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  • Pneumonia
  • PA film showing consolidated right upper lobe. Lateral film showing consolidation limited inferiorly by horizontal fissure (arrows).
  • Mycoplasmal pneumonia. “Classic” homogeneous consolidation of the right middle lobe caused by a serologically confirmed infection of Mycoplasma pneumoniae.PA film showing right middle-lobe pneumonia: note obscured cardiac border adjacent to the consolidation. Lateral view showing consolidation demarcated by horizontal and oblique fissures.
  • Legionella
  • A, Legionellosis, initial chest radiograph showing left lower lobe consolidation.B, Legionellosis, initial chest computed tomography demonstrates left lower lobe alveolar infiltrate and pleural effusion.
  • B, Legionellosis, initial chest computed tomography demonstrates left lower lobe alveolar infiltrate and pleural effusion. C, Legionellosis, chest computed tomography performed 6 weeks later (and after a 3-week course of macrolide) demonstrates partial resolution of left lower lobe alveolar infiltrate and disappearance of parapneumonicpleural effusion.
  • This x-ray shows a large lobar density in the right upper lobe with some area of incomplete consolidation in the density. The lower end of this opacity is bulging and the horizontal fissure is displaced downward.The lateral confirms large right upper lobe pneumonia with a bulging fissure seen in a densely consolidated lobe due to klebsiella pneumonia.
  • PA chest radiograph shows bilateral interstitial and alveolar opacities with an upper lung predominant distribution.
  • Pneumonia

    1. 1. Case 1• A previously healthy male, 32 had a running nose since last week presented with a 2-day history of fever, shaking chills (rigors), cough productive of rusty sputum, dyspnea, and chest pain getting worse with deep inspiration.• O/E Pt is alert, Vitals :T 39°C, HR 110, RR 25, BP 110/80. SaO2 is 92%.• He has reduced tactile fremitus, dullness to percussion, bronchial breath sounds and crackles at left 6-9 rib-interspaces posteriorly. 2-Nov-12
    2. 2. 2-Nov-12
    3. 3. What is your diagnosis? 2-Nov-12
    4. 4. Definition “ACUTE RESPIRATORY ILLNESS ASSOCIATED WITH PYREXIA AND COUGH, AND RECENTLY DEVELOPED RADIOGRAPHIC SIGNS OF CONSOLIDATION OF A PART OR PARTS OF ONE OR BOTH LUNGS” • The commonest infectious cause of death • Most of mortality at extremes of ages • Most cases are treatable if diagnosed and treated with appropriate antibiotics 2-Nov-12
    5. 5. 2-Nov-12
    6. 6. How severe is our patient’s pneumonia? 2-Nov-12
    7. 7. Applying CURB-65 Rule 2-Nov-12
    8. 8. Case 1• A previously healthy male, 32 had a running nose since last week presented with a 2-day history of fever, shaking chills (rigors), cough productive of rusty sputum, dyspnea, and chest pain getting worse with deep inspiration.• O/E Pt is alert, Vitals :T 39°C, HR 110, RR 25, BP 110/80 SaO2 is 92%.• He has reduced tactile fremitus, dullness to percussion, bronchial breath sounds and crackles at left 6-9 rib-interspaces posteriorly. 2-Nov-12
    9. 9. Classification of pneumonias• BRONCHO-pneumonia• LOBAR pneumonia • SEGMENTAL pneumonia • SUBSEGMENTAL pneumoniaAnd ‘Double’ pneumonia 2-Nov-12
    10. 10. 2-Nov-12
    11. 11. Distribution of lung involvement inlobar pneumonia and bronchopneumonia 2-Nov-12
    12. 12. 2-Nov-12
    13. 13. Classification of pneumonias• COMMUNITY ACQUIRED (CAP)• HOSPITAL ACQUIRED (HAP) (Nosocomial)• VENTILATOR ASSOCIATED (VAP)• Healthcare-associated (HCAP)• ASPIRATION (Alcoholics/epileptics/comatosed)• IMMUNOCOMPROMISED PATIENT (PICP) OR (HIV – associated) 2-Nov-12
    14. 14. Classification of pneumonias• Hospital-acquired (or nosocomial) pneumonia (HAP) is pneumonia that occurs 48 hours or more after admission and did not appear to be incubating at the time of admission.• Ventilator-associated pneumonia (VAP) is a type of HAP that develops more than 48 to 72 hours after endotracheal intubation.• Healthcare-associated pneumonia (HCAP) is defined as pneumonia that occurs in a non-hospitalized patient with extensive healthcare contact, as defined by one or more of the following: o Hospitalization in an acute care hospital for two or more days within the prior 90 days o Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days o Attendance at a hospital or hemodialysis clinic within the prior 30 days o Residence in a nursing home or other long-term 2-Nov-12 care facility
