3. CLASSIFICATIONS OF PNEUMONIA
Pneumonia is classified based on
Radiological
• lobar: commonly involves one or more lobe.
• lobular (bronchopneumonia): it is characterized by patchy alveolar opacity with bronchial
• and bronchiolar inflammation. commonly involves both lower lobes
• Interstitial pneumonia
Clinically
• Community acquired pneumonia (CAP).
• Nosocomial (hospital acquired).
• Suppurative and aspiration pneumonia.
• Pneumonia in immunocompromised.
4. ■ Lobar pneumonia
Mostly cause of lobar pneumonia are
Streptococcus pneumoniae
Haemophilus influenza
Klebsiella
5. ■ Broncho pneumonia
Most common are
Staphylococcus aureus(most seen after a period of influenza)
6. ■ Interstitial pneumonia
In interstitial pneumonia the inflammation is predominant in alveolar septa
Is mostly caused by viral agents
Mycoplasma pneumoniae (not viral)
Influenza virus
7. COMMUNITY ACQUIRED PNEUMONIA
■ Community acquired pneumonia may be typical or atypical
Typical community acquired pneumonia present with more of cardinal symptoms of
respiratory system than the constitutional symptoms and the local symptoms are more
evidence
Most bacterial infection that cause pneumonia usually present with typical pneumonia
Common cause of typical pneumonia are
Streptococcus pneumoniae
Hemophilus influenza
Staphylococcus aureus
Klebsiella pneumoniae
8. COMMUNITY ACQUIRED PNEUMONIA
■ ATYPICAL CAP
Atypical CAP present with mostly constitutional symptoms with milder respiratory
symptoms as compared to the typical
Also in physical examination atypical may present no findings
Therefore absence of crackles in pneumonia does not rule it out as a diagnosis
9.
10. Symptoms that suggest of pneumonia
as mostly likely diagnosis
■ Cough
Cough may be productive or dry cough(atypical pneumonia) , productive cough with
rusty sputum is most common caused by S.pneumoniae
It is important to note that the cough in pneumonia mostly is of early onset and it should
be differentiated with cough of acute bronchitis with mostly present with no
constitutional symptoms
■ Fever may be with chills and rigor
■ Dyspnea, hemoptysis and chest pain(pleuritic chest pain)
■ Anorexia ,nausea and vomiting
11. Findings of lung consolidation in
examining respiratory system
■ ON INSPECTION
Restricted chest movement
■ ON PALPATION
Trachea central located and cardiac apex beat in normal position
Vocal fremitus increased(mention the location)
Reduced chest expansion of affected side
■ PERCUSSION
Woody dullness
■ AUSCULTATION
Breath sound present (mention location)
Vocal resonance increased(mention location)
Whispering pectoriloquy (mention location)
Wet crackles
Pleural rub
12. ■ Other extrapulmonary symptoms
• Myalgia, arthralgia and malaise: common in Legionella and Mycoplasma.
• Myocarditis and pericarditis: common in Mycoplasma pneumonia.
• Headache, meningoencephalitis and other neurological abnormalities: common in Legionella
pneumonia.
• Abdominal pain, diarrhea and vomiting, hepatitis: common in Legionella pneumonia.
• Labial herpes simplex reactivation: common in pneumococcal pneumonia.
• Skin rashes, such as erythema multiforme and erythema nodosum: common in Mycoplasma
• pneumonia.
13. RISK FACTORS FOR PNEUMONIA
• Age: ,16 or .65 years.
• Co-morbidities: HIV infection, diabetes mellitus, chronic kidney disease, malnutrition.
• Upper respiratory tract infections, recent influenza infection or other viral respiratory infection.
• Pre-existing lung disease: such as cystic fibrosis, bronchiectasis, COPD, obstructing lesion
• (bronchial carcinoma, inhaled foreign body, inhalation from oesophageal obstruction).
• Lifestyle: cigarette smoking, excess alcohol, intravenous drug use.
• Iatrogenic: immunosuppressant therapy (prolonged use of steroid, cytotoxic drugs).
• Others: Hospitalized ill patient, indoor air pollution.
14. COMPLICATIONS
• Pulmonary: Lung abscess, pleurisy, pleural effusion, empyema thoracis, pneumothorax by S. aureus,
fibrosis of lung, collapse, ARDS, delayed or slow resolution.
• Cardiovascular: Pericarditis, myocarditis, endocarditis, arrhythmia, peripheral circulatory failure.
• Neurological: Meningism, meningoencephalitis.
