PNEUMONIAS BY DR BASHIR AHMED DAR ASSOCIATE PROFESSOR MEDICINE SOPORE KASHMIR

PNEUMONIAS By Dr Bashir Ahmed Dar Chinkipora Sopore Kashmir Associate Professor Medicine Email [email_address]

NOTE The purpose of this presentation is to take full detailed history in case of pneumonia to arrive at correct diagnosis. The presentation has been made very easy for undergraduate as well as for post graduate medical students. Description of various organisms and x-rays has made the task very simple.

Definition of Pneumonia Pneumonia is defined as inflammation of lung parenchyma The term pneumonitis is synonymous but is best avoided During the process of inflammation of alveoli there occurs inflammatory exudate that fill up air spaces and result in consolidation of lung.

Primary Pneumonia There is no pre-existing abnormality of respiratory system.

Secondary Pneumonia is characterized by absence of specific pathogenic organism in the sputum and presence of some pre-existing abnormality of respiratory system.

Secondary Pneumonia Examples are 1.Aspiration of pus from any foci,vomitus,gastric contents 2.Inhalation of septic matter during tonsilectomy,dental procedures. 3.Ineffective coughing as in post-traumatic,post-operatiive,paralysis laryngeal or phyrangeal. 4.Partial bronchial obstruction

Classifications by (causative agents) Pneumonia Classifications by (causative agents) Viral pneumonia Bacterial Pneumonia Fungal pneumonia Rickettsial pneumonia Protozoal pneumonia Radiation pneumonia Chemical pneumonia Aspiration pneumonia Hypostatic pneumonia

Viruses that cause acute pneumonia

Viruses that cause acute pneumonia Adenovirus Coronavirus influenza A and B viruses parainfluenza virus respiratory syncytial virus coxsackievirus A21 Rhinovirus viruses that cause rubella and measles often self limiting but can be complicated

Features of viral Pneumonias The clinical features differ from that of bacterial pneumonia. Symptoms are more than the chest signs and x-ray signs Course is mild and self limiting and resolves by 7-10 days time.

Features of viral Pneumonias It usually starts with a dry (nonproductive) cough Characteristic features or constitutional symptoms like fever ,headache,sore throat,dry cough,malaise,running nose,common cold,aches and pains precedes several days before viral pneumonia occurs than in bacterial pneumonia which is more abrupt in onset.

Features of viral Pneumonias Strikes primarily in the fall and winter and tends to be more serious in people with cardiovascular or lung disease . * Leucocyte count is usually normal or low * On x ray may show features of interstitial or of atypical pneumonia

Features of viral Pneumonias Viral pneumonia often goes unrecognized because the person may not appear very ill. The symptoms vary with age and whether the person has other health problems. Diagnosis confirmed by isolation of virus and serological tests

BACTERIA THAT CAUSE PNEUMONIA GRAM POSITIVE COCCI 1.Streptococcus Pneumoniae the most common 2. Streptococcus Pyogenes 3. Streptococcus Agalactiae

BACTERIA THAT CAUSE PNEUMONIA S- Pneumoniae generally resides in the nasopharynx and is carried asymptomatic in approximately 50% of healthy individuals. A strong association exists with viral illnesses, such as influenza. Viral infections increase Pneumococcal attachment to the receptors on activated respiratory epithelium. Once aerosolized from the nasopharynx to the alveolus,

BACTERIA THAT CAUSE PNEUMONIA Pneumococci infect type II alveolar cells. The pneumonic lesion progresses as pneumococci multiply in the alveolus and invade alveolar epithelium. Pneumococci spread from alveolus to alveolus through the pores of Kohn, thereby producing inflammation and consolidation along lobar compartments

BACTERIA THAT CAUSE PNEUMONIA Patients with pneumococcal pneumonia may produce bloody or rust-colored sputum.

BACTERIA THAT CAUSE PNEUMONIA Streptococcus agalactiae bacterium is a commensal organism in the genital tract and it can cause pneumonia in newborn babies. It does not happen too often, but the baby sometimes inhales fluid containing the bacteria during its journey down the birth canal and develops pneumonia soon after birth.

BACTERIA THAT CAUSE PNEUMONIA 4. Staphylococcus aureus is gram positive organism,affecting children and old people. as well as extreme ages.it can produce thin walled air filled cavities ("pneumatoceles"),

BACTERIA THAT CAUSE PNEUMONIA Commonly following influenza in debilitated patients and in those with cystic fibrosis. Abcess formation is very common. The abcesses are thin walled,multiple and commonly bilateral giving rise to patchy bronchopneumonia.

BACTERIA THAT CAUSE PNEUMONIA As opposed to other acute bacterial or lobar pneumonias which begin in alveoli, bronchopneumonia originates in small bronchioles. Typical bacteria causing this form of infection include Staphylococcus aureus and Gram-negative organisms such as Pseudomonas aeruginosa .

BACTERIA THAT CAUSE PNEUMONIA Since multiple sites are involved simultaneously a scattered appearance of heterogeneous opacities is the usual Eventually more and more alveoli are affected and ultimately a homogeneous opacification simulating lobar pneumonia may be observed.

BACTERIA THAT CAUSE PNEUMONIA Staphylococcal pneumonia is diagnosed by finding typical clusters of Gram-positive cocci by microscopy and subsequently a heavy growth of Staphylococcus aureus in a purulent (pus-laden) sputum that often appears creamy and bloodstained.

BACTERIA THAT CAUSE PNEUMONIA Staphylococcal organism can also cause Boils (pus-filled infections of hair follicles). Abscesses (collections of pus in pockets under the skin). Styes (infection of glands in the eyelid). Carbuncles (infections larger than an abscess, usually with several openings to the skin). Cellulitis (infection of the skin and the fat and tissues that lie immediately beneath it). Impetigo (a skin infection that produces pus-filled blisters).

