T

h
e

i
n Pneumonia is an inflammatory condition of the lung.[1] It is often characterized as including
v inflammation of the parenchyma of the lung (that is, the alveoli) and abnormal alveolar filling with
a fluid (consolidation and exudation).[2]
d
The alveoli are microscopic air filled sacs in the lungs responsible for gas exchange. Pneumonia can
i
result from a variety of causes, including infection with bacteria, viruses, fungi, or parasites, and
n
chemical or physical injury to the lungs. Its cause may also be officially described as unknown when
g
infectious causes have been excluded.
o Typical symptoms associated with pneumonia include cough, chest pain, fever, and difficulty in
r breathing. Diagnostic tools include x-rays and examination of the sputum. Treatment depends on the
g cause of pneumonia; bacterial pneumonia is treated with antibiotics.
a Pneumonia is common occurring in all age groups, and is a leading cause of death among the young,
n the old, and the chronically ill.[3] Vaccines to prevent certain types of pneumonia are available. The
i prognosis depends on the type of pneumonia, the treatment, any complications, and the person's
s underlying health.
m

c
a removed. (August 2009)
u Pneumonias can be classified in several ways. The primary system of classification is the combined
s clinical classification, which combines factors such as age, risk factors for certain microorganisms, the
e presence of underlying lung disease or systemic disease, and whether the person has recently been
s hospitalized.
Other classifications include according to the anatomic changes that can be found in the lungs during
s
autopsies, based on the microbial cause, and a radiological classification.
y
m
p Clinical
t Traditionally, clinicians have classified pneumonia by clinical characteristics, dividing them into
o "acute" (less than three weeks duration) and "chronic" pneumonias. This is useful because chronic
m pneumonias tend to be either non-infectious, or mycobacterial, fungal, or mixed bacterial infections
s caused by airway obstruction. Acute pneumonias are further divided into the classic bacterial
, bronchopneumonias (such as Streptococcus pneumoniae), the atypical pneumonias (such as the
interstitial pneumonitis of Mycoplasma pneumoniae or Chlamydia pneumoniae), and the aspiration
i pneumonia syndromes.
n
Chronic pneumonias, on the other hand, mainly include those of Nocardia, Actinomyces and
p Blastomyces dermatitidis, as well as the granulomatous pneumonias (Mycobacterium tuberculosis and
a atypical mycobacteria, Histoplasma capsulatum and Coccidioides immitis).[4]
r The combined clinical classification, now the most commonly used classification scheme, attempts to
t identify a person's risk factors when he or she first comes to medical attention. The advantage of this
, classification scheme over previous systems is that it can help guide the selection of appropriate initial
treatments even before the microbiologic cause of the pneumonia is known. There are two broad
b categories of pneumonia in this scheme: community-acquired pneumonia and hospital-acquired
y pneumonia. A recently introduced type of healthcare-associated pneumonia (in patients living outside
the hospital who have recently been in close contact with the health care system) lies between these
p two categories.
r
o
v
o
k
Community-acquired
Main article: Community-acquired pneumonia
Community-acquired pneumonia (CAP) is infectious pneumonia in a person who has not recently been
hospitalized. CAP is the most common type of pneumonia. The most common causes of CAP vary
depending on a person's age, but they include Streptococcus pneumoniae, viruses, the atypical bacteria,
and Haemophilus influenzae. Overall, Streptococcus pneumoniae is the most common cause of
community-acquired pneumonia worldwide. Gram-negative bacteria cause CAP in certain at-risk
populations. CAP is the fourth most common cause of death in the United Kingdom and the sixth in the
United States. The term "walking pneumonia" has been used to describe a type of community-acquired
pneumonia of less severity (because the sufferer can continue to "walk" rather than require
hospitalization).[5] Walking pneumonia is usually caused by the atypical bacterium, Mycoplasma
pneumoniae.[6]

