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Pneumonia is an infectious disease characterized by inflammatory processes affecting the lung
parenchyma. It is responsible for 10% of adult admissions to North American medical services.
It is a potentiallly lethal disease that is treatable therefore it is important that every medical
student, resident, and physician be able to recognize, diagnose, and treat pneumonia rapidly and
adequately. Careful history and physical exam and especially important in leading to rapid
diagnosis. The causes of pneumonia are numerous therefore it is almost always essential to
identify the specific microorganism responsible in order to provide effective treatment.

Pneumonia may be classified in different ways: etiological agent (bacterial vs. viral vs.
mycoplasmal), anatomically (lobular bronchopneumonia, lobar, interstitial), clinical presentation
(classical vs. atypical). These classifications will be discussed later.

A. Pathogenesis
Every day, our lungs are exposed to over 10 000 L of air containing many potentially disease
causing agents. However, the normal lung does not contain any bacteria because of different
effective defense mechanisms that clear or destroy bacteria:

a. u    u: eg sneezing, blowing nose


b.  
 u   u: mucociliary action clears particles deposited on the mucus film.
Particles are moved from the lung to the oropharynx where they are either swallowed or
expectorated.
c.      u Alveolar macrophages phagocytose particles deposited in the alveoli.
Digested particles are contained in the macrophages which are moved to ciliated bronchioles and
then to the oropharynx.

Sometimes these defenses may be impaired, as occurs in chronic diseases, immunodeficiency,


immunosuppressive treatments, leukopenia, very virulent organisms.

Mechanisms of Lung Defense Impairment:

a. loss or decreased cough reflex leading to aspiration of gastric contents


b. impaired or destroyed mucociliary transport: eg cigarette smoking, inhalation of corrosive
gases
c. impaired phagocytic or bactericidal action of alveolar macrophages: eg cigarette smoke,
anoxia
d. pulmonary congestion/edema
e. increased production of pulmonary secretions: eg cystic fibrosis

When lung defenses are impaired, microorganisms may enter the respiratory tract via different
routes of spread:
a. hematogenous
b. from a contiguous focus
c. inhalation of aerosolized particles
d. aspiration of oropharyngeal secretions (most common)

B. Etiology
Classical community acquired pneumonia is most frequently caused by S. pneumoniae.
However, H. influenzae and M. tuberculosis become more frequent in older age groups. Gram
negative bacilli are also sometime responsible for causing pneumonia.

Atypical pneumonia is usually caused by M. pneumoniae, C. pneumoniae, and numerous viruses


(incl. adenovirus, parainfluenza virus, respiratory syncytial virus).

[Table modified from Cecil Essentials of Medicine, 4th ed.]

  u  uu u   u    u


   u   u
children and younger S. pneumoniae, M. pneumoniae, C. pneumonia, RSV
adults
elderly adults S. pneumoniae, influenza virus, M. tubuerculosis
chronically ill S. pneumoniae, influeza virus, oropharyngeal flora, M.
tuberculosis, Gram neg. bacilli
hospitalized oropharyngeal flora, S. aureus, Gram neg. bacilli, L.
pneumophila

C. Clinical Features
Clinical features of pneumonia vary greatly according to etiologic agent responsible and
population affected.

Most patients have a cough, fever, increased heart rate, and increased respiration rate. Patients
may also experience pleuritic pain, hemoptysis, systemic upset, and confusion.

Classical community acquired pneumonia presents with abrupt onset of single shaking chill,
cough, rust-coloured sputum, and moderate fever.

Atypical community acquired pneumonia has a less severe course with more prominent systemic
symptoms and less prominent respiratory symptoms. Patients may only present with tachypnea,
dry cough, and mild fever.

D. Radiographic Patterns
Chest radiographs can rule out the possibility of pneumonia or help differentiate between
bacterial and viral pneumonias. Or, they may point to a diagnosis of presumptive pneumonia
when the patient presents with only mild symptoms, eg in the elderly.

The pattern of the chest radiograph gives clues to the etiology of pneumonia. Lobar
consolidation suggests a bacterial pathogen whereas patchy, bilateral infiltrates with little or no
pleural effusion are usually seen in atypical pneumonias.

Large pleural effusions may point to streptococcal pneumonia or tuberculosis. Cavitations


indicates a necrotizing pneumonia, such as that caused by tuberculosis or S. aureus.

It is important to remember that early in the course of acute bacterial pneumonias, the chest
radiographs may yield little information as they often appear normal initially. Therefore it is
important to conduct other laboratory tests, as will be discussed later.

E. Diagnosis
The use of chest radiographs in diagnosis has already been described in the previous section.
Other tests that may narrow the differential diagnosis include WBC count which tend to be
markedly elevated in bacterial pneumonia.

If the patient has a productive cough, it is important to obtain a sputum sample. Empiric therapy
for community acquired pneumonia without obtaining a sputum sample is effective in most
cases. However, this encourages the widespread and indiscriminate use of broad-spectrum
antibiotics and contributes to increases in antibiotic resistance.

A good sputum sample contains no squamous epithelial cells and at least 10-15 PMN per high
power field. If the patient is too ill to provide a sputum sample, nasotracheal or transtracheal
aspiration may be used.

The specimen should be gram stained and examined under oil immersion. This is often enough to
identify the pathogen. The presence of large numbers of PMNs and WBCs also suggests a
bacterial agent that is responsible. If only inflammatory cells and few WBC are seen, a
nonbacterial etiology should be considered.

If no clear diagnosis of bacterial pneumonia is fiound, the sample should be stained with an acid-
fast stain to indentify mycobacteria. Other less common stains are available to identify
legionnella and fungal pathogens. The sample should be cultured and tested for antibiotic
resistance.

F. Management and Treatment


Upon identification of the responsible pathogen, the patient should be immediately given
antibiotic treatment. Penicillin is the drug of choice for pneumococcal pneumonia. Erythromycin
can be used if the patient is allergic to penicillin or if the cultures were either inconclusive or
demonstrated an atypical pneumonia. Most patients can be treated on an outpatient basis.
Patients who are at risk for developing respiratory failure or who are tachypneic or hypoxemic
should be hospitalized. Their treatment may include some or all of the following:
- supplemental oxygen
- monitoring in critical care unit
- frequent clapping and drainage if patient cannot cough properly
- suctioning of oral secretions
- isolation in room with negative pressure if patient has suspected pulmonary TB
- analgesia for pleuritic pain
- fluid replacement

G. Prevention
Pneumococcal pneumonia is preventable in 60-80% of patients if they are given a pneumococcal
vaccine (23 valent Pneumovax II 0.5 mL sc).

This one-time vaccine should be offered to patients suffering from:


- chronic heart or lung conditions
- cirrhosis
- chronic renal failure, nephrosis
- diabetes mellitus
- immunosuppression, HIV infection, Hodgkin's diseae, multiple myeloma
- sickle-cell disease
- patients > 65 yo

Yearly influenza vaccine may also be indicated in these patients.