BACTERIA THAT CAUSE PNEUMONIA Septic shock. Severe joint problems (septic arthritis). Bone marrow infection (osteomyelitis). Internal abscesses anywhere within the body. Inflammation of the tissues that surround the brain and spinal cord (meningitis). Lung infection (pneumonia). Infection of the heart lining (endocarditis).

BACTERIA THAT CAUSE PNEUMONIA Some strains of staphylococcal bacteria produce toxins (poisons) when they grow and reproduce on food. If you eat food contaminated with staphylococcal bacteria, these toxins can cause staphylococcal food poisoning. The toxins can also cause scalded skin syndrome and, very occasionally, toxic shock syndrome.

BACTERIA THAT CAUSE PNEUMONIA Bacteria gram positive rods Bacillus anthracis is Anthrax or Wool-Sorters disease Associated with wool sorting, with animal handlers, and veterinarians,produces eschar

BACTERIA THAT CAUSE PNEUMONIA 2. Nocardia sp Beaded filamentous rod shaped bacteria, Pleura and chest wall involvment Actinomyces sp. Beaded filamentous rod shaped bacteria, causing rib destruction, cutaneous sinuses, cavitation, spreads to pleura and chest wall.

BACTERIA THAT CAUSE PNEUMONIA Caused by actinomyces israeli ,an anaerobic organism occuring in mouth as commensal When local defences break then can occur Three forms recognised Cervicofacial actinomycosis with discharging sinuses Abdominal actinomycosis with discharging sinuses

BACTERIA THAT CAUSE PNEUMONIA Then lastly pulmonary actinomycosis with widespread suppurative pneumonia with empyema often bilateral and persistent discharging chest wall sinuses The pus from sinuses contains sulphur granules

BACTERIA THAT CAUSE PNEUMONIA Bacteria Gram Negative cocci Neisseria meningitidis (meningococci) cause epidemics in military recruits,schools,young adults,overcrowded places. Moraxella catarrhalis

BACTERIA THAT CAUSE PNEUMONIA Bacteria gram negative rods 1. Klebsiella pneumoniae produces Current Jelly sputum, more commonly seen in patients with COPD, alcoholics, and the elderly.

BACTERIA THAT CAUSE PNEUMONIA ) Also called (friedlanders bacillus) Severe form of pneumonia with high mortality Upper lobes being most affected with massive lobar consolidation Sputum is jelly like and blood stained producing (current jelly sputum).

BACTERIA THAT CAUSE PNEUMONIA On x-ray there is consolidation and bulging of interlobar fissure characteristic finding. Sputum smear shows gram negative bacilli

BACTERIA THAT CAUSE PNEUMONIA 2.Pseudomonas aeruginosa produces green sputum, abscess formation, Common cause of pneumonia in cystic fibrosis and those with severely compromised respiratory defenses. 3. Acinetobacter sp.often found on respiratory therapy equipment and on human skin very difficult to treat due to multiple drug resistance. 4. Burkholderia pseudomallei exposure with contaminated soil

BACTERIA THAT CAUSE PNEUMONIA 6. Yersinia Pestis,causes Pneumonic plague Initial plague patients acquire this disease via flea bites and animal contacts like rats,rodents. Plague has three forms .

BACTERIA THAT CAUSE PNEUMONIA Forms of Plague Disease Pneumonic Bubonic Septicemic

BACTERIA THAT CAUSE PNEUMONIA 7. Francisella tularensis ,Tularemia Infection is via tick bite or contact with contaminated rabbits. 8. Hemophilus influenzae more commonly seen in patients with COPD, alcoholics, and the elderly. 9. Bordetella pertussis Whooping cough

BACTERIA THAT CAUSE PNEUMONIA 10. Bacteroides melaninogenicus anaerobe aspirationn 11.Fusobacterium sp.anaerobe Aspiration 12.Porphyromonas sp.anaerobe Aspiration 13.Prevotella sp.anaerobe 14.Proteus sp Aspiration 15.Serratia sp.

ANAEROBIC BACTERIA Following are anaerobic bacteria • Bacteroides • Fusobacterium • Porphyromonas • Prevotella • Actinomyces • Bifidobacterium • Clostridium • Peptostreptococcus • Propionibacterium

ANAEROBIC BACTERIA Are bacteria that do not live or grow in the presence of oxygen. Anaerobic bacteria can cause an infection when a normal barrier (such as skin, gums, or intestinal wall) is damaged due to surgery, injury, or disease. Usually produce small abcesses and cause foul smelling breath.

BACTERIA THAT CAUSE PNEUMONIA Infections with Pseudomonas, Haemophilus, and pneumococcal species are known to expectorate green sputum.

Gram-Negative Bacteria There are many groups of Gram-Negative bacteria such as Cyanobacteria, Spirochaetes, Green-Sulphur and Green Non-Sulphur Bacteria and Proteobacteria etc. Out of which, proteobacteria is one of the major group of known Gram-Negative bacteria (it includes bacteria like E-coli, Salmonella, Pseudomonas, Moraxella, Helicobacter, Stenotrophomonas, Legionella, Acetic Acid Bacteria etc.).

Gram-Negative Bacteria Along with the above mentioned bacteria, there are several other type of Gram-Negative bacteria such as Hemophilus influenzae (also known as Bacillus influenzae), Neisseria Meningitidis, Moraxella Catarrhalis, Neisseria Gonorrhoeae, Acinetobacter Baumanii (which comes under Nosocomical Gram-Negative bacteria group).

