Professional Documents
Culture Documents
By
Dr Bashir Ahmed Dar
Chinkipora Sopore
Kashmir
Associate Professor
Medicine
Email
drbashir123@gmail.com
NOTE
The purpose of this presentation is to take
full detailed history in case of pneumonia to
arrive at correct diagnosis.
The presentation has been made very easy
for undergraduate as well as for post
graduate medical students.
Description of various organisms and x-rays
have made the task very simple.
Definition of Pneumonia
Pneumonia is defined as inflammation of
lung parenchyma
The term pneumonitis is synonymous but is
best avoided
During the process of inflammation of
alveoli there occurs inflammatory exudate
that fill up air spaces and result in
consolidation of lung.
Primary Pneumonia
Protease
Viruses that cause acute pneumonia
Adenovirus
Coronavirus
influenza A and B viruses
parainfluenza virus
respiratory syncytial virus
coxsackievirus A21
Rhinovirus
viruses that cause rubella and measles
often self limiting but can be complicated
Features of viral Pneumonias
The clinical features differ from that of
bacterial pneumonia.
Symptoms are more than the chest signs
and x-ray signs
Viral pneumonia often goes unrecognized
because the person may not appear very ill.
Disease is mild and self limiting and
resolves by 7-10 days time.
Features of viral Pneumonias
It usually starts with a dry (nonproductive) cough
Characteristic features or constitutional symptoms
like fever ,headache,sore throat,dry
cough,malaise,running nose,common cold,aches
and pains precedes several days before viral
pneumonia occurs than in bacterial pneumonia
which is more abrupt in onset.
Features of viral Pneumonias
Occurs primarily in the cold and winter and
tends to be more serious in people with
cardiovascular or lung disease.
* Leucocyte count is usually normal or low
* The x ray may show features of interstitial or.
atypical pneumonia
* Diagnosis confirmed by isolation of virus and
serological tests.
BACTERIA THAT CAUSE
PNEUMONIA
GRAM POSITIVE COCCI
1.Streptococcus Pneumoniae
the most common
2. Streptococcus Pyogenes
3. Streptococcus Agalactiae
BACTERIA THAT CAUSE
PNEUMONIA
Streptococcus Pneumoniae generally
resides in the nasopharynx and is found in
approximately 50% of healthy individuals.
Pneumococci infect type II alveolar cells.
As the pneumococci reach the alveolar
spaces they come in contact with epithelium
of alveolus and produce alveolar lesions..
BACTERIA THAT CAUSE
PNEUMONIA
The pneumonic lesion progresses as
pneumococci multiply in the alveolus and
invade further alveolar epithelium. and start
spreading from alveolus to alveolus
through the pores of Kohn, thereby
producing inflammation and consolidation
along larger areas of the lung.The damage
may result in rust coloured sputum.
BACTERIA THAT CAUSE
PNEUMONIA
Streptococcus agalactiae bacterium is
usually found in genital tract of females and
it can cause pneumonia in newborn babies.
It does not happen too often, but the baby
sometimes inhales fluid containing the
bacteria during its journey down the birth
canal and develops pneumonia soon after
birth.
BACTERIA THAT CAUSE
PNEUMONIA
4. Staphylococcus aureus is gram positive
organism,affecting children and old people.
as well as extreme ages.it can produce thin
walled air filled cavities ("pneumatoceles"),
BACTERIA THAT CAUSE
PNEUMONIA
Abcess formation is very common.in
staphylococcal infection.
The abcesses are thin walled,multiple and
commonly bilateral giving rise to patchy
bronchopneumonia.
BACTERIA THAT CAUSE
PNEUMONIA
Sincemultiple sites are involved bilaterally
simultaneously a scattered appearance of
heterogeneous opacities is the usual result.
Eventually more and more alveoli may be
affected and ultimately a homogeneous
opacification simulating lobar pneumonia
may be observed.
BACTERIA THAT CAUSE
PNEUMONIA
Due to these small abcesses the staphylococcus
aureus produces purulent (pus-laden) sputum that
often appears creamy and may be bloodstained.
