PNEUMONIA

- Nahitha Nazir
Nazeeha S
WHAT IS PNEUMONIA?
Inflammation of lung parenchyma resulting in alveoli filled with inflammatory
exudate resulting in consolidation
Pneumonia may be classified anatomically as :
• lobar or lobular pneumonia
• bronchopneumonia
• interstitial pneumonia

Pathologically, there is a consolidation of alveoli or infiltration of the

interstitial tissue with inflammatory cells or both.
ETIOLOGY
• Viral etiology : Chiefly RSV, influenza, parainfluenza or adenovirus is present in -
40% patients.
• In over two-thirds of patients, a bacterial etiology is identified.
• Common bacterial agents in the first 2 months of life include gram negative
(Klebsiella, E. coli) and gram-positive organisms (pneumococci, staphylococci).
• Between 3 months to 3 years : Pneumococci, H. influenzae and staphylococci.
• After 3 years : Pneumococci and Staphylococci.
• Chlamydia and Mycoplasma species : Community- acquired pneumonia in
adolescents and children.
• Gram- negative organisms cause pneumonia in early infancy, severe malnutrition
and immunocompromised children.
Risk factors for pneumonia include :

• low birth weight

• malnutrition
• vitamin A deficiency
• lack of breastfeeding
• passive smoking
• large family size
• family history of bronchitis
• advanced birth order
• crowding
• air pollution
• Onset of pneumonia may be insidious starting with upper respiratory tract
infection or acute with high fever, tachypnea, dyspnea and grunting respiration.

• There is flaring of alae nasi and retractions of lower chest and intercostal spaces.

• Signs of consolidation are observed in lobar pneumonia.

Major Organisms and Pneumonia
• Pneumococcal pneumonia
• Staphylococcal pneumonia
• Hemophilus pneumonia
• Streptococcal pneumonia
• Primary atypical pneumonia
• Pneumonia due to gram negative organism
• Viral pneumonia
• Aliphatic hydrocarbon associated pneumonia
1.Pneumococcal pneumonia
• Due to S. pneumoniae : transmitted by droplets and are common in winter months
• Over- crowding and reduced host resistance predisposes the children to infection
with pneumococci.
• Pathogenesis : Bacteria multiply in the alveoli, resulting in an inflammatory
exudate. Scattered areas of consolidation occur that coalesce around bronchi and
later become lobular or lobar in distribution.
• The incubation period is 1 to 3 days.
Features
• The onset is abrupt with headache, chills, cough and high fever. Cough is
initially dry but may be associated with thick rusty sputum.
• Child may develop chest pain that is occasionally referred to the shoulder or
abdomen.
• Respiration is rapid.
• In severe cases, there may be grunting, chest indrawing, difficulty in feeding
and cyanosis.
• Percussion note is impaired, air entry is diminished, and crepitations and
bronchial breathing is heard over areas of consolidation.
• Bronchophony and whispering pectoriloquy may be observed.
• Meningismus may be present in apical pneumonia.
• The diagnosis is made on history, examination, X-ray findings of lobar
consolidation and leukocytosis.
• Bacteriological confirmation is difficult but sputum may be examined by Gram
staining and culture.

Treatment :

• Penicillin G 50000 IU/kg/day is given IV or IM in divided doses for 7 days.

• Therapy with IV cefotaxime, ceftriaxone or co-amoxiclav is equally effective
X- Ray chest showing lobar consolidation of right upper lobe
2.H. Influenzae pneumonia
• H. influenzae infections occur between the age of 3 months and 3 years, nearly
always associated with bacteremia.
• Infection begins in the nasopharynx and spreads locally or through blood.
• Patients present with moderate fever, dyspnea, grunting and retraction of lower
intercostal spaces.
• The presentation may mimic acute bronchiolitis
• Complications include bacteremia, pericarditis, empyema, meningitis and
polyarthritis.
• Treated with parenteral ampicillin (100 mg/kg/day) and co-amoxiclav.
Cefotaxime (100 mg/kg/day) and ceftriaxone (50-75 mg/kg/day) are satisfactory
agents for therapy.
3.Streptococcal pneumonia

• Streptococcal infection by group A beta-hemolytic streptococci may follow measles, varicella,

influenza or pertussis.
• Important cause of respiratory distress in newborns.
• Streptococci cause interstitial pneumonia, which may at times be hemorrhagic.
• The onset is abrupt with fever, chills, cough, dyspnea, rapid respiration and blood-streaked
sputum.
• Radiograph shows interstitial pneumonia with segmental involvement, diffuse peribronchial
densities or an effusion.
• Blood counts show neutrophilic leukocytosis.
• Penicillin G is recommended at doses of 50,000 to 100,000 IU/kg body weight, daily in
divided doses for 7-10 days.
• Alternative antibiotics include second or third generation cephalosporins (cefaclor,
cefuroxime, ceftriaxone, cefotaxime).
4.Staphylococcal pneumonia

• Occurs in infancy and childhood.

