Pneumonia & Suppurative Lung Diseases Pneumonia Inflammation of lung parenchyma (alveoli) Resulting consolidation (hardening) of lung parenchyma Etiology

Caused by varieties of infectious agents y Bacteria y Viruses y Fungi y Mycoplasma Mostly bacterial pneumonia (community acquired acute pneumonia) y Pneumococci y Klebsiella pneumoniae y Staphylococci y Streptococci y H. influenza y Pseudomonas aeruginosa Results when y Pulmonary defence mechanism are impaired y Resistance of host is lowered Pulmonary Defence Mechanism Cough reflex Mucociliary apparatus Phagocytic alveolar macrophages Clearing mechanism can be interfered with many factors Loss/ suppression of cough reflex y Aspiration of gastric contents in coma y Anesthesia y Neuromuscular disorders y Drugs y Chest pain (aspiration pneumonia) Injury to mucociliary apparatus y Cigarette smoking y Inhalation of hot/ corrosive gases y Viral infection y Genetic disorders Interfered phagocytic/ bactericidal action of alveolar macrophages y Alcohol y Smoking y Anoxia y O2 intoxication Pulmonary congestion & edema Accumulation of secretions y Cystic fibrosis y Bronchial obstruction Etiology & Anatomical pattern of Pneumonia Community acquired acute pneumonia Etiology Bacteria Chronic Pneumonia Localised lesion in immunocompromised patient Granulomatous inflammation y Mycobacterium tuberculosis y Fungal infection (Histoplasmosis, Blastomycosis, Coccidioidomycosis, Aspergillosis) Complication of Pneumonia Abscess formation y Due to tissue destruction & necrosis Pleuritis, Pleural Effusion, Empyema y Spread of infection to pleura cavity y Cause intra-pleural fibrinosuppurative reaction Organization of Exudates y Convert portion of lung into solid tissue with fibrous scar Bacterial Dissemination y Heart Valves y Pericardium y Brain y Kidneys y Spleen y Joints (resulting metastatic abscesses) y Endocarditis y Meningitis y Suppurative arthritis Septicemia Clinical Features Abrupt onset of high fever with chills Productive cough Mucopurulent sputum Pleuritic pain & Friction rub Radiological appearance y Well circumscribed radio-opacity (in Lobar pneumonia) y Focal Opacities (in Bronchopneumonia)

Anatomical involvement

Lobar pneumonia Bronchopneumonia

Community acquired atypical pneumonia Virus Mycoplasma Clamydia Interstitial pneumonia

Community Acquired Acute Pneumonia (Lobar pneumonia, Bronchopneumonia) Lobar Pneumonia Consolidation of a large portion of a lobe (or entire lobe)

Bronchopneumonia Patchy consolidation of lung May be one lobe or multilobar Frequently bilateral & basal

Uniformly consolidated lower lobe (gray hepatisation) Lower Lobe y Airless y Liver like texture y Gray white 4 Stages of inflammatory response in Lobar Pneumonia y Congestion y Red Hepatization y Gray Hepatization y Resolution Congestion Lung Heavy, Boggy, Red Vascular engorgement Intra-alveolar fluid with few neutrophils & numerous bacteria Distinct difference between upper lobe & consolidated lower lobe

Pattern of patchy distribution of a bronchopneumonia

Gross Lesions 3 4 cm in diameter Slightly elevated, dry, granular, gray-red to yellow Poorly delimited at margin Histology Suppurative Neutrophil-rich exudates that fills y Bronchi y Bronchioles y Adjacent alveolar spaces

Red Hepatization Massive confluent exudation with red cells, neutrophils & fibrin filling the alveolar spaces Gross y Lobe appear distinctly red, firm & airless y Liver-like consistency Gray Hepatization Progressive disintegration of red cells Macrophages replace PMN with fibrin deposition Presence of fibrosuppurative exudates Gross y Grayish brown y Dry surface

Resolution Consolidated exudates within alveolar spaces undergo progressive enzymatic digestion Produce a granular, semi fluid debris Resorbed & ingested by macrophages, coughed up or organized by fibroblasts growing into it