BACTERIA THAT CAUSE
PNEUMONIA
Staphylococcal organism can also cause
Boils
Abscesses
Styes
Carbuncles
Cellulitis
Impetigo
BACTERIA THAT CAUSE
PNEUMONIA
Septic shock.
septic arthritis
osteomyelitis
Internal abscesses anywhere within the
body
meningitis
endocarditis
BACTERIA THAT CAUSE
PNEUMONIA
Some strains of staphylococcal bacteria
produce toxins (poisons) when they grow
and reproduce on food. If you eat food
contaminated with staphylococcal bacteria,
these toxins can cause staphylococcal food
poisoning. The toxins can also cause
scalded skin syndrome and, very
occasionally, toxic shock syndrome.
BACTERIA THAT CAUSE
PNEUMONIA
Bacteria gram positive rods
2. Bacillus anthracis is Anthrax or Wool-Sorters
disease Associated with wool sorting, with
animal handlers, and veterinarians, and produces
eschar on skin.
BACTERIA THAT CAUSE
PNEUMONIA
2. Nocardia & Actinomyces
Beaded filamentous rod shaped bacteria,
causing rib destruction, cutaneous sinuses,
cavitation, and spreads to pleura and chest
wall.
BACTERIA THAT CAUSE
PNEUMONIA
Actinomyces israeli ,an anaerobic organism
occuring in mouth as commensal
When local defences break then can cause
three forms of disease.
1.Cervicofacial with discharging sinuses
Abdominal actinomycosis with discharging
sinuses.
BACTERIA THAT CAUSE
PNEUMONIA
And pulmonary actinomycosis with
widespread suppurative pneumonia with
discharging chest wall sinuses.
The pus from sinuses contain sulphur
granules.
BACTERIA THAT CAUSE
PNEUMONIA
Bacteria Gram Negative cocci
2. Neisseria meningitidis (meningococci)
cause epidemics in military
recruits,schools,young adults,overcrowded
places.
5. Moraxella catarrhalis
BACTERIA THAT CAUSE
PNEUMONIA
Bacteria gram negative rods
2. Klebsiella pneumoniae (friedlanders
bacillus) produces blood stained Current
Jelly sputum.
3. Upper lobes being most affected with
massive lobar consolidation.
BACTERIA THAT CAUSE
PNEUMONIA
2.Strongyloides stercoralis
3.Ascariasis.
4.Cryptosporidia
5.Hookworms
Protozoal or Parasitic
Pneumonia
A variety of parasites can affect the lungs.
These parasites typically enter the body
through the skin or by being swallowed.
Once inside, they travel to the lungs,
usually through the blood. One type of
white blood cell, the eosinophil, responds
vigorously to parasite infection. Eosinophils
in the lungs can lead to eosinophilic
pneumonia.
Rickettsial Pneumonia
Typhus fevers (epidemic and endemic)
Rocky mountain spotted fever,scrub typhus,
rickettsialpox
Louse-borne
flea-borne through rats and mouse fleas
Rickettsial Pneumonia
Q fever
Acute, self-limited, systemic disease that
spreads rapidly in cows, sheep, and goats,
slaughter houses, research facilities, where
handling of animals or their birth products
is a source of exposure.
Hepatosplenomegaly is a common finding.
Rickettsial Pneumonia
Rickettsia pneumonia usually gives rise to atypical
pneumonia.Vasculitis of small vessels is basic
underlying pathology in rickettsial infections.
Rickettsial infections usually present with fever,
skin rash and eschar.
Common fleas such as cat and dogs fleas and rat
fleas are reported worldwide, as are their
transmitted rickettsial diseases.
Features of Rickettsial
infection
Scrub typhus occurs over a wide area of
Asia and Pacific region. Chiggers (larval-
stage of trombiculid mites) are vectors for
scrub typhus. Chiggers prefer warm,
moist,and shady places.
Features of Rickettsial
infection
In Hong Kong, majority of the reported cases
contracted the diseases locally,in which half of the
spotted fever and scrub typhus cases were related
to outdoor activities,such as hiking or camping in
rural areas.Poor environmental hygiene conditions
such as inadequately managed rubbish collection
points and wet markets was a risk factor for
contracting murine typhus.
Features of Rickettsial
infection
At the site of entry commonly skin the organisms
localize in endothelial cells and enter into the cells.
It proliferates intracelluarly. A papule may be
formed that later ulcerates in the central. It is called
eschar. The organisms released from the infected
cells can infect endothelial cells in the blood vessels
throughout the body via lymphatic vessels. The
rickettsemia causes generalized vasculitis affecting
every organs in the body.
ATYPICAL BACTERIA
Are organisms that do not fit in virus,bacteria
or fungus.