Gram-Negative Bacteria People most likely to get sick with resistant Gram-negative germs are those who: • are seriously ill • are in the hospital for a long time • have taken many antibiotics or drugs used to destroy bacteria • have a disease that prevents the body from fighting infection • have been in a nursing home or long-term care setting • are on a ventilator or breathing machine

Clinical Features of Bacterial Pneumonia Onset is often sudden High grade fever Rigors and chills Sputum is rusty coloured or blood stained

Features of Bacterial Pneumonias In fact, the viral infection predisposes to bacterial pneumonia, by damaging some of the lung's defenses against infection. One important clue to this diagnosis is deterioration after initial improvement

Signs of Pneumonia Decreased chest movements Dull on percussion VF/VR increased Bronchial breathing Bronchophoney,aegophony and whispering pectoriloquy may be present Crepitations

Fungal Pneumonia Endemic fungi Histoplasmosis Blastomycosis Cryptococcosis Sporotrichosis - primarily a lymphocutaneous disease, but can involve the lungs as well Aspergillus Candida Coccidiodomycosis

Fungal Pneumonia Histoplasmosis All Chickens, bats, river valleys Coccidioidomycos All California, Southwest USA

Fungal Pneumonia Histoplasma capsulatum: Infection can result from exposure to contaminated bat caves or from excavation in endemic areas

Fungal Pneumonia Coccidioides immitis: Pneumonia may develop after travel to the southwestern United States and after exposure to a wind or rain storm in an endemic area.

Fungal Pneumonia Blastomyces dermatitidis: Patients may have traveled to the midwestern United States or the Canadian Shield.

Clinical features of fungal Pneumonias Occurs in a particular setting History of immunosupression like in AIDS,malignancy,Corticosteroid theraphy,radiation theraphy,antimalignant drugs. Debilitated bed ridden people,malnutrition. Has chronic serious pre-existing disease.

Clinical features of fungal Pneumonias People working in agriculture lands,caves,old buildings,places of bird droppings,soil. The disease runs a chronic course.

Fungal Pneumonia Diagnostic efforts must be escalated, progressing to more aggressive measures (fiberoptic bronchoscopy, fine needle aspiration, and rarely thoracoscopic or traditional open lung biopsy) until a specific diagnosis is reached. Skin tests

Protozoal Pneumonia Parasites causing pneumonia are 1.Toxoplasma gondii 2.Strongyloides stercoralis 3.Ascariasis. 4.Cryptosporidia 5.Hookworms

Protozoal or Parasitic Pneumonia A variety of parasites can affect the lungs. These parasites typically enter the body through the skin or by being swallowed. Once inside, they travel to the lungs, usually through the blood. One type of white blood cell, the eosinophil, responds vigorously to parasite infection. Eosinophils in the lungs can lead to eosinophilic pneumonia.

Rickettsial Pneumonia Typhus fevers (epidemic and endemic) Rocky mountain spotted fever,scrub typhus, rickettsialpox Louse-borne flea-borne through rats and mouse fleas

Rickettsial Pneumonia Q fever Acute, self-limited, systemic disease caused by the rickettsia Coxiella burnetii. Q fever spreads rapidly in cows, sheep, and goats, and in humans it tends to occur in localized outbreaks. Q fever common in slaughterhouses, research facilities, and plants, where handling of animals or their birth products is a source of exposure.

Rickettsial Pneumonia Q fever ranging from multiple segmental opacities to pleural effusion, lobar consolidation, or linear atelectasis.Hepatosplenomegaly is a common finding; it usually is accompanied with elevation of liver enzymes

Rickettsial Pneumonia Rickettsia pneumonia cannot be distinguished clinically, radiologically, or histologically from atypical pneumonia.

Features of Rickettsial infection Rickettsiae are small bacteria that are obligate intracellular parasites. They are maintained in nature through cycle involving reservoir mammals and arthropod vectors except louse borne typhus. Humans are incidental hosts via arthropod vector. Vasculitis of small vessels is basic underlying pathology. The severity of disease can range from mild to multi-organ failure and even fatal outcome. Patients usually present with fever, skin rash/eschar and headache

Features of Rickettsial infection The geographic and temporal distribution of rickettsioses is mainly determined by their vectors. Louse-transmitted diseases occur worldwide. Lice parasitize in poor people, preferentially in cold places and during wars. Common fleas such as cat and dogs fleas and rat fleas are reported worldwide, as are their transmitted diseases.

Features of Rickettsial infection For tick species, they are highly dependent on their environment. Thus, tick-transmitted rickettsial diseases are usually restricted to parts of the world where they can be transmitted by the local fauna. Pet dogs and cat may act as transport hosts which carry the infected ticks from its original habitats to home, where the humans may be exposed to the ticks.

Features of Rickettsial infection Scrub typhus occurs over a wide area of Asia and Pacific region. Chiggers (larval-stage of trombiculid mites) are vectors for scrub typhus. Chiggers prefer warm, moist,and shady places.

Features of Rickettsial infection In Hong Kong, majority of the reported cases contracted the diseases locally,in which half of the spotted fever and scrub typhus cases were related to outdoor activities,such as hiking or camping in rural areas. In contrast, poor environmental hygiene condition such as inadequately managed rubbish collection points and wet markets was a risk factor for contracting murine typhus.

Features of Rickettsial infection At the site of inoculation organisms localize in endothelial cells and entry into the cells by receptor mediated mechanism and phagocytosis. It proliferates intracelluarly. A papule may be formed and later ulcerates in the central. It is called eschar. The organisms released from the infected cells can infect endothelial cells in the blood vessels throughout the body via lymphatic vessels. The rickettsemia causes generalized vasculitis affecting every organs in the body.

Features of Rickettsial infection Diagnosis of rickettsial infection relies upon a combination of clinical, epidemiology and laboratory findings

ATYPICAL BACTERIA Are organisms that do not fit in virus,bacteria or fungus. Thus bacteria are called atypical and produce atypical pneumonia. These organisms do not stain with gram stain and do not follow any common morphological pattern.

