ASPIRATION PNEUMONIA NECROTIZING PNEUMONIA AND LUNG

Anaerobic oral flora (Bacteroides, Prevotella, ABSCESS

Fusobacterium,
Anaerobic bacteria (extremely common),
Peptostreptococcus), admixed with aerobic with or without mixed aerobic infection
bacteria
(Streptococcus pneumoniae, Staphylococcus Staphylococcus aureus, Klebsiella
aureus, pneumoniae, Streptococcus pyogenes
Haemophilus infl uenzae, and Pseudomonas PNEUMONIA IN THE
aeruginosa) IMMUNOCOMPROMISED HOST
CHRONIC PNEUMONIA Cytomegalovirus
Nocardia
Actinomyces
Pneumocystis jiroveci
Granulomatous: Mycobacterium tuberculosis Mycobacterium avium-intracellulare
and atypical Invasive aspergillosis
mycobacteria, Histoplasma capsulatum,
Coccidioides Invasive candidiasis
immitis, Blastomyces dermatitidis “Usual” bacterial, viral, and fungal organisms
(listed above)
Streptococcus pneumoniae
Most common cause of community-acquired acute pneumonia.
Examination of Gram-stained sputum; numerous
neutrophils containing the typical gram-positive, lancet shaped
diplococci S. pneumoniae is a part of the endogenous flora in 20% of
adults
In the early phase of illness, only 20% to 30% of patients have
positive blood cultures)
Pneumococcal vaccines containing capsular polysaccharides from the
common serotypes
Influenzavirus
• Type A viruses are most often involved.
• Hemagglutinins bind virus to cell receptors in the nasal passages
• Neuraminidase dissolves mucus and facilitates release of viral particles
• Influenza A produces worldwide epidemics. Pneumonia may be complicated by a superimposed bacterial pneumonia (usually Staphylococcus aureus).
• Influenza B causes major outbreaks.
• Antigen drift: minor mutation. Does not require new vaccine.
• Antigen shift: major mutation in hemagglutinin or neuraminidase. A new vaccine is required.
• Clinical: fever, headache, cough, myalgias, chest pain
• Vaccination: mandatory for people >65 yr old and people with chronic illnesses
• Associations: Reye syndrome with salicylate ingestion; Guillain-Barré syndrome
• Diagnosis: PCR
Rubeola
• Fever, cough, conjunctivitis, and excessive nasal mucus production
• Koplik spots in the mouth precede onset of the rash.
• Warthin-Finkeldey multinucleated giant cells are a characteristic finding
• Diagnosis: PCR
RSV • Most common cause of pneumonia and bronchiolitis (wheezing) in infants
• Infections primarily occur in winter.
• Causes otitis media in older children
• Hand washing and use of gloves prevents nosocomial outbreaks in nurseries
• Fusion protein causes cells to fuse, producing multinucleated giant cells.
• Rapid diagnosis by detection of antigen in nasopharyngeal wash. PCR is also useful for diagnosis.
SARS
• Develop severe respiratory infection
• Diagnose with viral detection by PCR assay or detection of antibodies
• Detection viral genome, PCR, ELISA
Chlamydia
Chlamydophila pneumoniae
• Second most common cause of atypical pneumonia
• Diagnosis: PCR
Chlamydia trachomatis
• Newborn pneumonia (passage through birth canal)
• Afebrile, staccato cough (choppy cough), conjunctivitis, and wheezing
• Diagnosis: PCR
Mycoplasma pneumoniae
• Most common cause of interstitial pneumonia
• Common in adolescents and military recruits (closed spaces)
• Risk factor for Guillain-Barré syndrome
• Insidious onset with low-grade fever
• Cold agglutinins in blood
• Complications: bullous myringitis, cold autoimmune hemolytic anemia caused by anti IgM antibodies
• Diagnosis: PCR
Coxiella burnetii • Usually transmitted without a vector
• Contracted by dairy farmers, veterinarians
• Associated with the birthing process of infected sheep, cattle, and goats and handling of milk or excrement
• Atypical pneumonia, myocarditis, granulomatous hepatitis
• Diagnosis: PCR
Streptococcus pneumoniae
• Gram-positive lancet-shaped diplococcus
• Most common cause of typical community-acquired pneumonia (50%–75%)
• Rapid onset, productive cough, signs of consolidation
• Urine antigen test is an excellent screen.