Hospital-acquired
Main article: Hospital-acquired pneumonia
Hospital-acquired pneumonia, also called nosocomial pneumonia, is pneumonia acquired during or
after hospitalization for another illness or procedure with onset at least 72 hrs after admission. The
causes, microbiology, treatment and prognosis are different from those of community-acquired
pneumonia. Up to 5% of patients admitted to a hospital for other causes subsequently develop
pneumonia. Hospitalized patients may have many risk factors for pneumonia, including mechanical
ventilation, prolonged malnutrition, underlying heart and lung diseases, decreased amounts of stomach
acid, and immune disturbances. Additionally, the microorganisms a person is exposed to in a hospital
are often different from those at home . Hospital-acquired microorganisms may include resistant
bacteria such as MRSA, Pseudomonas, Enterobacter, and Serratia. Because individuals with hospital-
acquired pneumonia usually have underlying illnesses and are exposed to more dangerous bacteria, it
tends to be more deadly than community-acquired pneumonia. Ventilator-associated pneumonia (VAP)
is a subset of hospital-acquired pneumonia. VAP is pneumonia which occurs after at least 48 hours of
intubation and mechanical ventilation.

Other types
• Severe acute respiratory syndrome (SARS)
SARS is a highly contagious and deadly type of pneumonia which first occurred in 2002 after
initial outbreaks in China. SARS is caused by the SARS coronavirus, a previously unknown
pathogen.

• Bronchiolitis obliterans organizing pneumonia (BOOP)

BOOP is caused by inflammation of the small airways of the lungs. It is also known as
cryptogenic organizing pneumonitis (COP).

• Eosinophilic pneumonia
Eosinophilic pneumonia is invasion of the lung by eosinophils, a particular kind of white blood
cell. Eosinophilic pneumonia often occurs in response to infection with a parasite or after
exposure to certain types of environmental factors.
 • Chemical pneumonia
Chemical pneumonia (usually called chemical pneumonitis) is caused by chemical toxicants such
as pesticides, which may enter the body by inhalation or by skin contact. When the toxic
substance is an oil, the pneumonia may be called lipoid pneumonia.

• Aspiration pneumonia
Aspiration pneumonia (or aspiration pneumonitis) is caused by aspirating foreign objects which
are usually oral or gastric contents, either while eating, or after reflux or vomiting which results
in bronchopneumonia. The resulting lung inflammation is not an infection but can contribute to
one, since the material aspirated may contain anaerobic bacteria or other unusual causes of
pneumonia. Aspiration is a leading cause of death among hospital and nursing home patients,
since they often cannot adequately protect their airways and may have otherwise impaired
defenses.

• Dust pneumonia
Dust pneumonia describes disorders caused by excessive exposure to dust storms, particularly
during the Dust Bowl in the United States. With dust pneumonia, dust settles all the way into the
alveoli of the lungs, stopping the cilia from moving and preventing the lungs from ever clearing
themselves.

• Necrotizing pneumonia, although overlapping with many other classifications, includes

pneumonias that cause substantial necrosis of lung cells, and sometimes even lung abscess.
Implicated bacteria are extremely commonly anaerobic bacteria, with or without additional
facultatively anaerobic ones like Staphylococcus aureus, Klebsiella pneumoniae and
Streptococcus pyogenes.[4] Type 3 pneumococcus is uncommonly implicated.[4]
• Opportunistic pneumonia includes those that frequently strike immunocompromised victims.
Main pathogens are cytomegalovirus, Pneumocystis jiroveci, Mycobacterium avium-
intracellulare, invasive aspergillosis, invasive candidiasis, as well as the "usual bacteria" that
strike immunocompetent people as well.[4]
• Double pneumonia is a historical term for acute lung injury (ALI) or acute respiratory distress
syndrome (ARDS).[7]. However, the term was, and is used still, especially by lay people, to
denote pneumonia affecting both lungs. Accordingly, the term 'double pneumonia' is more likely
to be used to describe bilateral pneumonia than it is ALI or ARDS.

Signs and symptoms

Main symptoms of infectious pneumonia
People with infectious pneumonia often have a cough producing greenish or yellow sputum, or phlegm
and a high fever that may be accompanied by shaking chills. Shortness of breath is also common, as is
pleuritic chest pain, a sharp or stabbing pain, either experienced during deep breaths or coughs or
worsened by them. People with pneumonia may cough up blood, experience headaches, or develop
sweaty and clammy skin. Other possible symptoms are loss of appetite, fatigue, blueness of the skin,
nausea, vomiting, mood swings, and joint pains or muscle aches. Less common forms of pneumonia
can cause other symptoms; for instance, pneumonia caused by Legionella may cause abdominal pain
and diarrhea, while pneumonia caused by tuberculosis or Pneumocystis may cause only weight loss and
night sweats. In elderly people, manifestations of pneumonia are seldom typical. They may develop a
new or worsening confusion (delirium) or may experience unsteadiness, leading to falls. Infants with
pneumonia may have many of the symptoms above, but in many cases they are simply sleepy or have a
decreased appetite.[9]

