Pneumonia Pneumonia is an acute infection of the parenchyma of the lung, caused by bacteria, fungi, virus, parasite etc.

Pneumonia may also be caused by other factors including X-ray, chemical, allergen. It is the common disease in our country, 2500000 cases occur annually, 125000 cases die of this disease. In aged or immunocompromised patient using immunosuppressive agents, transplantation, diabetes mellitus, uremia, alcoholism! "ith pneumonia. #he mortality is much higer. Pneumonia can be classified by pathogen or anatomy. $ccording to the pathogen classification, it is most useful to treat the patients by choosing convenient antimicrobial agents. In diagnosis, t"o classification can be combined altogether. .%lassification by pathogen &icroscopic e'amination in site of infection alveolar, bronchi or lung!, sputum culture, biopsy of lung tissues are useful to identifier the pathogen of the infection. 1. (acterial pneumonia 1! $erobic )ram-positive bacteria, such as streptococcus pneumoniae, staphylococcus aureus, )roup $ hemolytic streptococci. 2! $erobic )ram-negative bacteria, such as *lebsiella pneumoniae, +emophilus influen,ae, -scherichia coli. .! $naerobic bacteria. 2. $typical pneumonia includes legionnaies pneumonia, &ycoplasmal pneumonia and %hlamydia pneumonia and ects. .. /ungal pneumoniae /ungal pneumonia is commonly caused by candida. 0. 1iral pneumonia 1iral pneumonia may be caused by adenoviruses, respiratory syncytial virus, influen,a, cytomegalovirus, herpes simple'. 5. Pneumonia caused by other pathogen. 2ic*ettsias a fever ric*ettsia!, chlamydia psittaci, parasites, proto,oa. .%lassification by anatomy 1. 3obar4 Involvement of an entire lobe. 2. 3obular4 Involvement of parts of the lobe only, segmental or of alveoli contiguous to bronchi bronchopneumonia!. .. Interstitial . %lassification by ac5uired environment 1. %ommunity ac5uired pneumonia %$P!

%$P refers to pneumonia ac5uired outside of hospitals or e'tendedcare facilities . 6treptococcus pneumoniae remains the most commonly identified pathogen. 7ther pathogens include +aemophilus influen,ae, mycoplasma pneumoniae, %hlamydophilia pneumoniae, &ora'ella catarrhalis and ects. 2. +ospital ac5uired pneumonia +$P! +$P refers to pneumonia ac5uired in the hospital setting. -nteric )ram-negative organisms, 6. aureus, Pneudomonas aeruginosa, ects. Pneumococcal pneumonia Pneumococcal pneumonia is produced by streptococcus pneumoniae. It is the most commonly occurring bacterial pneumonia. Patients have the symptoms of sha*ing chill, sharp pain, cough, and blood-flec*ed sputum. -tiology, pathogenesis and pathology 6treptococcus pneumonia are encapsulated, gram-positive cocci that occur in chains or pairs. #he capsule "hich is a comple' polysaccharide has specific antigenicity. $t least 89 different immunogenic types e'ist by serologic test. #ype . is the most virulent, usually causing severe pneumonia in adults, but type 9,10,1: and 2. are virulents is children. #he pneumonia is directly proportional to the innoculum si,e and virulence of the organisms, and inversely related to the ade5uacy of pulmonary host defenses. Pathology 7nce a sufficient inoculum of sufficiently virulent pneumococci has reached the alveoli, pneumonia develops, first there is alveolar capillary congestion, stage of congestion, than fluid pours out from capillaries to fill the alveoli, spreading to ad;acent alveoli. #his infected tide carries pneumococci into contiguous areas until in flo" is stopped by an anatomic barrier, usually the visceral pleura investing a segment or a lobe of the lung. #his stage of pneumonia is called <red hepati,ation= because of the liver-li*e, reddish appearance of the consolidated lung. $ fe" hours after pulmonary capillaries dilate and edema fluid pours into the alveoli, polymorphnuclear leu*ocyte enter the alveolar spaces, rapidly fill the alveoli, and consolidate the lung called grey hepati,ation!. /inally, macrophages migrate into the consolidated alveoli and ingest the debris left behind as the acute infection resolves called resolution!. $ll of the four main stages of the inflammatory reaction described above may be present at the same time. In most cases, recovery is complete "ith restoration of normal pulmonary anatomy. In 5> to 10> of patients, infection may e'tend into the pleural space and result in an empyema or in 15> to 20> of patients, bacteria may enter the blood stream bacteremia! via the lymphatics and thoracic dust. Invasion of the blood