• Musculoskeletal: Septic arthritis.
• GIT: Meteorism (gaseous distension of stomach, intestine or abdomen).
• Others: Septicaemia, renal failure, hepatitis, ectopic abscess formation by S. aureus.
15. CRITERIA FOR ASSESSING SEVERITY
OF CAP
■ CURB 65 mnemonic is used to assessing the severity of the community acquired
pneumonia
• Confusion (mini mental score 8 or less or new disorientation in person, place or time).
• Urea .7 mmol/L or .20 mg/dl.
• Respiratory rate .30/min.
• Blood pressure (systolic BP ,90 mmHg and diastolic BP ,60 mmHg).
• Age .65 years
Each criteria is given 1 mark
16. CRITERIA FOR ASSESSING SEVERITY
OF CAP
1. CURB-65 score is used for management of CAP:
• Score 0 or 1: Home treatment.
• Score 2: Hospitalization.
• Score 3 or more: Manage in hospital, may require ICU (especially if score is 4 or 5).
17. CLINICAL CASES ON PNEUMONIA
CASE 1
A 73-year-old man attends his GP complaining of left-sided ‘sharp’ chest
pain. The pain is worse on inspiration, does not radiate and has
appeared in the past 2 days. He has not felt well for a week, with
uncontrollable shivering bouts and sweats. He has had a cough with
red-tinged sputum for 3 days.
He smokes 20 cigarettes a day, and he has angina complicated by a
myocardial infarction (MI) 2 years previously. He has recently felt
increasingly short of breath with effort.
18. CLINICAL CASES ON PNEUMONIA
■ ANSWER
The differential diagnoses are community-acquired streptococcal pneumonia, community-acquired
pneumonia caused by ‘atypical pathogen’, PE and tuberculosis (TB).
THE MAIN DIAGONOSIS
Symptoms typical of infection (fevers or sweats) with pleuritic chest pain suggest pneumonia, but
they can be associated with PE. Although there are no clinical features specific for a given pathogen,
Streptococcus pneumoniae remains the most common cause of community-acquired pneumonia.
The so-called ‘atypical’ pathogens such as Mycoplasma species, Legionella pneumophila and
Chlamydia species represent a substantial minority. In this patient, the age, presence of pleuritic
chest pain and cardiovascular comorbidity are all associated with streptococcal infections. The red-
tinged or rusty sputum is said to typify streptococcal infections, but haemoptysis may occur with
other pulmonary infections, especially TB.
19. CLINICAL CASES ON PNEUMONIA
■ INVESTIGATIONS TO BE DONE
• FBC – high leucocytosis (>20109/L) or leucopenia (<4109/L) carries a poor prognosis
• urea and electrolytes (U&Es) – high urea has a worse prognosis, and renal failure suggests
severe
• sepsis
liver function tests (LFTs) and creatine kinase – commonly abnormal in Legionella infections
• Sputum culture – unless previous antibiotics have been administered
• blood cultures and sensitivities – very sensitive marker for etiology if positive
• serum for serology – paired samples for atypical serology
• urine and blood samples – for pathogen antigens.
20. CLINICAL CASES ON PNEUMONIA
■ CASE 2
Mr ..., 42 years old, Government service holder, normotensive, nondiabetic, nonsmoker, hailing from
..., presented with high grade continued fever for ... days. The highest recorded temperature is
104°F. The fever is associated with chill and rigor, sometimes with profuse sweating, subsides with
paracetamol. The patient also complains of cough for ... days, which was initially dry, but for the last
few days, the cough is productive with purulent or yellowish sputum. He also complains of left sided
chest pain, which is sharp, stabbing in nature, more marked on coughing, and deep inspiration, also
on lying on the left side, and there is no radiation of pain. For the last ... days, he is experiencing
malaise, generalized bodyache and weakness. There is no history of breathlessness, hemoptysis or
contact with TB patient. His bowel and bladder habits are normal. There is no history of traveling,
exposure to firm animals or birds. There is no history of previous lung disease. For his illness he
took some paracetamol and cough syrup. No history of taking steroid, antibiotic, etc.
22. ■ A 40-year-old man without a significant past medical history comes to the emergency
room with a 3-day history of fever and shaking chills, and a 15-minute episode of rigor.