Pneumonia fills the lung's alveoli with fluid, keeping oxygen from reaching the bloodstream. The
alveolus on the left is normal, while the alveolus on the right is full of fluid from pneumonia.
Symptoms of pneumonia need immediate medical evaluation. Physical examination by a health care
provider may reveal fever or sometimes low body temperature, an increased respiratory rate, low blood
pressure, a high heart rate, or a low oxygen saturation, which is the amount of oxygen in the blood as
indicated by either pulse oximetry or blood gas analysis. People who are struggling to breathe, who are
confused, or who have cyanosis (blue-tinged skin) require immediate attention.
Findings from physical examination of the lungs may be normal, but often show decreased expansion
of the chest on the affected side, bronchial breathing on auscultation with a stethoscope (harsher sounds
from the larger airways transmitted through the inflamed and consolidated lung), and rales (or crackles)
heard over the affected area during inspiration. Percussion may be dulled over the affected lung, but
increased rather than decreased vocal resonance (which distinguishes it from a pleural effusion).[9]
While these signs are relevant, they are insufficient to diagnose or rule out a pneumonia; moreover, in
studies it has been shown that two doctors can arrive at different findings on the same patient.[10][11]

Cause
This section needs additional citations for verification.
Please help improve this article by adding reliable references. Unsourced material may be challenged and
removed. (August 2009)

Upper panel shows a normal lung under a microscope. The white spaces are alveoli that contain air.
Lower panel shows a lung with pneumonia under a microscope. The alveoli are filled with
inflammation and debris.
Pneumonia can be caused by microorganisms, irritants and unknown causes. When pneumonias are
grouped this way, infectious causes are the most common type.
The symptoms of infectious pneumonia are caused by the invasion of the lungs by microorganisms and
by the immune system's response to the infection. Although more than one hundred strains of
microorganism can cause pneumonia, only a few are responsible for most cases. The most common
causes of pneumonia are viruses and bacteria. Less common causes of infectious pneumonia are fungi
and parasites.

Viruses
Main article: Viral pneumonia
Viruses have been found to account for between 18—28% of pneumonia in a few limited studies.[12]
Viruses invade cells in order to reproduce. Typically, a virus reaches the lungs when airborne droplets
are inhaled through the mouth and nose. Once in the lungs, the virus invades the cells lining the
airways and alveoli. This invasion often leads to cell death, either when the virus directly kills the cells,
or through a type of cell controlled self-destruction called apoptosis. When the immune system
responds to the viral infection, even more lung damage occurs. White blood cells, mainly lymphocytes,
activate certain chemical cytokines which allow fluid to leak into the alveoli. This combination of cell
destruction and fluid-filled alveoli interrupts the normal transportation of oxygen into the bloodstream.
As well as damaging the lungs, many viruses affect other organs and thus disrupt many body functions.
Viruses can also make the body more susceptible to bacterial infections; for which reason bacterial
pneumonia may complicate viral pneumonia.[12]
Viral pneumonia is commonly caused by viruses such as influenza virus, respiratory syncytial virus
(RSV), adenovirus, and parainfluenza.[12] Herpes simplex virus is a rare cause of pneumonia except in
newborns. People with weakened immune systems are also at risk of pneumonia caused by
cytomegalovirus (CMV).