    15. 15. CAP - MicrobiologyTypical CAP Atypical CAP Strept. Pneumoniae  Influinza + other viruses Hemophilus influinzae  Mycoplasma Legionella pneumophila pneumoniae Staphylococcus aureus  Legionella pneumophila Gram negative bacilli  Chlamydia Pneumoniae Moraxella catarrhalis  Chlamydia psittaci  Coxiella burneti 2-Nov-12
    16. 16. CAP - PresentationTypical CAP Atypical CAP an abrupt onset,  a progressive onset, high fever, chills,  fever without chills, productive cough,  dry cough, thoracic pain,  headache, myalgia, focal clinical signs,  diffuse crackles, lobar or segmental  interstitial infiltrates on chest radiographic findings, radiograph, leukocytosis, and  modest leukocytosis, sputum Gram stain that is  sputum Gram stain (and positive for possibly culture) that is bacteria, frequently of a negative for bacteria single predominant type.  Mostly due to intracellular Mostly due to extracellular bacteria or to viruses. bacteria such as S. pneumoniae, Staph aureus, and H. influenzae. 2-Nov-12
    17. 17. Other Pneumonias - MicrobiologyWhat are the differences?HAP, VAP, and HCAP may be caused by• Specific pathogens and can be polymicrobial.• Common pathogens include • Aerobic gram-negative bacilli (eg, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterobacter spp, Acinetobacter spp) • Gram-positive cocci (eg, Staphylococcus aureus, including MRSA, Streptococcus spp). • Viruses or fungi are significantly less common• Organisms may be multi-drug resistant 2-Nov-12
    18. 18. Case 2• A heavy smoker bank accountant of 46 years presented with high grade fever, worsening cough, little rusty sputum production and Rt pleuritic chest pain after a visit to Skardu two days ago (in the month of January).• O/E confused, RR 36/min, T 102 OF, P 110/min, BP 80/60, Hb 16.8 g/dl, TLC 18000 (88% N), Urea 32 mg/dl (5.3 mmol/L) Sputum Smear showed Gram Positive diplococci 2-Nov-12
    19. 19. ` 2-Nov-12
    20. 20. Streptococcus pneumoniae are Gram-positive, lancet-shaped cocci incouples Streptococcus pneumoniae A mucoid strain on blood agar showing alpha hemolysis (green zone surrounding colonies). Note the zone of inhibition around a filter paper disc impregnated with optochin. Viridans streptococci are not inhibited by optochin. 2-Nov-12
    21. 21. Streptococcus pneumoniaeQuellung (capsular swelling)reaction can be used todemonstrate the presence ofa specific capsular type of thebacterium. 2-Nov-12
    22. 22. Case 3• An 18 years old previously healthy medical student living in college hostel developed worsening dry cough with high grade pyrexia for three days. Two days ago he developed severe pain in Rt ear.• O/E Alert, Mildly Jaundiced, P: 120/min RR:32/min, T 101OF, BP: 110/80• Labs: Hb 13.4, TLC 8800, Normal Dif. S Bil 2.5 mg/dl ALT 34 iu/L, Urea 4 mmol/L 2-Nov-12
    23. 23. 2-Nov-12
    24. 24. 2-Nov-12
    25. 25. 2-Nov-12
    26. 26. 2-Nov-12
    27. 27. Mycoplasma PneumoniaExtrapulmonary manifestations CAHA (immune  Arthralgia hemolytic anemia)  Cervical Meningitis, lymphadenopathy, meningoencephalitis  Bullous myringitis Myalgia  Diarrhea Myocarditis, Pericarditis  Nausea and vomiting Skin eruptions  Hepatitis (EM/SJS) 2-Nov-12
    28. 28. Case 4• Male, 60, admitted to hospital with 2-wk H/O myalgia, headache, dyspnoea and cough without sputum.• O/E severely ill, cyanosed and delirious with T:39°C; P:110/min, RR:40/min and BP:110/60mmHg. PO2:43mmHg, PCO2:37mmHg, TLC 4600/cumm and urea 4 mmol/L.• He had received amoxicillin for 6 days before admission without improvement. CXR shows extensive bilateral multilobar consolidation. He kept birds as a hobby and one of his budgerigars 2-Nov-12
    29. 29. The clinical diagnosis of psittacosis was subsequently confirmed byserology tests. He was treated with intravenousfluids, oxygen and tetracycline and recovered fully 2-Nov-12
    30. 30. CT scan of the chest demonstrates patchy multifocal ground glassattenuation opacities (arrows). 2-Nov-12
    31. 31. Case 5 65-year-old female presented with acute respiratory failure. She had been sick for two weeks with fever, confusion, diarrhea, cough, and purulent sputum production. Her medical checkup two months ago was unremarkable. Urea 11 mmol/L, Creatinine 3.2 CXR and later CT chest obtained 2-Nov-12