He also reports a nonproductive cough, anorexia, and the development of right-sided
pleuritic chest pain. Shortness of breath has been present for the past 12 hours. What is
the most likely diagnosis
■ ANS: CAP
23. ■ 105. A 40-year-old man without a significant past medical history comes to the emergency room with
a 3-day history of fever and shaking chills, and a 15-minute episode of rigor. He also reports a
nonproductive cough, anorexia, and the development of right-sided pleuritic chest pain. Shortness of
breath has been present for the past 12 hours. Chest x-ray reveals a consolidated right middle lobe
infiltrate, and CBC shows an elevated neutrophil count with many band forms present. Which of the
following statements regarding pneumonia in this patient is correct?
1. If the sputum Gram stain shows multiple squamous epithelial cells and the culture is reported as
mixed flora, the patient probably has a viral infection.
2. If the Gram stain reveals numerous gram-positive diplococci, numerous white blood cells, and few
epithelial cells, Streptococcus pneumoniae is the most likely pathogen.
3. Although S pneumoniae is the agent most likely to be the cause of this patient’s pneumonia, this
diagnosis would be unlikely if blood cultures prove negative.
4. The absence of rigors would rule out a diagnosis of pneumococcal pneumonia.
5. Penicillin is still the drug of choice in pneumococcal pneumonia.
24. Short questions
1. A 32-year-old woman with a 5-year history of HIV infection is noted to have a CD4 count of 100
cells/mm3. She is admitted to the hospital with a 2-week history of fever, shortness of breath,
and a dry cough. Which of the following diagnostic tests would most likely confirm the diagnosis?
1. Silver stain of the sputum
2. Gram stain of the sputum showing gram-positive diplococci
3. Acid-fast smear of the sputum
4. Serum cryptococcal antigen
■ 1
25. 1. Which of the following is the most likely organism to cause a lobar pneumonia in a patient with
AIDS?
1. Pneumocystis jirovecii
2. Mycobacterium tuberculosis
3. Histoplasmosis capsulatum
4. Streptococcus pneumoniae
■ 4
26. ■ A 44-year-old woman infected with HIV is noted to have a CD4 count of 180 cells/mm3. Which of
the following is recommended as a useful prophylactic agent in this patient at this point?
■ A. Fluconazole
B. Azithromycin
C. Trimethoprim-sulfamethoxazole D. Ganciclovir
■ C
27. ■ A 36-year-old woman with HIV is admitted with new-onset seizures. The CT scan of the head
reveals multiple ring-enhancing lesions of the brain. Which of the following is the best therapy for
the likely condition?
1. Rifampin, isoniazid, ethambutol
2. Ganciclovir
3. Penicillin
4. Sulfadiazine with pyrimethamine
■ 4
28. CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
Presentation of a Case:
On inspection:
•The patient is dyspnoeic with pursing of lips, respiratory rate is 30/min.
•Chest is barrel shaped with indrawing of lower intercostal space on inspiration (due to low flat
diaphragm).
•There is suprasternal and supraclavicular space excavation with prominent accessory muscles of
respiration.
29. 1. On palpation:
• Trachea is central, tracheal tug is present (descent of trachea during inspiration).
• Cricosternal distance (distance between suprasternal notch and cricoid cartilage) is reduced
(normally
• 3 fingers or more).
• Apex beat is not felt.
• Chest expansion is reduced and chest movement is vertical.
• Vocal fremitus is reduced on both sides.
2. On percussion:
• Increased resonance or hyperresonance in both lung fields.
• Obliteration of liver and cardiac dullness (liver dullness may be lower down).
3. On auscultation:
• Breath sound is diminished vesicular with prolonged expiration.
• Few rhonchi are present (mention, if any).
• Vocal resonance is normal.
30. Clinical features
1. Usually the patient is above 40 years, male and smoker. Features are:
• Chronic cough and sputum production, which is progressively increasing.
• Progressively increasing breathlessness.
• There may be hemoptysis and morning headache (due to hypercapnia).
31. Systemic features of COPD
■ Muscular weakness, peripheral oedema due to impaired salt and water excretion, weight
■ loss due to altered fat metabolism, increased osteoporosis, increased circulating inflammatory
markers.
32. Risky factors
■ EXPOSURE FACTORS
• Smoking (commonest): Active or passive.
• Indoor and outdoor air pollution.
• Occupation: Exposure to dust, fumes, smokes, chemicals etc. (e.g., coal miners and those
• who work with cadmium).
• Urban dweller.
• Low socio-economic status.
• Low birth weight.
• Poor lung growth that may be due to childhood infections or maternal smoking.
• Infections: Recurrent lung infection, persistent adenovirus in lung tissue, HIV infection is
• associated with emphysema.
• Cannabis smoking (controversial).
33. Risky factors
■ Host factor
• Genetic factors: a1-antitrypsin deficiency.