Bacteria
Main article: Bacterial pneumonia
The bacterium Streptococcus pneumoniae, a common cause of pneumonia, photographed through an
electron microscope.
Bacteria are the most common cause of community acquired pneumonia with Streptococcus
pneumoniae the most commonly isolated bacteria.[13] Another important Gram-positive cause of
pneumonia is Staphylococcus aureus, with Streptococcus agalactiae being an important cause of
pneumonia in newborn babies. Gram-negative bacteria cause pneumonia less frequently than gram-
positive bacteria. Some of the gram-negative bacteria that cause pneumonia include Haemophilus
influenzae, Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa and Moraxella
catarrhalis. These bacteria often live in the stomach or intestines and may enter the lungs if vomit is
inhaled. "Atypical" bacteria which cause pneumonia include Chlamydophila pneumoniae, Mycoplasma
pneumoniae, and Legionella pneumophila.
Bacteria typically enter the lung when airborne droplets are inhaled, but can also reach the lung through
the bloodstream when there is an infection in another part of the body. Many bacteria live in parts of
the upper respiratory tract, such as the nose, mouth and sinuses, and can easily be inhaled into the
alveoli. Once inside, bacteria may invade the spaces between cells and between alveoli through
connecting pores. This invasion triggers the immune system to send neutrophils, a type of defensive
white blood cell, to the lungs. The neutrophils engulf and kill the offending organisms, and also release
cytokines, causing a general activation of the immune system. This leads to the fever, chills, and fatigue
common in bacterial and fungal pneumonia. The neutrophils, bacteria, and fluid from surrounding
blood vessels fill the alveoli and interrupt normal oxygen transportation.

Fungi
Main article: Fungal pneumonia
Fungal pneumonia is uncommon, but it may occur in individuals with immune system problems due to
AIDS, immunosuppresive drugs, or other medical problems. The pathophysiology of pneumonia
caused by fungi is similar to that of bacterial pneumonia. Fungal pneumonia is most often caused by
Histoplasma capsulatum, blastomyces, Cryptococcus neoformans, Pneumocystis jiroveci, and
Coccidioides immitis. Histoplasmosis is most common in the Mississippi River basin, and
coccidioidomycosis in the southwestern United States.

Parasites
Main article: 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. There, as in other
cases of pneumonia, a combination of cellular destruction and immune response causes disruption of
oxygen transportation. One type of white blood cell, the eosinophil, responds vigorously to parasite
infection. Eosinophils in the lungs can lead to eosinophilic pneumonia, thus complicating the
underlying parasitic pneumonia. The most common parasites causing pneumonia are Toxoplasma
gondii, Strongyloides stercoralis, and Ascariasis.

Idiopathic
Main article: Idiopathic interstitial pneumonia
Idiopathic interstitial pneumonias (IIP) are a class of diffuse lung diseases. In some types of IIP, e.g.
some types of usual interstitial pneumonia, the cause, indeed, is unknown or idiopathic. In some types
of IIP the cause of the pneumonia is known, e.g. desquamative interstitial pneumonia is caused by
smoking, and the name is a misnomer.

Diagnosis
Pneumonia as seen on chest x-ray. A: Normal chest x-ray. B: Abnormal chest x-ray with shadowing
from pneumonia in the right lung (white area, left side of image).
CT of the chest demonstrating right sided pneumonia (left side of the image).
If pneumonia is suspected on the basis of a patient's symptoms and findings from physical examination,
further investigations are needed to confirm the diagnosis. Information from a chest X-ray and blood
tests are helpful, and sputum cultures in some cases. The chest X-ray is typically used for diagnosis in
hospitals and some clinics with X-ray facilities. However, in a community setting (general practice),
pneumonia is usually diagnosed based on symptoms and physical examination alone.[citation needed]
Diagnosing pneumonia can be difficult in some people, especially those who have other illnesses.
Occasionally a chest CT scan or other tests may be needed to distinguish pneumonia from other
illnesses.

Investigations
An important test for pneumonia in unclear situations is a chest x-ray. Chest x-rays can reveal areas of
opacity (seen as white) which represent consolidation. Pneumonia is not always seen on x-rays, either
because the disease is only in its initial stages, or because it involves a part of the lung not easily seen
by x-ray. In some cases, chest CT (computed tomography) can reveal pneumonia that is not seen on
chest x-ray. X-rays can be misleading, because other problems, like lung scarring and congestive heart
failure, can mimic pneumonia on x-ray.[14] Chest x-rays are also used to evaluate for complications of
pneumonia (see below.)
If antibiotics fail to improve the patient's health, or if the health care provider has concerns about the
diagnosis, a culture of the person's sputum may be requested. Sputum cultures generally take at least
two to three days, so they are mainly used to confirm that the infection is sensitive to an antibiotic that
has already been started. A blood sample may similarly be cultured to look for bacteria in the blood.
Any bacteria identified are then tested to see which antibiotics will be most effective.
A complete blood count may show a high white blood cell count, indicating the presence of an
infection or inflammation. In some people with immune system problems, the white blood cell count
may appear deceptively normal. Blood tests may be used to evaluate kidney function (important when
prescribing certain antibiotics) or to look for low blood sodium. Low blood sodium in pneumonia is
thought to be due to extra anti-diuretic hormone produced when the lungs are diseased (SIADH).
Specific blood serology tests for other bacteria (Mycoplasma, Legionella and Chlamydophila) and a
urine test for Legionella antigen are available. Respiratory secretions can also be tested for the presence
of viruses such as influenza, respiratory syncytial virus, and adenovirus. Liver function tests should be
carried out to test for damage caused by sepsis.[9]