    32. 32. 2-Nov-12
    33. 33. After3 weeks course of macrolide 2-Nov-12
    34. 34. Investigations in CAPROUTINE INVESTIGATIONS IN CAP• Chest X-ray +/- CT chest• Blood: CBC with reticulocytes• Tests for microbiological identification: 2-Nov-12
    35. 35. Differential diagnosisPULMONARY INFARCTIONPULMONARY/PLEURAL TUBERCULOSISPULMONARY EDEMANEOPLASTIC DISEASESUBDIPHRAGMATIC INFLAMMATION Subphrenic abscess, Amebic liver abscess, cholycystitis, pancreatitisRARE CONDITIONS Pulmonary eosinophilia, connective tissue diseases, Wegener’s granuloma 2-Nov-12
    36. 36. Approach to a patient with CAP History Examination Chest x-ray PNEUMONIA diagnosed CLUES TO LIKELY PATHOGEN•Environmental clues •Bird or animal contact•Season •Immunosuppression?•Recent hotel stay •Co-morbidity•Current epidemic •Age 2-Nov-12
    37. 37. Case 6 A 34-year-old woman is admitted with a history of fever, chills, and reddish sputum like red currant jelly for 10 days. She is on pulse steroid therapy for lupus nephritis. On physical examination, pulse 113 bpm; temperature 101°F; respirations 35/min; blood pressure 110/78 mm Hg. She looks ill and has crackles in the right upper lung field. Lab data: Hb 12 g/dL; WBCs 25.0/μL; N 92% BUN 8 mmol/L; creatinine 1.7 mg/dL 2-Nov-12
    38. 38. 2-Nov-12
    39. 39. 2-Nov-12
    40. 40. Klebsiella pneumoniae on aMacConkey agar plate. 2-Nov-12
    41. 41. Klebsiella pneumonia. Downward bulging of the minor fissure (arrow)due to massive enlargement of the right upper lobe with inflammatoryexudate. 2-Nov-12
    42. 42. Case 7• Male, 65, known diabetic with h/o 30 cpy presents with a 4-day history of productive cough with greenish sputum and shortness of breath. He has left-sided chest pain that is worse with deep inspiration and complained of fever and chills on the day of admission.• On physical exam, he has a temperature of 103°F; pulse 120 bpm; respirations 32/min; BP 100/68.• Lungs: increased tactile vocal fremitus with bronchial breath sounds on the left side posteriorly. 2-Nov-12
    43. 43. 2-Nov-12
    44. 44. Production of pyocyanin, water-soluble green pigment of Pseudomonas aeruginosa 2-Nov-12
    45. 45. Pseudomonas aeruginosa on an 2-Nov-12agar plate.
    46. 46. Case 8A 53-year-old man with a bone marrow transplant presented with one month hitory of dry cough and low grade pyrexia. CXR and CT scan show bilateral dense airspace and ground-glass opacities associated with airway dilatation. The distribution is predominantly central and upper lung. 2-Nov-12
    47. 47. 2-Nov-12
    48. 48. PCP pneumonia in a young HIV- CT scan of the chest demonstratespositive patient. cystic air spaces of varying sizes thatCXR demonstrates are consistent with pneumatoceles.predominantly central airspacedisease with peripheral sparing. 2-Nov-12
    49. 49. Pneumonia in theimmunocompromised hostMechanism Cause Organisms  Marrow Aplasia Staph. aureusNeutropenia  AMM Gram negative bacteria  Marrow infiltration Candida/ Aspergillus  AIDS Strept. pneumoniaeT cell defect  CLL H. influinzae  Lymphoma Staph. aureus  Immunosuppressants Gram negative bacteria  BMT Pneumocystis carinii  Splenectomy Myco. tuberculosis  CLL Strept. pneumoniae Antibody  Myeloma H. influinzaeproduction 2-Nov-12
    50. 50. Case 9 A 56-year-old male non-smoker is admitted with shortness of breath, right sided chest pain, and productive cough. He has a history of seizure disorder and is on anticonvulsants. Phenytoin level is within therapeutic range. On examination, there is dullness to percussion in the right upper chest with decreased breath sounds. Sputum for AFB and fungi are negative on initial smear and cultures are pending. 2-Nov-12
    51. 51. 2-Nov-12
    52. 52. Case 10 A 29-year-old man is admitted with cough, rusty sputum production, fever, chills, and decreased O2 saturation. His chest x-ray shows a right upper lobe nonhomogeneous opacity. He is treated with IV antibiotics but does not improve. On the fifth hospital day, CXR is repeated 2-Nov-12
    53. 53. 1: 15.09.2008 2: 20.09.20082-Nov-12
    54. 54. 3: 12.10.20082-Nov-12 4: 22.10.2008
    55. 55. Complications of pneumonia Respiratory failure Septicemia/ hypotension: ARF Atrial fibrillation Pleural effusion/ empyema Lung abscess Jaundice Pericarditis/myocarditis/endocarditis 2-Nov-12
    56. 56. 2-Nov-12