ATYPICAL BACTERIA These are the bacteria's that will be called as atypical bacteria and causing also atypical pneumonias like other viral agents etc.and constitute following organisms Legionella Mycoplasma pneumoniae Chlamydia trachomatis an afebrile pneumonia, usually seen in 2 wk to 6 months of age Chlamydia psittaci Chlamydia pneumoniae , Chlamydia trachomatis This is a sexually transmitted disease that may also cause pneumonia and bronchitis. It usually is a subacute infection of early infancy producing a sudden cough and eosinophilia without fever that lasts from 1-3 weeks, but it may occur in adults too.

ATYPICAL BACTERIA Chlamydia pneumoniae , Chlamydia trachomatis Are transmitted to infants at birth from the cervix of an infected mother. Adults having chlamydial pneumonia are usually immunocompromised with the infection spreading from the eye (conjunctival) to the respiratory tract via the nasolacrimal duct. Coxiella burnetii (Q-fever) ingestion of comtaminated milk, or inhalation of contaminated aerosols from barnyard animals Mycobacterium tuberculosis and other Mycobacterium

Classification of Pneumonias BY SITE LOBAR PNEUMONIA INTERSTITIAL PNEUMONIA BRONCHOPNEUMONIA

Lobar Pneumonia Organisms cause inflammatory exudate that fill up air spaces and result in consolidation of whole lobe of lung

Broncho-Pneumonia Common cause is satphylococcal infection. Bronchopneumonia is characterized by patchy exudative consolidation of lung parenchyma due to terminal bronchiolitis with consolidation of peribronchial alveoli. Common also with gram negative organisms

Pathogenesis of Bronchopneumonia There is initial terminal bronchiolitis with patchy consolidation of peribronchial lung tissue. Bronchioles are plugged by the swollen mucosa and their secretion. As a result, the air cannot enter the alveoli. The imprisoned air in the alveoli is absorbed causing collapse of the alveoli. Collapsed areas are surrounded by areas of compensatory emphysema. Consolidated areas are surrounded, from inside outwards, by areas of congestion, collapse and emphysema . Resolution of the exudate usually restores normal lung structure. Organization may occur and result in fibrous scarring in some cases. Aggressive disease may produce abscesses.

Broncho-Pneumonia Bronchopneumonia may occur as a complication of some disease. E.g. In children - Diphtheria , Measles , Whooping Cough In adult - Influenza, typhoid & Paratyphoid fever etc It is often seen in two extremes of life (in infants & old age).

Broncho-Pneumonia 1. Bilateral (less often unilateral), patchy consolidation with intervening normal lung tissue. 3. Lesion is more extensive at the base of the lung and often fuses together resembling lobar pneumonia (confluent bronchopneumonia). 4. Range from red to gray depending on age of the lesion.

Atypical or Interstitial or viral Pneumonia Atypical pneumonia as already said is caused by atypical bacteria that do not gram stain or do not fit in any category like in virus or bacteria.some special fungi and rickettsia and most of viruses can also cause this type of pneumonia .The inflammation is confined to interalveolar septa or interstitial spaces between alveoli and radiologically gives appearance of reticulonodular pattern.

Atypical or Interstitial or viral Pneumonia In the next slide you will see white spaces that are alveolar spaces and are empty and clear.but surrounded by swollen interstitial tissue infiltrated with inflammatory cells.

Atypical or Interstitial or viral Pneumonia Causes Mycoplasma Legionella Chlamydia Pneumocystis carinni . coxiella Viruses

Atypical or Interstitial or viral Pneumonia Fungi Histoplasma capsulatum (histoplasmosis) Coccidioides immitis (coccidioidomycosis)

Atypical or Interstitial or viral Pneumonia

Causes of Interstitial & atypical pneumonia Mycoplasma pneumonia occurs in Adolescents and young adults Legionnaire's disease (summer peak) Adult Cooling towers, condensers, excavation sites Water tanks Psittacosis Adult Psittacine birds, pigeons, turkeys, pet shops, zoos

Causes of Interstitial & atypical pneumonia Q fever Adult Cattle, sheep, goats, contaminated milk, birthing various livestock Tularemia Adult Rabbits, ticks Anthrax Adult Goat hair/skin, wool, bonemeal fertilizer Viral pneumonia Winter All

Causes of Interstitial & atypical pneumonia Histoplasmosis All Chickens, bats, river valleys Coccidioidomycos All California, Southwest USA

LEGIONELLA Occurred first in military personnel called legionnairs while using tank water etc.

Legionella pneumonia(legionnairs disease) Caused by legionella pneumophila Transmitted in water droplets orginating in infected humidifier ,cooling systems and from stagnant water in cisterns and shower heads Cough with mucoid scanty sputum Gastrointestinal symptoms like nausea,abdominal pain and diarrhoea and mental confusion or delirium are common

Atypical or Interstitial or viral Pneumonia As the conditions caused by these agents have different courses and respond to different treatments, the identification of the specific causative pathogen is important

Atypical or Interstitial or viral Pneumonia In atypical pneumonia the x ray finding usually do not show lobar type of picture but meaning that the affection is restricted to small areas that is interstitial spaces between alveoli, rather than involving a whole lobe. As the disease progresses, however, the look can tend to be lobar pneumonia. There is also absence of leukocytosis. Extrapulmonary symptoms, give some clue to the causing organism.

Atypical or Interstitial or viral Pneumonia In atypical pneumonia the symptoms are generally more but if you look for chest sings they are very little or absent even the x-ray may not show any thing. Though the patient looks worse.so this type of setting is called occult pneumonia.

Atypical or Interstitial or viral Pneumonia In atypical pneumonia if you look at x ray chest you will find infiltration(white haziness) commonly begins in the perihilar region (where the bronchus begins) and spreads in a wedge- or fan-shaped fashion toward the periphery of the lung field. Or u may find network of reticular shadows as small linear striations running in all directions on which may be small white nodular appearance. Or may be small patchy.

Atypical or Interstitial or viral Pneumonia The most common pathogen of this group is Mycoplasma pneumoniae. It ranks second only to S. pneumoniae. onset is usually more insidious.