Combining findings
One study created a prediction rule that found the five following signs best predicted infiltrates on the
chest radiograph of 1134 patients presenting to an emergency room:[15]
• Fever > 37.8 °C (100.0 °F)
• Pulse > 100 beats/min
• Rales/crackles
• Decreased breath sounds
• Absence of asthma
The probability of an infiltrate in two separate validations was based on the number of findings:
• 5 findings – 84% to 91% probability
• 4 findings – 58% to 85%
• 3 findings – 35% to 51%
• 2 findings – 14% to 24%
• 1 findings – 5% to 9%
• 0 findings – 2% to 3%
A subsequent study[16] comparing four prediction rules to physician judgment found that two rules, the
one above[15] and also[17] were more accurate than physician judgment because of the increased
specificity of the prediction rules.

Differential diagnosis
Several diseases and/or conditions can present with similar clinical features to pneumonia. Chronic
obstructive pulmonary disease (COPD) or asthma can present with a polyphonic wheeze, similar to that
of pneumonia. Pulmonary edema can be mistaken for pneumonia (and vice versa), especially in the
elderly, due to its similar symptoms and signs. Other diseases to be taken into consideration include
bronchiectasis, lung cancer and pulmonary emboli.[9]

Appearance on X ray

AP CXR showing left lower

AP CXR showing
lobe pneumonia associated with
Normal AP CXR Normal lateral CXR right lower lobe
a small left sided pleural
pneumonia
effusion
A lateral CXR showing AP CXR showing
Right upper lobe pneumonia as
right lower lobe pneumonia of the
marked by the circle.
pneumonia lingula of the left lung

Prevention
There are several ways to prevent infectious pneumonia. Appropriately treating underlying illnesses
(such as AIDS) can decrease a person's risk of pneumonia. Smoking cessation is important not only
because it helps to limit lung damage, but also because cigarette smoke interferes with many of the
body's natural defenses against pneumonia.
Research shows that there are several ways to prevent pneumonia in newborn infants. Testing pregnant
women for Group B Streptococcus and Chlamydia trachomatis, and then giving antibiotic treatment if
needed, reduces pneumonia in infants. Suctioning the mouth and throat of infants with meconium-
stained amniotic fluid decreases the rate of aspiration pneumonia.
Vaccination is important for preventing pneumonia in both children and adults. Vaccinations against
Haemophilus influenzae and Streptococcus pneumoniae in the first year of life have greatly reduced the
role these bacteria play in causing pneumonia in children. Vaccinating children against Streptococcus
pneumoniae has also led to a decreased incidence of these infections in adults because many adults
acquire infections from children. Hib vaccine is now widely used around the globe. The childhood
pneumococcal vaccine is still as of 2009 predominantly used in high-income countries, though this is
changing. In 2009, Rwanda became the first low-income country to introduce pneumococcal conjugate
vaccine into their national immunization program.[18]
A vaccine against Streptococcus pneumoniae is also available for adults. In the U.S., it is currently
recommended for all healthy individuals older than 65 and any adults with emphysema, congestive
heart failure, diabetes mellitus, cirrhosis of the liver, alcoholism, cerebrospinal fluid leaks, or those
who do not have a spleen. A repeat vaccination may also be required after five or ten years.[19]
Influenza vaccines should be given yearly to the same individuals who receive vaccination against
Streptococcus pneumoniae. In addition, health care workers, nursing home residents, and pregnant
women should receive the vaccine.[20] When an influenza outbreak is occurring, medications such as
amantadine, rimantadine, zanamivir, and oseltamivir can help prevent influenza.[21][22]