Interstitial Pneumonia (Community Acquired Atypical Pneumonia) (Viral & Mycoplasma Pneumonia) Morphology Histology Patchy or whole lobe Inflammatory reaction in Interstitial Tissue Bilateral or unilateral (virtually within walls of alveoli) Red-blue, Congested, Subcrepitant Alveolar septa Widened, Edematous Pleuritis or Pleural Effusion (infrequent) (with mononuclear infiltrates of L, H, P & N in acute cases) Alveoli Free of exudates Pink hyaline membrane in alveolar walls

Suppurative Lung Diseases Bronchiectasis Permanent dilatation of bronchi & bronchioles Caused by destruction of muscle & elastic tissue Resulting from/ associated with chronic necrotizing infection

Lung Abscess Local suppurative process within the lung Characterized by Necrosis of Lung Tissue

Etiology Obstruction & Infection (major cause) y Obstruction (mucus, tumor, FB) y Impaired normal clearing mechanism y Pooling of secretion distal to obstruction y Inflammation of airways Severe Infection y Necrotizing fibrosis y Dilatation of airways Congenital/ Hereditary y Cystic fibrosis y Intralobular sequestration of lung y Immunodeficiency state y 1° Ciliary Dyskinesia y Kartagener syndrome Morphology Lower lobes, Bilaterally Vertical air passages Most severe in most distal bronchi & bronchioles Gross Airways Dilated (up to 4X) Cylindrical Saccular Bronchiectasis Bronchiectasis Long, tube-like Fusiform or saccular enlargement of airways distention Dilated airways can be followed directly out to pleural surfaces Cysts filled with mucopurulent secretions

Etiology & Pathogenesis Causes y Oropharyngeal surgical procedures y Sinobronchial infection y Dental sepsis y Bronchitis Organisms y Aerobic & Anaerobic streptococci y Staphylococcus aureus y GN organisms Mechanisms Aspiration of infective material (cough reflexes depressed) y Acute alcoholism y Coma y Anesthesia y Sinusitis y Gingivodental sepsis y Debilitation Antecedent primary bacterial infection y Post-pneumonic abscess y Fungal infection y Bronchiectasis Septic embolism Neoplasia Morphology Size few mm to large cavities of 5 6 cm Single or multiple Abscesses due to Aspiration More common on right (more vertical right main bronchus) More single Pneumonia or Bronchiectasis Multiple Basal Diffusely scattered

Empyema Collection of pus in pleural cavity Suppurative pleuritis Presence of purulent pleural exudates Characterized by y Loculated y Pus (yellow-green, creamy) (composed of neutrophils admixed with other leukocytes) Etiology Contiguous spread of organisms (from intrapulmonary infection) Lymphatic dissemination Haematogenous dissemination Direct extension of infection below diaphragm (subdiaphragmatic or liver abscess) (especially on right side) Clinical Course May resolve with antibiotics Obliterate pleural space/ envelope the lungs (Embarass pulmonary expansion)

Lung Abscess

Bronchiectasis Bronchial tubes are extremely dilated Thickened, Fibrotic wall Adjacent lung is almost completely destroyed

Cavity filled with suppurative debris If communication with air passage y Partially drain y Air-containing cavity Continued infection y Large y Fetid y Green-black y Multilocular cavities (gangrene of lung) Suppurative destruction of lung parenchyma within central area of cavitation

Abscessing Bronchopneumonia Several abscesses Irregular Rough-surfaced walls Areas of tan consolidation

Bronchiectasis Focal area of dilated bronchi Histology Full-blown, active case y Intense acute & chronic inflammatory exudation within the walls of bronchi & bronchioles Desquamation of lining epithelium Extensive areas of necrotizing ulceration Clinical course Cor pulmonale Lung abscess Metastatic brain abscesses Amyloidosis

Old pulmonary abscess cavity Multiloculated with delicate strands of fibrous tissue No evidence of acute inflammation in wall Fairly normal surrounding lung Course Most resolve with antimicrobial therapy Extension of infection into pleural cavity empyema Hemorrhage Septic emboli Brain abscess, Meningitis 2° Amyloidosis

2 Lung Abscess (Left lung) Upper lobe Lower lobe

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