Staphylococcus aureus
• Gram-positive cocci in clumps
• Yellow sputum
• Commonly superimposed on influenza pneumonia and measles pneumonia
• Major lung pathogen in CF and IV drug abusers
• Accounts for 3%–5% of community-acquired pneumonias
• Hemorrhagic pulmonary edema, abscess formation, and pneumatoceles (thin-walled air-filled cysts that
develop in the lung parenchyma, usually after pneumonia;
• Diagnosis: culture, antigen detection, PCR
Corynebacterium diphtheriae
• Gram-positive rod
• Toxin inhibits protein synthesis by ADP ribosylation of elongation factor 2 involved in protein synthesis
• Toxin also impairs β-oxidation of fatty acids in the heart (myocarditis with fatty change).
• Toxin-induced pseudomembranous inflammation produces shaggy gray membranes in the oropharynx
and trachea; toxic myocarditis (death).
• Diagnosis: culture, PCR
Bacillus anthracis
• Gram-positive rod
• Habitat: soil
• Capsule inhibits phagocytosis
• Exotoxins: protective antigen (PA), edema factor (EF; activates adenylate cyclase), and lethal factor (LF; inhibits a signal transduction protein
involved in cell division).
• Transmission: direct contact with animal skins or products (most commonly sheep and cattle) and entry of the organisms
through abrasions or cuts; inhalation (use in germ warfare)
• Cutaneous anthrax (90%–95% of cases): occurs through direct contact with infected or contaminated animal products. Resembles insect bite but
eventually swells to form a black scab, or eschar, with a central area of necrosis (malignant pustule). If left untreated, death occurs in 20% of patients.
• Pulmonary anthrax: “first sign of the disease is death.” It is contracted by inhalation of spores that are present incontaminated hides or delivered by
biological weapons. Produces a necrotizing pneumonia, meningitis, and pronounced splenomegaly. It disseminates throughout the rest of the body,
leading to death.
• Prevention: A vaccine is available for high-risk patients (e.g., veterinarians, soldiers entering developing countries).
• Diagnosis: culture, PCR
Actinomyces israelii
• Gram-positive filamentous bacteria. Strict anaerobe. Present in normal flora in the tonsils and adenoids.
• Produces draining sinuses in the jaw, abscesses in chest cavity, and abdomen. Pus contains sulfur granules (yellow specks) that contain the bacteria.
• Diagnosis: gram stain, culture
Nocardia asteroides
• Gram-positive filamentous bacteria. Strict aerobe. Partially acid fast.
• Produces granulomatous microabscesses in the lungs
• Frequently disseminates to the CNS and kidneys
• Diagnosis: culture, antibody detection
Bacteria gram-negative
Bordetella pertussis
• Gram-negative rod
• Pili attach to cilia in the upper respiratory tract. Toxin stimulates adenylate cyclase, which catalyzes the addition of ADP
ribose to the inhibitory subunit of the G protein complex. Toxin also produces absolute lymphocytosis (normal-appearing
lymphocytes) often in leukemoid reaction range.
• Produces whooping cough. Transmitted by droplet infection.
• Catarrhal phase: lasts 1–2 weeks. Mild coughing, rhinorrhea, and conjunctivitis.
• Paroxysmal coughing phase: lasts 2–5 weeks. Characteristic 4–5 coughs in succession on expiration, followed by an
inspiratory whoop. Absolute lymphocytosis may produce a leukemoid reaction (20,000–50,000 cells/mm3). Lymphocytes
are normal in appearance.
• Convalescence phase: lasts 1–2 weeks. Slow decline in coughing and lymphocytosis.
• Complications: hemorrhage into skin, conjunctiva, bronchus, brain from coughing. Otitis media, meningoencephalitis
(10%), rectal prolapse from coughing, and pneumonia. Pneumonia is the most common cause of death in children
<3 yr old. Children <1 yr old have no protection from the mother’s immunoglobulins.
• Diagnosis: nasopharyngeal swabs using special cough plate; direct immunofluorescence of swab material
Haemophilus influenza
• Gram-negative rod
• Common cause of sinusitis, otitis media, and conjunctivitis (pink eye)
• Accounts for 3%–10% of community-acquired pneumonias
• Inspiratory stridor may be caused by acute epiglottitis.