Treatment
In the United States more than 80% of cases of community acquired pneumonia are treated without
hospitalization.[13] Typically, oral antibiotics, rest, fluids, and home care are sufficient for complete
resolution. However, people who are having trouble breathing, with other medical problems, and the
elderly may need greater care. If the symptoms get worse, the pneumonia does not improve with home
treatment, or complications occur, then hospitalized may be recommended. Over the counter cough
medicine has not been found to be helpful in pneumonia.[23]

Bacterial
Antibiotics improve outcomes in those with bacterial pneumonia.[24] Initially antibiotic choice
depends on the characteristics of the person affected such as age, underlying health, and location the
infection was acquired.
In the UK empiric treatment is usually with amoxicillin, erythromycin, or azithromycin for community-
acquired pneumonia.[25] In North America, where the "atypical" forms of community-acquired
pneumonia are becoming more common, macrolides (such as azithromycin), and doxycycline have
displaced amoxicillin as first-line outpatient treatment for community-acquired pneumonia.[13][26]
The use of fluoroquinolones in uncomplicated cases is discouraged due to concerns of side effects and
resistance.[13] The duration of treatment has traditionally been seven to ten days, but there is
increasing evidence that short courses (three to five days) are equivalent.[27] Antibiotics recommended
for hospital-acquired pneumonia include third- and fourth-generation cephalosporins, carbapenems,
fluoroquinolones, aminoglycosides, and vancomycin.[28] These antibiotics are often given
intravenously and may be used in combination.

Viral
No specific treatments exist for most types of viral pneumonia including SARS coronavirus,
adenovirus, hantavirus, and parainfluenza virus with the exception of influenza A and influenza B.
Influenza A may be treated with rimantadine or amantadine while influenza A or B may be treated with
oseltamivir or zanamivir. These are beneficial only if they are started within 48 hours of the onset of
symptoms. Many strains of H5N1 influenza A, also known as avian influenza or "bird flu," have shown
resistance to rimantadine and amantadine.

Aspiration
There is no evidence to support the use of antibiotics in chemical pneumonitis without bacterial
superinfection. If infection is present in aspiration pneumonia, the choice of antibiotic will depend on
several factors, including the suspected causative organism and whether pneumonia was acquired in the
community or developed in a hospital setting. Common options include clindamycin, a combination of
a beta-lactam antibiotic and metronidazole, or an aminoglycoside.[29] Corticosteroids are commonly
used in aspiration pneumonia, but there is no evidence to support their use either.[29]

Complications
Sometimes pneumonia can lead to additional complications. Complications are more frequently
associated with bacterial pneumonia than with viral pneumonia. The most important complications
include:

Respiratory and circulatory failure

Because pneumonia affects the lungs, often people with pneumonia have difficulty breathing, and it
may not be possible for them to breathe well enough to stay alive without support. Non-invasive
breathing assistance may be helpful, such as with a bi-level positive airway pressure machine. In other
cases, placement of an endotracheal tube (breathing tube) may be necessary, and a ventilator may be
used to help the person breathe.
Pneumonia can also cause respiratory failure by triggering acute respiratory distress syndrome
(ARDS), which results from a combination of infection and inflammatory response. The lungs quickly
fill with fluid and become very stiff. This stiffness, combined with severe difficulties extracting oxygen
due to the alveolar fluid, create a need for mechanical ventilation.

Pleural effusion. Chest x-ray showing a pleural effusion. The A arrow indicates "fluid layering" in the
right chest. The B arrow indicates the width of the right lung. The volume of useful lung is reduced
because of the collection of fluid around the lung.
Sepsis and septic shock are potential complications of pneumonia. Sepsis occurs when microorganisms
enter the bloodstream and the immune system responds by secreting cytokines. Sepsis most often
occurs with bacterial pneumonia; Streptococcus pneumoniae is the most common cause. Individuals
with sepsis or septic shock need hospitalization in an intensive care unit. They often require
intravenous fluids and medications to help keep their blood pressure from dropping too low. Sepsis can
cause liver, kidney, and heart damage, among other problems, and it often causes death.