Thus these bacteria are called atypical and
produce atypical pneumonia.
These organisms also do not stain with gram
stain.
ATYPICAL BACTERIA
Following organisms constitute atypical bacteria.
Legionella
Mycoplasma
Chlamydia trachomatis an afebrile pneumonia, usually seen in 2 wk to
6 months of age
Chlamydia psittaci
Chlamydia pneumoniae
Chlamydia trachomatis is a sexually transmitted disease that may also
cause pneumonia and bronchitis and conjuctivitis in early infancy by
passing through contaminated genital tract, but it may occur in adults
too.
ATYPICAL BACTERIA
Other organisms that cause atypical pneumonia
are
Coxiella burnetii (Q-fever) ingestion of
comtaminated milk, or inhalation of contaminated
aerosols from barnyard animals
Mycobacterium tuberculosis and other
Mycobacterium
And some species of fungi ,viruses and protozoa
Classification of Pneumonias
BY SITE
LOBAR PNEUMONIA
BRONCHOPNEUMONIA
INTERSTITIAL OR ATYPICAL
PNEUMONIA
Lobar Pneumonia
Consolidation or pneumonia of whole lobe
of lung is called lobar pneumonia.
Broncho-Pneumonia
Liver
Diaphragm
Abomasum
This is the same lung cut open showing deposits of fibrin between
sections of lung with bronchopneumonia.
These are lungs from a cow with severe Pasteurella
bronchopneumonia.
This is severe bacterial bronchopneumonia and pleuritis in a pig caused by
Actinobacillus pleuropneumonia.
This is a closer look at the same lung.
Again, note the black line. The
darker red tissue has severe Pasteurella
bronchopneumonia. The white spots
are abscesses.
Here is the same lung cut open to show
The severe bronchopneumonia and numerous
abscesses (white spots)
Bacterial pneumonia in a pig. Areas with inflammation are dark
pink. Normal lung is light pink.
This is the same lung cut open showing areas of inflammation (dark pink)
and Normal tissue (light pink)
These are the lungs from a cow
with chronic
bronchopneumonia. The
areas with
inflammation
are to the right of the
black lines. Within the
areas of inflammation
are numerous
abscesses
(white spots).
This is the same lung cut open to show
areas of inflammation and abscess
formation (white spots). The
normal lung is the white
colored region to the
far right.
This is severe fibrinous pleuritis
and pneumonia caused by aspirating
foreign material into the lung.
This is the same lung cut open to show regions
of the lung with severe inflammation
and necrosis.
These are the lungs of a horse with chronic, fibrous pleuritis. Note
how the fibrous material appears organized and is stuck to the
surface of the lung.
Atypical or Interstitial or viral
Pneumonia
Atypical pneumonia as already said is caused by
atypical bacteria that do not gram stain or do not
fit in any category like in virus or bacteria. Most
of viruses produce this type of pneumonia
also.The inflammation is confined to interalveolar
septa or interstitial spaces between alveoli and
radiologically gives appearance of reticulonodular
pattern.linear thread like opacities here and there
in lungs.
Atypical or Interstitial or viral
Pneumonia
In the next slide you will see white spaces
that are alveolar spaces and are empty and
clear.but surrounded by swollen interstitial
tissue infiltrated with inflammatory
cells,typical of interstitial pneumonia.
CAUSES OF ATYPICAL
PNEUMONIA
Following organisms constitute atypical bacteria and cause atypical
pneumonia
Mycoplasma
Legionella
Chlamydia trachomatis
Chlamydia psittaci
Chlamydia pneumoniae
Q-fever
Tularemia
Anthrax
Viruses
Fungi
CAUSES OF ATYPICAL
PNEUMONIA
Others like
Histoplasmosis
Coccidiodomycosis
Mycoplasma
Mycoplasmosis is a collective term for
infectious diseases caused by the micro-
organisms called mycoplasmas. There are a
number of mycoplasmas that can infect
poultry, number of bird species including
chickens, turkeys, gamebirds and pigeons.
Mycoplasma pneumonia occurs in
Adolescents and young adults.
Mycoplasma
EXTRA PULMONARY MANIFESTATIONS
gastrointestinal
musculoskeletal
dermatologic
cardiac
neurologic symptoms
The most common pathogen of atypical pneumonia is
Mycoplasma pneumoniae. It ranks second only to S.
pneumoniae
LEGIONELLA
Occurred first in military personnel called
legionnairs while using tank water etc.