stream by pneumococci may lead to serious metastatic disease at a number of e'tra pulmonary sites meningitis, arthritis, pericarditis, endocarditis, peritonitis, otitis media etc!. %lincal manifestation &any patients have had an upper respiratory infection for several days before the onset of pneumonia. 7nset usually is sudden, half cases "ith a sha*ing chill. #he temperature rises during the first fe" hours to .:-00. #he pulse accelerates. 6harp pain in the involved hemi thora'. #he cough is initially dry "ith pin*ish or blood-flec*ed sputum. )astrointestinal symptoms such as, anore'ia, nausea, vomiting, abdominal pain, diarrhea may be mista*en as acute abdominal inflammation. 6igns #he acutely ill patient is tachypneic, and may be observed to use accessory muscles for respiration, and even to e'hibit nasal flaring. /ever and tachycardia are present, fran* shoc* is unusual, e'cept in the later stages of infection or ?I%. $uscultation of the chest reveals bronchovesicular or tubular breath sounds and "et rales over the involved lung. $ consolidation occurs, vocal and tactile fremitus is increased. %omplications %omplications are less seen recently. If sepsis occurs, the patient may become dus*y, cyanotic, confused and shoc*. 1. sepsis 2. lung abscess or empyema 3. pleural effusion, pleuritis 4. ARDS , ARF 5. pneumot ora! ". #!trapulmonary infections 3aboratory e'amination #he peripheral "hite blood cell @(%! count is often 10-.010:A3, of 80> in the polymorphonuclear leu*ocytes. +o"ever, in alcoholics or immunosuppressed patients. It may be normal or lo" of more value is the @(% differential, "hich consists predominantly of polymorphonuclear leu*ocytes left shift!. (efore using antibiotic, the culture of blood of 20> is positive. &icroscopic e'amination and culture of e'pectorated purulent sputum bet"een 20-08 hours can be used to identify pneumococci. %olony counts of bacteria from bronchoalveolar lavage "ashings obtained during endoscopy are seldom available early in the

course of illness. Bse of the P%2 may amplify pneumococcal ?C$ and improve potential for detection. X-ray e'amination %hest radiographs reveal a lobar distribution and an air space pattern of disease. If blunting of the costophrenic angle is noted, the finding is believed to represent an effusion.

?iagnosis and differential diagnosis #he clinical picture and radiographic features associated "ith, it is not difficult to ma*e the diagnosis. 1. pulmonary tuberculosis 2. 7ther microbial pneumonias4 Dlebsiella pneumonia, staphylococal pneumonia, pneumonias due to ) -! bacilli, viral and mycoplasmal. .. $cute lung abscess 0. (ronchogenic carcinoma 5. Pulmomary infarction #reament 1. $ntibiotic therapy $ll patients "ith suspected pneumococcal pneumonia should be treated as promptly as possible "ith penicillin ). #he dose and route of delivery may have to be on the basis of patients status adverse reaction or complication that occur. /or patients "ho are believed to be allergic to penicillin, one may select a first or second generation cephalosporin or erythromycin, clindamycin, or a fluoro5uinolone. #reatment "ith any effective agent should be given for at least 5 to E day or after the patients have been afebrile for 2-. days.

2. 6upportive measure 6upportive measure are generally used in the initial management of acute pneumococcal pneumonia4 6uch measures include bed restF monitoring vital signs and urine outputF administering an occasional analgesic to relieve pleuritic painF replacing fluids, if the patient is dehydratedF correcting electrolytesF o'ygen therapy. @hen relieving pleuritic pain or providing sedation in situations re5uiring it, care should be ta*en to not use e'cessively high doses of analgesics or sedatives that might depress the respiratory center. If possible, antipyretics should also be avoided because these agents interfere "ith the evaluation of fever as a measurement of the patientGs progress, and cause a dehydration. .. #reatment of complications -mpyema develops in appo'imately 5> of patients "ith pneumococcal pneumonia, although pleural effusion commonly develop in 10>-20> patients. %hest X-ray "ith lateral decubitus films are often useful in the early recognition of pleural effusion, pleural fluid that is removed should be sub;ected to routing e'amination. If pneumococcal bactermia occurs, e'tra pulmonary complications such as arthritis, endocarditis must be e'cluded, because their therapy re5uires higher dosages. 0. #reament of infections shoc* 1! #reatment in intensive care units 2! cardiac rhythm, blood pressure, cardiac performance, o'ygen delivery, and metabolic derangements can be monitored .! $de5uate o'ygenation and ventilatory support sometimes mechanical ventilation! 0! -ffective antibiotic therapy 5! &aintain blood pressure, including maintain circulation blood volume, use of dopamine 5. Prognosis Prognosis is much better. $ny of the follo"ing factors ma*es the prognosis less favorable and convalescence more prolonged elderlyF involvement of 2 or more lobesF underlying chronic diseases heart lung *edney! normal temperature and @(% count H5000F immunodeficiency "ith severe complication. Prevention #he most important preventive tool available is using a poly valent pneumococcal vaccine in those "ith chronic lung diseases, chronic liver diseases, splenectomy, diabetes mellitus and aged. Stap ylococcus pneumonia 6taphylococcal pneumonia is usually caused by staphylococcus aureus. It is often a complication of influen,a, but may be primary,