• Pneumonia may be primary infection of the parenchyma or secondary
to staphylococcal septicemia.
• It may be a complication of measles, influenza and cystic fibrosis or
follow staphylococcal pyoderma.
• In infants, the pneumonic process is diffuse initially, but soon the lesions
suppurate resulting in broncho- alveolar destruction.
• Multiple micro abscesses are formed, which erode the bronchial wall and
discharge their contents in the bronchi.
• Air enters the abscess cavity during inspiration; progressive inflation results
in formation of pneumatoceles that are pathognomonic of staphylococcal
pneumonia.
• Staphylococcal lung abscesses may erode into the pericardium causing
purulent pericarditis.
• Complications : pyo- pneumothorax and pericarditis are highly suggestive of
the diagnosis.
X ray chest showing Staphylococcal pneumonia ( arrow shows pneumatocoele )
Management

• Pneumatoceles do not require specific measures.

• Empyema and pyopneumothorax are treated by intercostal drainage
under water seal or low pressure aspiration.
• Metastatic abscesses require surgical drainage.
• Significant pleural thickening that might prevent expansion of the
underlying lung may require decortication, thoracotomy or
thoracoscopic surgery.
• The child is hospitalized.
• Fever is controlled with antipyretics and hydration is maintained by IV
fluids.
• Oxygen is administered to relieve the dyspnea and cyanosis.
• Antibiotic therapy should be prompt and carried out with penicillin G,
co-amoxiclav, cloxacillin or ceftriaxone.
• If the patient does not respond, vancomycin, teicoplanin or linezolid
may be used.
5.Atypical pneumonia
• Etiological agent of primary atypical pneumonia is Mycoplasma pneumoniae, a
small free living organism. Other pathogens include Chlamydia and Legionella
spp.
• The disease is transmitted by droplet infection
• The incubation period is 12 to 14 days; onset of the illness may be insidious or
abrupt.
• Initial symptoms are malaise, headache, fever, sore throat, myalgia and cough.
• Cough is dry at first but later associated with mucoid expectoration, which may be
blood streaked.
• X-ray findings are more extensive than suggested by physical findings. Infiltrates
involve one lobe, usually the lower.

• Diagnosis is made by detection of IgM antibody by ELISA during the acute

stage; IgG antibodies are present after 1 week.

• Treated with macrolide antibiotics (erythromycin, azithromycin, clarithromycin)

or tetracycline for 7-10 days
6.Pneumonia due to gram negative bacteria

• E. coli, Klebsiella and Pseudomonas affect small children (<2 months old),
children with malnutrition and poor immunity.
• Pseudomonas may colonize airways of patients with cystic fibrosis and causes
recurrent pulmonary exacerbations.
• The onset of illness is gradual.
• Signs of consolidation are minimal.
• Radiograph shows multiple areas of consolidation; those with E. coli or
Klebsiella pneumoniae may have pneumatoceles.
• Administration of IV cefotaxime or ceftriaxone (75-100 mg/kg/day) with or
without an aminoglycoside is recommended for 10 to 14 days.
• In case of suspected Pseudomonas infection, ceftazidime is the drug of choice.
7.Viral pneumonia
• Respiratory syncytial virus is the chief cause under 6 months of age.
At other ages, parainfluenza, influenza and adenoviruses are common.
• Presenting with extensive interstitial pneumonia.
• Clinical signs of consolidation are absent.
• Radiological signs consist of perihilar and peribronchial infiltrates.
8.Aliphatic hydrocarbon associated pneumonia
• Kerosene exerts its toxic effects on the lungs and central nervous system.
• Milk and alcohol promote absorption through the gastrointestinal tract.
• Since kerosene has low viscosity and low surface tension, it diffuses quickly from
the pharynx into the lungs.
• Features of hydrocarbon pneumonia include cough, dyspnea, high fever,
vomiting, drowsiness and coma.
• X-ray film of the chest shows ill-defined homogeneous or patchy opacities, and
may resemble miliary mottling.
• Gastric lavage is avoided to prevent inadvertent aspiration.
• The patient is kept on oxygen.
• Routine antibiotics are not indicated.
Management
• Early assessment and diagnosis: Clinical evaluation, Imaging studies, Laboratory
tests
• Classification based on severity: Mild, Moderate, Severe
• Appropriate treatment strategy
• Prevention using vaccines
• Complications and follow up
REFERENCE

• Ghai Essential Pediatrics

THANK YOU