• Swelling of the epiglottis produces a “thumbprint sign” on a lateral radiograph of the neck
• Most common bacterial cause of acute exacerbation of preexisting COPD
• Diagnosis: culture, antigen detection
Moraxella catarrhalis
• Gram-negative diplococcus
• Common cause of typical pneumonia, especially in older adults
• Second most common pathogen causing acute exacerbation of COPD
• Common cause of chronic bronchitis, sinusitis, and otitis media
Pseudomonas aeruginosa
• Green sputum (pyocyanin pigment)
• Water-loving bacteria most often transmitted by respirators
• Most common cause of nosocomial pneumonia and death caused by pneumonia in CF
• Pneumonia is often associated with infarction caused by vessel invasion by the bacteria
Klebsiella pneumoniae
• Gram-negative fat rod surrounded by a mucoid capsule
• Common gram-negative organism causing lobar pneumonia and typical pneumonia in elderly patients in nursing homes
• Common cause of pneumonia in alcoholics; however, S. pneumoniae is still the most common pneumonia in alcoholics
• Typical pneumonia associated with blood-tinged, thick, mucoid currant jelly sputum
• Lobar consolidation and abscess formation are common.
Legionella pneumophila
• Gram-negative rod (requires IF stain or Dieterle silver stain to identify in tissue
• Water-loving bacterium (water coolers; mists in produce section of grocery stores; outdoor restaurants in summer; rain forests in zoos)
• Risk factors: alcoholic, smoker, immunosuppression
• Interstitial pneumonia associated with high fever, dry cough, flulike symptoms. Accounts for 2%–8% of adult community-acquired
pneumonias.
• May produce tubulointerstitial disease with destruction of the JG apparatus leading to hyporeninemic hypoaldosteronism
(type IV renal tubular acidosis [hyponatremia, hyperkalemia, metabolic acidosis]).
• Urine antigen test is an excellent screen.
Yersinia pestis • Gram-negative rod
• Cause of plague
• Transmitted by bite of rat flea. person to person by droplet infection.
• Macrophages cannot kill bacteria because V and W antigens provide protection.
• Three types of disease: bubonic (most common), pneumonic (transmitted by aerosol), and septicemic
• Bubonic type: bite by rat flea that has recently bitten an infected ground squirrel. Infected lymph nodes enlarge (usually
in the groin), mat together, and drain to the surface (buboes).
Cryptococcus neoformans
• Budding yeast with narrow-based buds. Surrounded by a thick capsule Forms pseudohyphae Found
in pigeon excreta (around buildings, outside office windows, under bridges;
• Primary lung disease (40%): granulomatous inflammation with caseation. Do not have to be
immunocompromised to acquire the disease.
Aspergillus fumigatus • branching septate hyphae
• Aspergilloma: fungus ball (visible on radiography) may develop in a preexisting cavity in the lung
(e.g., old TB site).
Cause of massive hemoptysis (invades blood vessels).
• Allergic bronchopulmonary aspergillosis: type I and type III HSRs. IgE levels increased and
eosinophilia is present. There is intense inflammation of airways and mucus plugs in the terminal
bronchioles. Repeated attacks may lead to bronchiectasis and interstitial lung disease.
• Vessel invader: causes hemorrhagic infarctions and a necrotizing bronchopneumonia
Mucor spp.
• Wide-angled hyphae without septa • Clinical settings: diabetes mellitus, immunosuppressed patients
• Vessel invader and produces hemorrhagic infarctions in the lung.
• Invades the frontal lobes in patients with diabetic ketoacidosis (rhinocerebral mucormycosis)
Coccidioides immitis
• Contracted by inhaling arthrospores in dust
• Spherules with endospores in tissues
• Flulike symptoms and erythema nodosum
• Granulomatous inflammation with caseous necrosis
Histoplasma capsulatum
• Most common systemic fungal infection
• Contracted by inhalation of microconidia in dust contaminated with excreta from bats
• Yeast forms are present in macrophages
• Granulomatous inflammation with caseous necrosis
• Simulates TB lung disease: produces coin lesions, consolidations, miliary spread, and cavitation
• Marked dystrophic calcification of granulomas.
Blastomyces dermatitidis
Most often associated with fishing (most common), hunting, gardening, exposure to beaver dams (beavers are reservoirs for the fungus)
• Yeasts have broad-based buds and nuclei
• Male-dominant disease
• Produces skin and lung disease. Skin lesions simulate squamous cell carcinoma.
• Granulomatous inflammation with caseous necrosis

Pneumocystis jiroveci • Cysts and trophozoites are present in tissue. Cysts attach to type I pneumocytes in the lungs.
• Similar to fungi but have no ergosterol in the plasma membrane
• Primarily an opportunistic infection. Occurs when the CD4 count is <200 cells/mm3.
• Common initial AIDS-defining infection
• Predominantly produces pulmonary disease with dense consolidation and patchy areas of induration in the lungs Patients develop fever, dyspnea, and severe hypoxemia. Diffuse
intraalveolar foamy exudates with cup-shaped
cysts are best visualized with silver or Giemsa stains.
• Chest radiography shows diffuse alveolar and interstitial infiltrates