LEGIONELLA
So in legionella pneumonia there will be
history of contact with Cooling towers,
condensers,Water tanks,AC
coolers,washings etc.
There is also history of GIT disturbances.
Chlamydial infection
Due to
Chlamydia trachomatis
Chlamydia psittaci
Chlamydia pneumoniae
Chlamydia trachomatis is a sexually transmitted
disease that may also cause pneumonia and
bronchitis and conjuctivitis in early infancy by
passing through contaminated genital tract, but it
may occur in adults too.
Chlamydial infection
Chlamydia psittaci infection will have
history of contact with pigions,pet shops
and zoo.
Q- FEVER
Q fever is common rickettsial disease that
gives rise to pneumonia.In Q fever there
will be history of contact with cattle, sheep,
goats, contaminated milk, birthing various
livestock
TULAREMIA--ANTHRAX
Tularemia will have history of contact
with Rabbits, ticks
Tularemia also causes lymph gland
involvement.
Anthrax has contact with Goat hair/skin,
wool, bone meal fertilizer and causes black
spot on skin due to ulcer surrounded by
edema called eschar.
TULARAEMIA SKIN &
GLANDULAR
ANTHRAX ESCHAR
HISTOPLASMOSIS
People with atypical pneumonia due
histoplasmosis will have history of contact
with Chickens, bats, river valleys .It also
produces skin leisions.
Coccidioidomycos
foundin people residing in
California,Southwest USA.
HISTOPLASMOSIS
COXIELLA BURNETII
Skintesting for
histoplasmosis,coccidioidomycosis.
.
Classification by mode of acquiring
pneumonia
2.Nosocomial pneumonia
Community acquired
pneumonia
This indicates pneumonia occuring in a
person
in a community outside hospital .
◆ new cough
◆ new infiltrate or progressive
infiltrate on
chest radiograph.
In wards,icu,and in patients on mechanical
vetillation
ASPIRATION PNEUMONIA
OCCUR IN FOLLOWING SETTINGS
Altered Level of Consciousness
Alcoholism
Seizures
Drugs
Anesthesia
Central nervous system disorders
Trauma
Dysphagia
Esophageal disorders
Neurological disorders
Mechanical Disruption of Functional Barriers
Nasogastric tubes
RISK FACTORS
- Asplenia
– HIV/AIDS
– Elderly
Defective Clearing mechanism
– Cough/gag Reflex – Coma, paralysis, sick.
– Mucosal Injury – smoking, toxin aspiration
– Low Alveolar defense - Immunodeficiency
– Pulmonary edema – Cardiac failure, embol.
RISK FACTORS
Hypogammaglubolinemia
Sever Neutrogena
Corticosteroid therapy
Environmental risk factors.
– Obstructions – foreign body, tumors
- Prolonged mechanical ventilation
- extremes of age
RISK FACTORS THAT FORM BASIS OF
SECONDARY PNEUMONIAS
* Partial bronchial obstruction by tumour
causes stasis of secretions and secondary
infection distal to site of obstruction
Vomiting and aspiration during
anaesthesia,sleep,coma,alcholism
Inhalation of septic matter during
tonsillectomy,dental procedure,or general
anaesthesia
Route of Entry
Aspiration
Inhalation
Inoculation
Colonization (in patients with COPD)
Hematogenous spread (patients with
sepsis)
Direct spread
Route of Entry
Typical pneumonia is usually acquired by
droplet spread of the pathogen through
sneezing,coughing etc. The organism may
also manifest itself as a suprainfection in
patients previously infected by an upper or
lower respiratory viral infection.
Route of Entry
So the most common way you catch
pneumonia bacterial or viral is to breathe
infected air droplets from someone who has
pneumonia or common cold,running
nose,sneezing etc. Another cause is an
improperly cleaned air conditioner. Yet
another source of infection in your lungs is
spread by an infection from somewhere else
in your body, such as your kidney.
Route of Entry
Spread is common in industrialized cities,
lower socioeconomic groups or in cases of
crowded living quarters. The incidence of
bacterial pneumonia increases in winter and
spring in temperate zones.
Route of Entry
Congestion
Red Hepatisation
Summary of Stages of
Lobar Pneumonia:
Four stages:
Congestion – vasodilatation
– Red Hepatization - Exudation+RBC
– Gray Hepatization - neutro & Macrophages.