Atypical or Interstitial or viral Pneumonia A combination of the clinical, epidemiologic, radiographic, and laboratory features can specify a certain etiology so that empiric treatment can begin.

Mycoplasma Mycoplasmosis is a collective term for infectious diseases caused by the micro-organisms called mycoplasmas. There are a number of mycoplasmas that can infect poultry, number of bird species including chickens, turkeys, gamebirds and pigeons. Mycoplasma pneumonia occurs in Adolescents and young adults

Mycoplasma Mycoplasma pneumoniae can be communicated through close personal contact via respiratory droplets or contact with poultry or birds chicken etc. EXTRAPULMONARY MANIFESTATIONS: gastrointestinal musculoskeletal dermatologic cardiac neurologic symptoms

Mycoplasma Depending on the severity of illness, additional studies may be done, include: Complete blood count (CBC) Blood cultures Blood tests for antibodies to mycoplasma Bronchoscopy Open lung biopsy (only done in very serious illnesses when the diagnosis cannot be made from other sources)

Mycoplasma Sputum culture to check for mycoplasma bacteria A urine test or a throat swab may also be done. Individuals working or living in crowded areas including homeless shelters or schools are at a greater risk of developing mycoplasma pneumonia. Patients may report exposure to overcrowded institutions such as jails, shelters for homeless persons, or military training camps.

Mycoplasma The symptoms associated with this condition include chest pain, cough and excessive sweating. The cough is not bloody and is usually dry. Those suffering from this condition may also get fever, headache and sore throat.

Legionnaire's disease (summer peak) Adult Cooling towers, condensers, excavation sites,water tanks. Interstitial / atypical Pneumonia Legionella pneumophila: Patients may report exposure to contaminated air-conditioning cooling towers, exposure to a grocery store mist machine, or a visit or recent stay in a hospital with a contaminated water system.

Psittacosis Has three species Chlamydia psittaci C. trachomatis C. pneumoniae Transmission occurs person to person via respiratory secretions in case of C.pneumoniae

Interstitial / atypical Pneumonia Coxiella burnetii: This is related to exposure to infected parturient cats, cattle, sheep, or goats. Chlamydia psittaci: Patients may report exposure to turkeys, chickens, ducks, or psittacine birds. •Travel history

Interstitial / atypical Pneumonia Burkholderia (Pseudomonas) pseudomallei (melioidosis): This infection may result from travel to Thailand or other countries in Southeast Asia. M tuberculosis: Pneumonia may develop in immigrants from Asia or Africa.

Interstitial / atypical Pneumonia Chemical pneumonia (usually called chemical pneumonitis) is caused by chemical toxicants such as pesticides, which may enter the body by inhalation or by skin contact. When the toxic substance is an oil, the pneumonia may be called lipoid pneumonia

Serological tests for atypical pneumonia Mycoplasma pneumoniae > complement fixation test, IgM by latex agglutination or ELISA, cold agglutinins Legionella pneumophila >rapid microagglutination test, test for Legionella antigen in the urine. Chlamydia spp >microimmunofluorescence, ELISA Coxiella burnetii >complement fixation test.

Serological tests for atypical pneumonia Skin testing for histoplasmosis,coccidioidomycosis. serologic tests. A four fold or greater rise in titer is confirmatory of an acute infection.

SOME OTHER FORMS OF PNEUMONIA Eosinophilic pneumonia is invasion of the lung by eosinophils, a particular kind of white blood cell. Eosinophilic pneumonia often occurs in response to infection with a parasite or after exposure to certain

SOME OTHER FORMS OF PNEUMONIA Chemical pneumonia (usually called chemical pneumonitis) is caused by chemical toxicants such as pesticides, which may enter the body by inhalation or by skin contact. When the toxic substance is an oil, the pneumonia may be called lipoid pneumonia

Classification by mode of acquiring pneumonia 1.Community acquired pneumonia 2.Nosocomial pneumonia

Community acquired pneumonia This indicates pneumonia occuring in a person in a community outside hospital . Common organisms responsible are Streptocccus pneumoniae Haemophilus influenzae Moraxella catarrhalis .

Nosocomial pneumonia Acquired by a patient in the following settings: in a hospital after being admitted for >48 hours or <7 days after a patient is discharged from hospital.

Nosocomial Bacterial Pneumonia - Etiology Gram-negative enteric bacilli (predominant) Gram-positive cocci, including: Staphylococcus aureus ( e.g., MRSA ), Streptococcus pneumoniae Anaerobes Others

Nosocomial pneumonia new cough new infiltrate or progressive infiltrate on chest radiograph, accompanied by: fever or hypothermia, leukocytosis, sputum production Etiology: polymicrobial In wards,icu,and in patients on mechanical vetillation

ASPIRATION PNEUMONIA OCCUR IN FOLLOWING SETTINGS Altered Level of Consciousness Alcoholism Seizures Drugs Anesthesia Central nervous system disorders Trauma Dysphagia Esophageal disorders Neurological disorders Mechanical Disruption of Functional Barriers Nasogastric tubes

Coliforms" - bacteria related to Escherichia coli from GIT etc- and Pseudomonas aeruginosa can also cause bronchopneumonia in ICU patients who require assisted ventilation to support their breathing

RISK FACTORS THAT FORM BASIS OF SECONDARY PNEUMONIAS Pre existing disease like Partial bronchial obstruction by tumour causes stasis of secretions and secondary infection distal to site of obstruction In acute bronchitis,bronchietasis and lung abcess ,the pus may be carried to alveoli

RISK FACTORS Ineffective coughing post surgery,laryngeal paralysis,bulbar paralysis Vomitting and aspiration during anaesthesia,sleep,coma,alcholism Aspiration Inhalation of septic matter during tonsillectomy,dental procedure,or general anaesthesia