Pleural effusion, empyema, and abscess

Occasionally, microorganisms infecting the lung will cause fluid (a pleural effusion) to build up in the
space that surrounds the lung (the pleural cavity). If the microorganisms themselves are present in the
pleural cavity, the fluid collection is called an empyema. When pleural fluid is present in a person with
pneumonia, the fluid can often be collected with a needle (thoracentesis) and examined. Depending on
the results of this examination, complete drainage of the fluid may be necessary, often requiring a chest
tube. In severe cases of empyema, surgery may be needed. If the fluid is not drained, the infection may
persist, because antibiotics do not penetrate well into the pleural cavity.
Rarely, bacteria in the lung will form a pocket of infected fluid called an abscess. Lung abscesses can
usually be seen with a chest x-ray or chest CT scan. Abscesses typically occur in aspiration pneumonia
and often contain several types of bacteria. Antibiotics are usually adequate to treat a lung abscess, but
sometimes the abscess must be drained by a surgeon or radiologist.

Prognosis
With treatment, most types of bacterial pneumonia can be cleared within two to four weeks.[30] Viral
pneumonia may last longer, and mycoplasmal pneumonia may take four to six weeks to resolve
completely.[30] The eventual outcome of an episode of pneumonia depends on how ill the person is
when he or she is first diagnosed.[30]
In the United States, about one of every twenty people with pneumococcal pneumonia die. In cases
where the pneumonia progresses to blood poisoning (bacteremia), just over 20% of sufferers die.[31]
The death rate (or mortality) also depends on the underlying cause of the pneumonia. Pneumonia
caused by Mycoplasma, for instance, is associated with little mortality. However, about half of the
people who develop methicillin-resistant Staphylococcus aureus (MRSA) pneumonia while on a
ventilator will die.[32] In regions of the world without advanced health care systems, pneumonia is
even deadlier. Limited access to clinics and hospitals, limited access to x-rays, limited antibiotic
choices, and inability to treat underlying conditions inevitably leads to higher rates of death from
pneumonia. For these reasons, the majority of deaths in children under five due to pneumococcal
disease occur in developing coutries.[33]
Adenovirus can cause severe necrotizing pneumonia in which all or part of a lung has increased
translucency radiographically, which is called Swyer-James Syndrome[34]. Severe adenovirus
pneumonia also may result in bronchiolitis obliterans, a subacute inflammatory process in which the
small airways are replaced by scar tissue, resulting in a reduction in lung volume and lung compliance.
[34]
Clinical prediction rules
Clinical prediction rules have been developed to more objectively prognosticate outcomes in
pneumonia. These rules can be helpful in deciding whether or not to hospitalize the person.
• Pneumonia severity index (or PORT Score)[35] – online calculator
• CURB-65 score, which takes into account the severity of symptoms, any underlying diseases,
and age[36] – online calculator

Epidemiology
Pneumonia is a common illness in all parts of the world. It is a major cause of death among all age
groups and is the leading cause of death in children in low income countries.[24] In children, many of
these deaths occur in the newborn period. The World Health Organization estimates that one in three
newborn infant deaths are due to pneumonia.[37] Over two million children under five die each year
worldwide and it is estimated that up to 1 million of these (vaccine preventable) deaths are caused by
the bacteria Streptococcus pneumoniae, and over 90% of these deaths take place in developing
countries.[38] Mortality from pneumonia generally decreases with age until late adulthood with
increased mortality in the elderly.
In the United Kingdom, the annual incidence of pneumonia is approximately 6 cases for every 1000
people for the 18–39 age group. For those over 75 years of age, this rises to 75 cases for every 1000
people. Roughly 20–40% of individuals who contract pneumonia require hospital admission of which
between 5–10% are admitted to a critical care unit. The mortality rate in the UK is around 5–10%.[9] In
the United States community acquired pneumonia affects 5.6 million people a year making it the 6th
leading cause of death.[13]
More cases of pneumonia occur during the winter months than during other times of the year.
Pneumonia occurs more commonly in males than females, and more often in Blacks than Caucasians
due to differences in synthesizing Vitamin D from sunlight. Individuals with underlying illnesses such
as Alzheimer's disease, cystic fibrosis, emphysema, tobacco smoking, alcoholism, or immune system
problems are at increased risk for pneumonia.[39] These individuals are also more likely to have
repeated episodes of pneumonia. People who are hospitalized for any reason are also at high risk for
pneumonia.

