.1)
-Differential diagnosis of bilateral signs:
Pulmonary edema, acute bronchitis, alveolitis, bronchiectasis, clinical and radiographic features of pneumonia may develop as a result of atelectasis or pooled secretions in old, immobile, or post operative patients. Super infection is common; prevent it with physiotherapy. (Ref.2)
-Physical examination;
The breathing pattern and the position assumed in bed can indicate the patient’s discomfort, reveal tachypnea, and demonstrate splitting of the chest to minimize pleuritic pain.
Percussion and auscultation of the chest may reveal signs of lung consolidation (dullness, inspiratory crackles, or bronchial breath sounds). Appearance of the skin and mucous membrane can help assess fluid status, indicate cyanosis, or reveal needle tracks in users of illicit drugs. The presence of clubbing may indicate underlying lung disease. The cardiac examination may reveal murmurs consistent with associated endocarditis or pleuropericardial rubs. Abdominal distention due to paralytic illness is common in bacterial pneumonia, particularly if it involves the lower lobes. An altered mental status may be due to high fever, hypoxemia, or complicating meningitis.
-Examination of Gram’s stained specimen of expectorated sputum:
Simple and inexpensive test that also helps in determining the most appropriate therapy. The lack of dominant bacteria on the sample suggests the possibility of less common causes of pneumonia (Legionella, TB, and fungi);
-Blood counts:
Leukocytosis with left shift;
-Blood culture;
-X-ray:
Its major purpose is to establish whether pneumonia is present or not. Diagnosing the ineffective agent is virtually impossible based on radiological features. Basic radiological features of pneumonia are one or more consolidated areas.
Radiological,
It can be difficult to distinguish between pneumonia, pulmonary edema and pulmonary infarction, being clinical features much more important in deciding the issue.
In patients presenting with consolidation of one or two lobes supplied by a common bronchus, mainly if loss of volume is also present, obstruction of a major bronchus should be considered (remember carcinoma is a common cause of obstruction).
2.6 Clinical presentation
2.6.1 Bacterial Pneumonia
Bacterial pneumonia is an infection that causes irritation, swelling, and congestion in the lungs. It is also called bacterial pneumonitis (new-mo-NI-tis). It occurs most often in the winter.
Bacterial pneumonia can attack anyone from infants through the very old. Alcoholics, the debilitated, post-operative patients, people with respiratory diseases or viral infections and people who have weakened immune systems are at greater risk.
Pneumonia bacteria are present in some healthy throats. When body defenses are weakened in some way, by illness, old age, malnutrition, general debility or impaired immunity, the bacteria can multiply and cause serious damage.
Usually, when a person's resistance is lowered, bacteria work their way into the lungs and inflame the air sacs.
The tissue of part of a lobe of the lung, an entire lobe, or even most of the lung's five lobes becomes completely filled with liquid (this is called "consolidation"). The infection quickly spreads through the bloodstream and the whole body is invaded.
The streptococcus pneumonia is the most common cause of bacterial pneumonia. It is one form of pneumonia for which a vaccine is available.
Symptoms:
The onset of bacterial pneumonia can vary from gradual to sudden. In the most severe cases, the patient may experience shaking chills, chattering teeth, severe chest pain, and a cough that produces rust-colored or greenish mucus.
A person's temperature may rise as high as 105 degrees F. the patient sweats profusely, and breathing and pulse rate increase rapidly. Lips and nailbeds may have a bluish color due to lack of oxygen in the blood. A patient's mental state may be confused or delirious.
Physical examination:
The patient is tachypneia and tachycardiac. Consolidation of the underlying lung is reflected in diminished breath sounds on auscultation over the affected area accompanied by inspiratory crackles as pus-filled alveoli open during lung expansion.
The chest radiograph and sputum examination and culture are the most useful diagnostic tests in gram-positive and gram-negative bacterial pneumonia.
X-ray patterns
Consolidation of an entire or the majority of a lobe (lobar consolidation), producing an opaque lobe, except for air bronchograms.
Blood count:
The complete blood count usually reflects a leukocytosis with predominance of polymorphonuclear cells; in some instances, particularly pneumococcus, the elevation of the WBC count may be pronounced. However, normal or mildly elevated WBC counts don’t exclude bacterial pneumonic disease. The patient may also be hypoxic as reflected by low oxygen saturation on arterial blood gas or pulse oximetry.
Although clinical appearance of gram-positive and gram-negative pneumonias are similar, there are epidemiological and clinical clues that render one or more likely than the others.
2.6.1.1 Gram-positive bacteria:
Pneumococcus is the most common community-acquired bacterial pneumonia, accounting for 25-60% of cases and frequently follows a viral illness. The sudden, rapid onset of dramatic rigor, pleuritic chest pain, rust colored sputum, tachypneia, fever, tachycardia. It is particularly prevalent and severe in-patients with splenic dysfunction, diabetes mellitus, chronic cardiopulmonary or renal disease, or HIV infection. Staphylococcus aureus pneumonia occurs in both the community and hospital setting. Community acquired disease is identified most frequently in young infants, patients with early cystic fibrosis. Staphylococcus aureus is an important cause of Nosocomial Pneumonia. Group B streptococcus is the most common cause of bacterial pneumonia among neonates, where it typically causes a clinical
And radiographic picture nearly indistinguishable from hyaline membrane disease. Group A streptococcus is an uncommon cause of community-acquired pneumonia.
2.6.1.2 Enteric Gram-Negative Bacteria:
Community-acquired enteric gram-negative pneumonia is identified most frequently among patients with chronic illness, especially alcoholism and diabetes mellitus. The enteric gram-negative bacteria are also leading causes of Nosocomial pneumonia, since the upper respiratory tract becomes rapidly colonized with gram negative organisms after hospitalization, particularly among critically ill patients and those receiving antibiotics or H2-receptor antagonists. The gram-negative bacilli are associated with high mortality, sometimes exceeding 50%; their potential to produce significant morbidity and mortality has recently been enhanced by the emergence of highly antibiotic-resistant organisms in some hospital settings.
2.6.1.3 Nonenteric Gram-Negative Bacteria:
The most prominent associated with pneumonia are pseudomonas, haemophilus, and moraxella. Like the enteric G-ve organism, pseudomonas aeruginosa is a frequent cause of hospital-acquired pneumonia. Haemophilus influenza type B historically has been a prominent pathogen in childhood pneumonia. Two different clinical presentation of H.influenza pneumonia is still seen in adults. They are the bronchopneumonia forms and the segmental or labor involvement predominates. Moraxella catarrhalis, an important cause of otitis media and sinusitis, has been found to be an increasingly important cause of lower respiratory tract infections in immunocompetent and hospitalizes patients.