– Resolution – few macrophages, normal.
Complications of Pneumonia
A painful pleuritis
pleural effusion
Pyothorax
Empyema
Fibrosis due to laying down of fibroblasts in
non resolving pneumonia called
carnification of lung.
Necrotizing lung & lung abcess
Complications of Pneumonia
1. Pulmonary fibrosis.
2. Bronchiectasis
3. Lung abscess
4. Empyema
5. Bacteraemia with abscess in other organs
6.ARDS
7.Bacteremia
8.Collapse of lung
9.Hemoptysis
Complications of Pneumonia
Parapneumonic effusions
Septic arthritis
Endocarditis
Pericarditis
Respiratory failure
Mental symptoms
Investigations of Pneumonia
Total and differential count
PBF
Blood ,urine,sputum culture/sensitivity
Gram staining/stain for AFB
Fiberoptic bronchoscopy with bronchial
washing/ brushing /biopsy
Investigations of Pneumonia
X-ray chest
CT chest
Serological tests
ABG
Other all routine basic tests
TREATMENT OF
PNEUMONIA
Uncomplicated pneumonia
Erythromycin 250-500mg 6 hrly or with
combination with cefuroxime or Amoxycillin or
Ampicillin 500 mg 6-8 hrly x 7-10 days.
Azithromycin 500mg x3-5 days if pt intolerant to
erythromycin
Consider levofloxacin 500 mg once a day if pt
elderly
TREATMENT OF
PNEUMONIA
Moderately sick
Ceftriaxone 1-2 gram once or BD iv and
erythromycin or azithromycin 500 mg daily
Ampicillin –clauvulanic acid plus
erythromycin or azithromycin
TREATMENT OF
PNEUMONIA
Severely sick
Ceftriaxone 1-2 gram once or twice a day
plus either azithromycin 500 mg a day or
levofloxacin 500 once a day x 7-10days
TREATMENT OF
PNEUMONIA
In multiresistant cases and in
staphylococcal or gram negative infection
can give multiresistant strains give
Vancomycin 500mg to 1 gram I/V twice
daily.
TREATMENT OF
PNEUMONIA
For klebsiella,legionella,actinomycosis
Gentamycin, ceftriaxone for two weeks
even Azithromycin.
Rifampicin be given in legionella also
TREATMENT OF
PNEUMONIA
For actinomycosis also Benzyle penicillin
10-20 million units iv 6 hrly day.
In severe cases piperacillin plus tazobactam
or Meropenem.
Clindamycin 800mg 8 hrly followed by
300 mg orally 8hrly in aspiration
pneumonia.
Treatment for rickettsial
infection
Rickettsialinfections respond promptly to
early treatment with the antibiotics like
Doxycycline
Chloramphenicol
Tetracycline
Treatment for fungal infections
Firstgive test dose as follows: 1 mg in 20
ml of D5W over 30 minutes to 1 hour;
monitor vital signs every 30 minutes for
next 2 hours.if no untoward reaction occurs
then do as follows.
Treatment for fungal infections
Amphotericin B comes in a vial that
contains 50mg of powder. Each vial needs
to be mixed with 10ml of Water for
Injection. The dose is then drawn up and
again mixed with 500mL of dextrose and
shaken.
Treatment for fungal infections
then give 0.25 to 0.5 mg/kg daily by slow
I.V. infusion (0.1 mg/ml over 2 to 6 hours)
or 1mg/10mL. with or without flucytosine
for two weeks to several months.even on
alternate days.
X-RAYS
ON VARIOUS TYPES OF
PNEUMONIA
Anatomy
Normal
Chest
Radiograph
Anatomy
Lobes
Right upper lobe:
Lobes (continued)
Right middle lobe:
Lobes (continued)
Right lower lobe:
Lobes (continued)
Left lower lobe:
Lobes (continued)
Left upper lobe with Lingula:
Lobes (continued)
Lingula:
Lobes (continued)
Left upper lobe - upper division:
RUL pneumonia
RML pneumonia
RLL pneumonia
LUL pneumonia
LLL pneumonia
What’s happened here?
Right upper
lobe collapse
Bulging Fissure Sign
disease showing
Bilateral patchy
opacification
with consolidation
Patchy broncho
pneumonia more on
left side.
Thank you.
Always take proper detailed history
of a patient.