particularly in infants and the aged. It occurs in immunocompromissed patients such as diabetes mellitus, nematologic disease leu*emia, lymphoma, leu*openia!, $I?6, liver disease, malnutrition, alcoholism. 6taphylococcal bacteremia complicating infections at other sites furuncles, carbuncles! may cause hematogenous pulmonary involvement due to blood spread!. 6ome or all of the symptoms of pneumococcal pneumonia high fever, sha*ing chill, pleural pain, productive cough! may be present, sputum may be copious and salmon-colored. Prostration is often mar*ed. $ccording the symptoms, signs of pneumonia, leu*ocytosis and a positive sputum or blood culture, the diagnosis can be made. )ram stain of the sputum provides earliest diagnostic clue. %hest X-ray early in the disease sho"s many small round areas of densities that enlarge and coalesce to from abscess, and leave evidence of multiple cavities. Bntil the sensitivity results are *no", a penicillinase Iresistant penicillin or a cephalosporin should be given. #herapy is continued for 2 "ee*s after the patient has become afebrile and the lungs have sho"n signs of clearing. 1ancomycin is the drug of choice for patients allergic to penicillin and cephalosporin and for those not responding to other antistaphylococcal drugs and for &26$. Pneumonia cause$ by %lebsiella Dlebsiella pneumonia also named /riedlander pneumonia! is an acute lung infection, caused by Dlebsiella pneumoniae 1, it occurs much more in aged, malnutrition, chronic alcoholism, and in "hom "ith bronchial pulmonary disease. #he onset usually is sudden, "ith high fever, cough, pleuritic pain, abundant sputum, cyanosis, tachycardia my be present, half cases "ith a sha*ing chill. 6hoc* appears in early stage. %linical manifestations are similar to sever pneumococcal pneumonia. #he sputum is viscid and <ropy=, and may be <bric* red= in color. %hest X-ray sho"s a do"n"ard curve of the hori,ontal interlobar fissure, if the right upper lobe is involved. $reas of increased radiance "ithin dense consolidation suggest cavitation. It constitutes 2> of bacterial pneumonia, but mortality may be as high as .0>. @hen an elderly patient suffered from acute pneumonia "ith sever to'ic symptom, viscid and <bric* red=, sputum must consider this disease. #he diagnosis is determined by bacterial e'amination of sputum. -arly using antimicrobial therapy is important for patients "ith survivable illnesses, the third or fourth generation cephalosporin and aminoglycoside Danamycin, $mi*acin, )entamycin! are often used. &ycoplasmal pneumonia &ycoplasmal pneumonia is caused by &ycoplasmal pneumoniae.

&ycoplasmal pneumoniae is one of the smallest organisms 125150m capable of replication in cell-free media. Infection is spread form person to person by respiratory secretions e'pelled during bouts of coughing, causing epidemic or sporadic occurance. It commonly occurs in children, adolescent, mainly in fall and "inter. It constitutes more than 1A. of non bacterial pneumonias, or 10> of pneumonias from all cause. &ycoplasmal pneumonia is caused by &ycoplasmal pneumoniae. &ycoplasmal pneumoniae is one of the smallest organisms 125150m capable of replication in cell-free media. Infection is spread form person to person by respiratory secretions e'pelled during bouts of coughing, causing epidemic or sporadic occurance. It commonly occurs in children, adolescent, mainly in fall and "inter. It constitutes more than 1A. of non bacterial pneumonias, or 10> of pneumonias from all cause. %ellular infiltrate around bronchioles, and in alveolar interstitium, consists mostly of mononuclear elements. %linical findings #he illness begins insidiously "ith constitutional symptomatology4 malaise, sore throat, cough, fever, myalgia, half of cases have no symptom. %hest X-ray findings are manifold. &ost patients have unilateral lo"er lobe segmental abnormalities. #he earliest signs are an interstitial accentuation of mar*ing "ith subse5uent patch air space consolidation and thic*ened bronchial shado"s. #he pneumonia may persist for .-0 "ee*s a slight leu*ocytosis is seen, "ith a normal differential count. #he diagnosis is generally proved by a single antibody titer of 14.2 or greater, a titer of cold agglutinins of 14.2 or greater a single Ig& determination. #he most promising in terms of speed, sensitivity and specificity is P%2 although cost and lac* of general availability limit its routine use. #herapy $ definite clinical response is seen to erythromycin and tetracyclines. Co"adays ne"er generation of fluoro5uinolones are effective.

 1. 2. %ecil #e'tboo* of &edicine21st edition .. !