RISK FACTORS Aspiration of gastric contents in pts with gastro-oesophageal reflux disease(HCL may directly and quickly cause lung damage resulting in chemical pneumonia

RISK FACTORS Infection with opportunistic pathogen in immunocompromised host (AIDS,Malignancy).TB,Fungal,and cryptosporidia, toxoplasma infection can take over

RISK FACTORS - Asplenia HIV/AIDS Elderly Defective Clearing mechanism Cough/gag Reflex – Coma, paralysis, sick. Mucosal Injury – smoking, toxin aspiration Low Alveolar defense - Immunodeficiency Pulmonary edema – Cardiac failure, embol. Obstructions – foreign body, tumors - Prolonged mechanical ventilation - extremes of age

RISK FACTORS Hypogammaglubolinemia Sever Neutrogena Corticosteroid therapy Environmental risk factors Aspergillosis (air, water) Legionella (water) Histoplasmosis (bird droppings & bat caves) Psittacosis (pet birds) Anthrax (soil)

Route of Entry Aspiration Inhalation Inoculation Colonization (in patients with COPD) Hematogenous spread (patients with sepsis) Direct spread

Route of Entry Typical pneumonia is usually acquired by droplet spread of the pathogen through sneezing,coughing etc. The organism may also manifest itself as a suprainfection in patients previously infected by an upper or lower respiratory viral infection. There is no age-specific predisposition

Route of Entry So the most common way you catch pneumonia bacterial or viral is to breathe infected air droplets from someone who has pneumonia or common cold,running nose,sneezing etc. Another cause is an improperly cleaned air conditioner. Yet another source of infection in your lungs is spread by an infection from somewhere else in your body, such as your kidney.

Route of Entry Germs are spread both by aerosolized droplets that you breathe in (such as from a sneeze), and through body fluids left on surfaces like counter tops and door handles. If you avoid people who are coughing or sneezing, and wash your hands frequently, you can reduce your chances of catching a virus or bacterial infection.

Route of Entry I would suggest keeping everything sprayed with a antibacterial agent of some sort, strict hand washing, You could also buy face masks and gloves for you and your children until another person is no longer contagious.

Route of Entry Spread is common in industrialized cities, lower socioeconomic groups or in cases of crowded living quarters. The incidence of bacterial pneumonia increases in winter and spring in temperate zones.

Pathogenesis how organism reaches alveoli

Pathogenesis of Pneumonia Congestion Red Hepatisation Grey Hepatization Resolution

Four phases of pneumonia are 1. Congestion (1-2 days) 2. Red hepatization (2nd-4th day) 3. Gray hepatization (4th-6th day) 4. Resolution (6th day onwards)

Congestion (1-2 days) Organism after entry from various routes Come in contact with alveolar walls The capillaries in alveolar walls in response increase their blood supply by dilatation so that inflammatory cells reach there quickly for defense, increased blood flow and dilatation result thus in congestion of that turns lung into mild reddish colour.

Red hepatization (2nd-4th day) Because of this congestion and dilatation there is outpouring of red cells and hemorrhage into alveoli as well as some polymorphs the consistency of the affected lung thus becomes like a liver and very red in colour, this stage therefore has been named “red hepatization”.

Gray hepatization (4th-6th day) In this stage the macrophages appear which phagocytose the fragmented polymorphonuclear leukocytes and red cells and other inflammatory debris.The lung now no longer remains congested but still remains firm in this stage of “gray hepatization”. Its due to WBCs,lymphocytes ,macrophages that colour is grey.

Gray hepatization (4th-6th day) Polymorphonuclear leukocytes, at this stage produce the rusty sputum since RBCs are broken down and release haemosidren mixed with sputum is rusty.

Resolution (6 th day onwards) The alveolar exudates is then removed and the lung gradually returns to normal.

Summary of Stages of Lobar Pneumonia: Four stages: Congestion – vasodilatation Red Hepatization - Exudation+RBC Gray Hepatization - neutro & Macrophages. Resolution – few macrophages, normal.

Complications of Pneumonia A painful pleuritis pleural effusion Pyothorax Empyema Fibrosis due to laying down of fibroblasts in non resolving pneumonia called carnification of lung. Necrotizing lung & lung abcess

The pleural surface at the lower left demonstrates areas of yellow-tan purulent exudate. Pneumonia may be complicated by a pleuritis. Initially, there may just be an effusion into the pleural space. There may also be a fibrinous pleuritis. However, bacterial infections of lung can spread to the pleura to produce a purulent pleuritis. A collection of pus in the pleural space is known as empyema .

Complications of Pneumonia 1. Pulmonary fibrosis. 2. Bronchiectasis 3. Lung abscess 4. Empyema 5. Bacteraemia with abscess in other organs 6.ARDS 7.Bacteremia 8.Collapse of lung 9.Hemoptysis

Complications of Pneumonia Parapneumonic effusions Septic arthritis Endocarditis Pericarditis Respiratory failure Mental symptoms

Investigations of Pneumonia Total and differential count PBF Blood ,urine,sputum culture/sensitivity Gram staining/stain for AFB Fiberoptic bronchoscopy with bronchial washing/ brushing /biopsy

Investigations of Pneumonia X-ray chest CT chest Serological tests ABG Other all routine basic tests

TREATMENT OF PNEUMONIA Uncomplicated pneumonia Erythromycin 250-500mg 6 hrly or with combination with cefuroxime or Amoxycillin or Ampicillin 500 mg 6-8 hrly x 7-10 days. Azithromycin 500mg x3-5 days if pt intolerant to erythromycin Consider levofloxacin 500 mg once a day if pt elderly

TREATMENT OF PNEUMONIA Moderately sick Ceftriaxone 1-2 gram once or BD iv and erythromycin or azithromycin 500 mg daily Ampicillin –clauvulanic acid plus erythromycin or azithromycin

TREATMENT OF PNEUMONIA Severely sick Ceftriaxone 1-2 gram once or twice a day plus either azithromycin 500 mg a day or levofloxacin 500 once a day x 7-10days

TREATMENT OF PNEUMONIA In multiresistant cases and in staphylococcal or gram negative infection can give multiresistant strains give Vancomycin 500mg to 1 gram I/V twice daily.