History
Hippocrates, the ancient Greek physician known as the "father of medicine"
WPA poster, 1936/1937
The symptoms of pneumonia were described by Hippocrates (c. 460 BC – 370 BC):
Peripneumonia, and pleuritic affections, are to be thus observed: If the fever be acute, and if
there be pains on either side, or in both, and if expiration be if cough be present, and the
sputa expectorated be of a blond or livid color, or likewise thin, frothy, and florid, or having
any other character different from the common... When pneumonia is at its height, the case
is beyond remedy if he is not purged, and it is bad if he has dyspnoea, and urine that is thin
and acrid, and if sweats come out about the neck and head, for such sweats are bad, as
proceeding from the suffocation, rales, and the violence of the disease which is obtaining
the upper hand.[40]
However, Hippocrates referred to pneumonia as a disease "named by the ancients." He also reported
the results of surgical drainage of empyemas. Maimonides (1138–1204 AD) observed "The basic
symptoms which occur in pneumonia and which are never lacking are as follows: acute fever, sticking
[pleuritic] pain in the side, short rapid breaths, serrated pulse and cough."[41] This clinical description
is quite similar to those found in modern textbooks, and it reflected the extent of medical knowledge
through the Middle Ages into the 19th century.
Bacteria were first seen in the airways of individuals who died from pneumonia by Edwin Klebs in
1875.[42] Initial work identifying the two common bacterial causes Streptococcus pneumoniae and
Klebsiella pneumoniae was performed by Carl Friedländer[43] and Albert Fränkel[44] in 1882 and
1884, respectively. Friedländer's initial work introduced the Gram stain, a fundamental laboratory test
still used to identify and categorize bacteria. Christian Gram's paper describing the procedure in 1884
helped differentiate the two different bacteria and showed that pneumonia could be caused by more
than one microorganism.[45]
Sir William Osler, known as "the father of modern medicine," appreciated the morbidity and mortality
of pneumonia, describing it as the "captain of the men of death" in 1918, as it had overtaken
tuberculosis as one of the leading causes of death in his time. (The phrase was originally coined by
John Bunyan with regard to consumption, or tuberculosis.[46]) However, several key developments in
the 1900s improved the outcome for those with pneumonia. With the advent of penicillin and other
antibiotics, modern surgical techniques, and intensive care in the twentieth century, mortality from
pneumonia dropped precipitously in the developed world. Vaccination of infants against Haemophilus
influenzae type b began in 1988 and led to a dramatic decline in cases shortly thereafter.[47]
Vaccination against Streptococcus pneumoniae in adults began in 1977 and in children began in 2000,
resulting in a similar decline.[48]

Society and culture

Because of the very high burden of disease in developing countries and because of a relatively low
awareness of the disease in industrialized countries, the global health community has declared
November 2 to be World Pneumonia Day, a day for concerned citizens and policy makers to take action
against the disease.[1]

Pathophysiology of hypertension
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A diagram explaining factors affecting arterial pressure

The pathophysiology of hypertension is an area of active research, attempting to explain causes of
hypertension, which is a chronic disease characterized by elevation of blood pressure. Hypertension
can be classified as either essential or secondary. Essential hypertension indicates that no specific
medical cause can be found to explain a patient's condition. About 90-95% of hypertension is essential
hypertension.[1][2][3][4] Secondary hypertension indicates that the high blood pressure is a result of
another underlying condition, such as kidney disease or tumours (adrenal adenoma or
pheochromocytoma). Persistent hypertension is one of the risk factors for strokes, heart attacks, heart
failure and arterial aneurysm, and is a leading cause of chronic renal failure.[5]
Most mechanisms leading to secondary hypertension are well understood. The pathophysiology of
essential hypertension remains an area of active research, with many theories and different links to
many risk factors.
Cardiac output and peripheral resistance are the two determinants of arterial pressure.[6] Cardiac output
is determined by stroke volume and heart rate; stroke volume is related to myocardial contractility and
to the size of the vascular compartment. Peripheral resistance is determined by functional and anatomic
changes in small arteries and arterioles.

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