PNEUMONIA

Prof. Dr. redha

2023
Pneumonia :
Is defined as infection of the lower
respiratory tract parenchyma by agents
such as bacteria, viruses, fungi, or even
parasite with recently developed
radiological pulmonary shadowing
which may be segmental, lobar or
multilobar.
 pneumonias are usually classified:
* Community- or
* Hospital-acquired, or
* Those occurring in
immunocompromised hosts.
Other classification :
 'Lobar pneumonia' is a radiological and
pathological term referring to homogeneous
consolidation of one or more lung lobes, often
with associated pleural inflammation;
 bronchopneumonia refers to more patchy
alveolar consolidation associated with
bronchial and bronchiolar inflammation often
affecting both lower lobes.
It should be distinguished from Pneumonitis,
which is an inflammation of the lungs from a
variety of noninfectious causes, including
chemicals, blood, radiation, and autoimmune
processes.

Pneumonia, the sixth leading cause of death in the

United States, is responsible for 4 to 10 million
respiratory infections each year.
 Community-acquired pneumonia (CAP)
o The incidence varies with age, being much higher
in the very young and very old, in whom the
mortality rates are also much higher.
o World-wide, CAP continues to kill more children
than any other illness.
o Most cases are spread by droplet infection and
occur in previously healthy individuals but several
factors may impair the effectiveness of local
defenses and predispose to CAP (Box below).
 (CAP)

o Strep. pneumonia (Fig.below) remains the

most common infecting agent,

o Viral infections are an important cause of

CAP in children, and their contribution to
adult CAP is increasingly recognized.

o A
Factors that predispose to pneumonia
• Cigarette smoking
• Upper respiratory tract infections
• Alcohol
• Corticosteroid therapy
• Old age
• Recent influenza infection
• Pre-existing lung disease
• HIV
• Indoor air pollution
 Presentation:
What are the symptoms and signs of pneumonia?
Pneumonia is generally defined by:
• The presence of symptoms and signs of an acute
lower respiratory tract infection, together with:
• New radiographic shadowing consistent with infection
• No better alternative explanation for the presentation.
• It is worth noting that individual symptoms and
clinical signs alone cannot reliably differentiate
pneumonia from other non-pneumonic lower
respiratory tract infections.
• The clinical history for pneumonia may include one or
more of:
 Fever
 Shortness of breath
 Cough
 Sputum production
 Rigors or night sweats
 Mental confusion
 Pleuritic chest pain
On examination the signs may include:
• Fever (often greater than 38°C)
• Raised respiratory rate
• Hypotension
• Low oxygen saturation
• Focal chest signs such as decreased chest expansion,
dullness on percussion, bronchial breathing, or
crackles (none, some, or all of these may be present).
• Elderly patients are more likely to present with
nonspecific features such as falls, reduced mobility,
confusion, and fever may be absent.
Common clinical features of community-acquired
pneumonia
Legionella  Middle to old age.
pneumophila  Local epidemics around contaminated source, e.g. cooling
systems in hotels, hospitals. Person-to-person spread
unusual.
 Some features more common, e.g. headache, confusion,
malaise, myalgia, high fever and vomiting and diarrhea.
 Laboratory abnormalities include hyponatremia, elevated
liver enzymes, hypoalbuminemia and elevated creatine
kinase.
 Smoking, corticosteroids, diabetes, chronic kidney disease
increase risk
Chlamydia  Young to middle-aged.
pneumoniae  Large-scale epidemics or sporadic; often mild, self-limiting
disease.
 Headaches and a longer duration of symptoms before
hospital admission.
 Usually diagnosed on serology
Haemophilus More common in old age and those with underlying lung
influenzae disease (COPD, bronchiectasis)

Staphylococcus  Associated with debilitating illness and often

aureus preceded by influenza.
 Radiographic features include multilobar shadowing,
cavitation, pneumatocoeles and abscesses.
 Dissemination to other organs may cause
osteomyelitis, endocarditis or brain abscesses.
 Mortality up to 30%

Chlamydia psittaci  Consider in those in contact with birds, especially

recently imported and exotic.
 Malaise, low-grade fever, protracted illness,
hepatosplenomegaly and occasionally headache with
meningism
Coxiella burnetii  Consider in workers in dairy farms, abattoirs and
(Q fever, 'querry' hide factories (as amniotic fluid and placenta carry
fever) high risk).
 Risk of infection increases with age and male sex.
 Acute illness characterised by severe headache,
high fever, hepatitis, myalgia, conjunctivitis.
 Chronic disease causes endocarditis, hepatomegaly

Klebsiella  More common in men, alcoholics, diabetics, elderly,

pneumoniae hospitalized patients, and those with poor dental
(Freidländer's hygiene.
bacillus)  Predilection for upper lobes and particularly liable
to suppurate and form abscesses.
 May progress to pulmonary gangrene
Actinomyces  Mouth commensal.
israelii  Cervicofacial, abdominal or pulmonary infection,
empyema, chest wall sinuses, pus with sulphur
granules
 Primary viral pneumonias
Influenza, May cause pneumonia commonly complicated by
parainfluenza, measles secondary bacterial infection

Herpes simplex May cause tracheobronchitis or pneumonia in the

immunosuppressed
Varicella • May cause severe pneumonia.
• Heals with small nodules that calcify and become
visible on chest X-ray
Adenovirus Pneumonia reported in malnourished children and
immunocompromised adults
Cytomegalovirus (CMV)Pneumonia may be a major problem in transplant
recipients (particularly bone marrow) and those with
AIDS
Coronavirus (Urbani SARS (severe acute respiratory distress syndrome)
SARS-associated should be suspected if a high fever (> 38°C), malaise,
coronavirus) muscle aches, a dry cough and breathlessness follow
within 10 days of travel to an area affected by an
 Differential diagnosis of pneumonia

 Pulmonary infarction
 Pulmonary/pleural TB
 Pulmonary oedema (can be unilateral)
 Pulmonary eosinophilia
 Malignancy: bronchoalveolar cell carcinoma
 Rare disorders: cryptogenic organising pneumonia/
bronchiolitis obliterans organising
pneumonia (COP/BOOP)
Investigations
A chest X-ray usually provides confirmation of the
diagnosis.
In lobar pneumonia, a homogeneous opacity localized to the
affected lobe or segment usually appears within 12-18 hours of
the onset of the illness (Fig.).

Radiological examination is helpful if a complication such as :

• Parapneumonic effusion.
• Intrapulmonary abscess formation .
• Empyema is suspected.
 Assessment of disease severity
The CURB-65 scoring system helps guide antibiotic and
admission policies, and gives useful prognostic
information (Fig. ).