TREATMENT OF PNEUMONIA For klebsiella,legionella,actinomycosis Gentamycin, ceftriaxone for two weeks even Azithromycin. Rifampicin be given in legionella also For actinomycosis also Benzyle penicillin 10-20 million units iv 6 hrly day. In severe cases piperacillin plus tazobactam or Meropenem. Clindamycin 800mg 8 hrly followed by 300 mg orally 8hrly in aspiration pneumonia.

Treatment for rickettsial infection Rickettsial infections respond promptly to early treatment with the antibiotics doxycycline chloramphenicol tetracycline

Treatment for fungal infections First give test dose as follows: 1 mg in 20 ml of D5W over 30 minutes to 1 hour; monitor vital signs every 30 minutes for next 2 hours.if no untoward reaction occurs then do as follows.

Treatment for fungal infections Amphotericin B comes in a vial that contains 50mg of powder. Each vial needs to be mixed with 10ml of Water for Injection. The dose is then drawn up and again mixed with 500mL of dextrose and shaken.

Treatment for fungal infections then give 0.25 to 0.5 mg/kg daily by slow I.V. infusion (0.1 mg/ml over 2 to 6 hours) or 1mg/10mL. with or without flucytosine for two weeks to several months.even on alternate days. fatal infections may require higher dosages (1 to 1.5 mg/kg daily).

Treatment for fungal infections The Amphotericin B should NEVER be mixed with Normal Saline or Half Normal Saline as it will precipitate. Flush I.V. line with 5% dextrose injection before and after infusion. Pretreat with antihistamines, antipyretics, or corticosteroids, as prescribed.

Treatment for fungal infections What to Monitor in Patients Receiving Amphotericin B The following should be monitored more aggressively during the initial 2 weeks of therapy. 1.The patient's temperature, pulse, respiration, and blood pressure should be recorded every 30 minutes for 2 to 4 hours.and keep eye on

Treatment for fungal infections 2. BUN, SCr 3. Potassium, magnesium, sodium, and other electrolytes 4. CBC Since patient tolerance varies greatly, the dosage of amphotericin B must be individualized and adjusted according to the patient's clinical status (e.g., site and severity of infection, etiologic agent, cardio-renal function, etc.).

Treatment for fungal infections The efficacy and safety of 2 weeks of intravenous itraconazole (200 mg twice daily for 2 days, then 200 mg once daily for 12 days) followed by 12 weeks of oral itraconazole capsules 200 mg twice daily were also evaluated in a multicentre, open trial in 31 immunocompromised patients with invasive pulmonary aspergillosis .

Treatment for fungal infections FLUCYTOSINE Older children: A dose of 50 mg/kg every 6 or 8 hours is normally used in older children. Always check the blood level after 1–2 days if a dose as high as this is used in a young baby.

Treatment for viral infections flucytosine 250,250mg capsules are also available and given as 50-150mg/kg/day 6-8 hrly x 4-6 weeks. or may be 2 weeks followed by fluconazole. so is with amphotericin x 10days or 4-6 weeks. amphotericin B alone (0.5 mg/kg/day; or amphotericin B (0.5 mg/kg/day) plus 5-flucytosine (150 mg/kg/day; intravenously. Therapy was given for an average duration of 10 days in some groups.

Treatment for viral infections Acyclovir The duration of intravenous therapy with Acyclovir is usually 5 days. The doses recommended above (5 or 10mg/kg bodyweight or 500mg/m2 ) should be given every 12 hours.

Treatment for viral infections Adults: 5 mg/kg infused at a constant rate over at least 1 hour, every 8 hours for 7 days in adult patients with normal renal function. oral dose 800mg 4 hrly x7-10days Chronic Suppressive Therapy for Recurrent Disease: 400 mg 2 times daily for up to 12 months

BULGING FISSURE KILEBSILLA PNEUMONIA

Afebrile Pneumonia Syndrome Afebrile pneumonia syndrome (APS) is a relatively uncommon disease of neonates and infants younger than 6 months. APS was first described as a vertically transmitted infection of newborns and young infants by the female genital tract pathogens Chlamydia trachomatis, cytomegalovirus (CMV), and Ureaplasma urealyticum

Afebrile Pneumonia Syndrome More recently, other potential causes of the syndrome have been recognized, including respiratory syncytial virus (RSV), parainfluenza virus, adenovirus, and Pneumocystis jiroveci.

Afebrile Pneumonia Syndrome Early symptoms of respiratory disease in neonates and infants are frequently nonspecific and include changes in feeding status, listlessness, irritability, and poor color. Onset may be acute or subacute. Typically, infants are afebrile or have only a low-grade fever (<102°F).

Afebrile Pneumonia Syndrome Viral afebrile pneumonia syndrome (APS) typically has a more rapid onset, with a 1- to 2-day history of rhinorrhea and, often, a brassy cough. Nonspecific findings of poor feeding, lethargy, and irritability may be accompanied by congestion, apnea (uncommon), and cyanosis (rare). Fever is often absent in very young infants.

Factors that are associated with increased risk of contracting APS in infants include the following : Low socioeconomic status Young maternal age Multiple maternal sex partners Unmarried maternal status Exposure to other children at home or in daycare Exposure to secondhand smoke

Pneumocystis carinii pneumonitis (PCP) is a common opportunistic disease that occurs almost exclusively in persons who have profound immunodeficiency. PCP was and still is the most common life-threatening opportunistic infection occurring in patients with HIV disease.

The taxonomy of P carinii has not been established. If it is either a protozoan or a fungus. Recent studies show P carinii more closely resemble fungi than protozoa. Eriksson places P carinii in a new family, Pneumocystidaceae , and in a new order, Pneumocystidales (Ascomycota).

The mode of replication of P carinii has not been established. However, the stages in its life cycle have been characterized. Sporozoites excyst through breaks in the cyst wall and then are termed trophozoites. The means by which the trophozoite form progresses to the cyst phase is not known.

The portal of entry for P carinii has not been firmly established; however, because with rare exceptions the organism has been found only in the lung, inhalation is a likely mode of transmission. Airborne transmission has been demonstrated in animals. In most individuals, the organism is dormant and sparsely dispersed in the lung, with no apparent host response (latent infection). In susceptible (immunocompromised) hosts, the organism occurs in massive numbers.

With rare exceptions, P carinni causes disease only when natural mechanisms of host defense are compromised.

Pneumocystis carinii has been found in the lungs of rats, rabbits, mice, dogs, sheep, goats, ferrets, chimpanzees, guinea pigs, horses, and monkeys. The organism has been reported in lower animals and humans from all continents. Animal to animal transmission by the airborne route has been demonstrated. Because about 70 percent of healthy individuals may have humoral antibody to P carinii , subclinical infection must be highly prevalent.

Tachypnea and fever are consistent features of the pneumonitis, and diffuse bilateral alveolar disease can be observed by radiography. Diagnosis requires the identification of P carinii in pulmonary tissue or lower airway fluids. Such specimens may be obtained by lung biopsy, inducement of sputum, bronchoalveolar lavage, or needle aspiration of the lung. The Gomori, Giemsa, fluorescence-labelled antibody, or toluidine blue O stains may be used to identify the organism.

Four drugs currently available for therapy of P carinii pneumonitis are: Pentamidine isethionate Trimethoprim-Sulfamethoxazole atovaquone trimetrevate Trimethoprim-sulfamethoxazole is preferred because of its low toxicity and greater efficacy.

BACTRIM-DS Bactrim DS tablet contains. 160 mg of trimethoprim and 800 mg of Sulfamethoxazole. 21 days course

Prednisolone 40 mg bid x 5 days, then 40 mg/day x 5 days, then 20 mg/day to completion of treatment

Alternative Treatments: TMP 15 mg/kg/day PO + dapsone 100 mg/day x 21 days Pentamidine 4 mg/kg/day IV x 21 days -Atovaquone 750 mg PO bid with meal x 21 days PCP is the most frequently identified serious in HIV disease

PCP Site of Infection: Attaches to and damages type I pneumocytes. Results in interstitial inflammation with infiltration of lymphocytes and macrophages in interstitial tissue of lungs.

PCP: Extrapulmonary Infection Extrapulmonary sites of infection: Reticuloendothelial system (liver, spleen, bone marrow) Sinuses, middle ear, eye, and dermis around head.

Patients at Risk AIDS at CD4 < 200. Congenital and acquired defects in cellular immunity. Organ transplantation recipients. Chemotherapy. Corticosteroids. Malnutrition. Premature birth.

PCP: Clinical Features Cough Usually nonproductive, occasionally whitish sputum. Dyspnea Fever May be accompanied by night sweats, but not rigors. Rales May be present, but are often absent.

PCP: Pearls Similar to atypical pneumonias. Physical examination is often less severe than x-ray findings. Gradual onset

PCP: CXR Findings 90-95% have pulmonary infiltrates. Combined interstitial & alveolar infiltrates. Predominantly at bases and centrally. Pneumothorax can be present. Lace like appearance.

Histologic Diagnosis Sputum (induced if necessary): Diagnostic Flexible Bronchoscopy with Bronchoalveolar lavage to find pnuemocytis carinii in sputum and secretions. .

Histological Diagnosis Transbronchial biopsy: Percutaneous Lung aspiration: Open lung biopsy: Only in rapidly deteriorating patients with a negative bronchoscopy.

Histologic Diagnosis Future techniques: Serum PCR? Stains: Gram and Giemsa stain both cyst and trophozoites. Gomori ’ s silver and Toluidine stains for cysts.

Pathophysiology Pneumocystis infection is specific to the lung Trophozoites bind tightly to alveolar epithelium, but do not invade cells CD4 T cells recognize pathogen and recruit macrophages Macrophages release TNF- α which propagates immune response through further recruitment and cytokine release

Pathophysiology continued Results in a large inflammatory response which can lead to diffuse alveolar damage, impaired gas exchange, and respiratory failure

Diagnosis continued Gomori methenamine silver (GMS) stain from BAL specimen showing “crushed ping-pong ball” appearance of cyst wall

Diagnosis continued Calcofluor white stains the fungal cyst wall for rapid diagnosis

Diagnosis continued Immunofluorescence showing trophozoites (arrowheads) and cysts (arrows)

Radiographic Findings Typically see bilateral, ground glass opacities that progress over time to become homogenous and diffuse 10% of HIV patients will show upper lobe cysts Less common to see solitary or multiple nodules, upper lobe predominance, or pneumothorax Rare to see pleural effusion or lymphadenopathy (search for another cause) HRCT is more sensitive during early stages when CXR will likely appear normal

PA Chest Radiograph Demonstrates bilateral, perihilar, R > L, ground glass opacities

PA Chest Radiograph Progressive disease showing extensive ground glass opacification with consolidation

PA Chest Radiograph Diffuse ground glass opacity with reticular pattern indicating cyst formation

PA Chest Radiograph Diffuse, ground glass opacities with large left sided pneumothorax Cysts predispose patients to pneumothorax

PA Chest Radiograph Patchy, ground glass opacities in the apices in an AIDS patient on pentamidine prophylaxis

PNEUMONIAS BY DR BASHIR AHMED DAR ASSOCIATE PROFESSOR MEDICINE SOPORE KASHMIR

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