• Airway hyper-reactivity.
• More in male and Caucasians.
• Biofuel mass.
34. Organism that may precipitate COPD
1. Hemophilus influenzae and S. pneumoniae. Other less common organisms
2. are Moraxella catarrhalis, Chlamydia pneumoniae and Pseudomonas aeruginosa.
35. What are the complications of COPD
• Pulmonary hypertension.
• Cor pulmonale.
• Respiratory failure.
• Secondary infection.
• Polycythemia.
36. cases
■ A 66-year-old retired publican attends the respiratory outpatient clinic complaining of
severe exercise limitation as a result of breathlessness. He has trouble moving about the
house and rarely goes outside. He feels worse in the mornings and describes wheeze.
His symptoms have developed over 3 years. His general practitioner (GP) has tried
inhalers, but they have not helped. He has had a cough with sputum for more than 10
years. He has been a smoker for more than 40 years and has smoked five to ten
cigarettes per day over this time.
ANSWER :COPD
37. Look for the following sign
■ Look for signs of respiratory failure (central cyanosis)
■ hypercapnia (bounding high-volume pulse, flapping tremor)
■ cor pulmonale (raised jugular venous pressure [JVP], ankle or sacral oedema).
■ Physical signs of airflow obstruction usually occur only when severe airflow obstruction is
present, such as pursed-lipped breathing, hyperinflated thorax, paradoxical in-drawing of
the intercostal spaces, resonant percussion note, poor breath sounds and wheeze.
38. ■ A 70-year-old patient with chronic obstructive lung disease requires 2 L/min of
nasal O2 to treat his hypoxia, which is sometimes associated with angina. The
patient develops pleuritic chest pain, fever, and purulent spu- tum. While using his
oxygen at an increased flow of 5 L/min he becomes stuporous and develops a
respiratory acidosis with CO2 retention and wors- ening hypoxia. What would be
the most appropriate next step in the man- agement of this patient?
A. Stop oxygen.
B. Begin medroxyprogesterone.
C. Intubate and begin mechanical ventilation.
D .Observe patient 24 hours before changing therapy.
E. Begin sodium bicarbonate.
ANS:C
CASE 2
39. ■ A 60-year-old male has had a chronic cough with clear sputum pro- duction for
over 5 years. He has smoked one pack of cigarettes per day for 20 years and
continues to do so. X-ray of the chest shows hyperinflation without infiltrates.
Arterial blood gases show a pH of 7.38, PCO2 of 40 mm Hg, and PO2 of 65 mm Hg.
Spirometry shows an FEV1/FVC of 45% without bronchodilator response. Which of
the following is the most important treatment modality for this patient?
A Oral corticosteroids
B.Home oxygen
C.Broad-spectrum antibiotics
D.Smoking cessation program
E.Oral theophylline
ANS:D
40. DIFFUSED PARECHYMAL LUNG
DISEASE
■ Q:What is DPLD?
A: DPLD are a heterogeneous group of diseases characterized by diffuse lung injury and inflammation
■ that can progress to lung fibrosis. Previously, it was called interstitial lung disease (ILD).
■ Q:Why is it called DPLD?
A: The term DPLD is preferred than ILD, because the pathological lesion involves the alveoli along
■ with interstitium.
■ Q:What history do you like to take in DPLD? A: As follows:
• Onset of the disease: Acute or chronic.
• History of connective tissue disease like rheumatoid arthritis, systemic sclerosis, dermatomy-
• ositis, SLE.
• History of drugs and smoking.
• Occupational and environmental history.
41. Classification
1. Q:Classify DPLD.
A: DPLD is classified into 6 groups:
2. 1. Granulomatous DPLD (e.g., sarcoidosis).
2. Granulomatous DPLD with vasculitis (e.g., Wegener’s granulomatosis, Churg–Strauss
3. syndrome, microscopic vasculitis).
3. Idiopathic interstitial pneumonia (IIP):
1. a) Idiopathic pulmonary fibrosis (IPF), previously called cryptogenic fibrosing alveolitis (90%).
2. b) Idiopathic interstitial pneumonia other than IPF (10%):
1. - Desquamated interstitial pneumonia.
2. - Acute interstitial pneumonia.
3. - Nonspecific interstitial pneumonia.
4. - Respiratory bronchiolitis.
5. - Cryptogenic organizing pneumonia (COP), also called bronchiolitis obliterans organizing pneumonia (BOOP).
6. - Lymphocytic interstitial pneumonia.
42. 4. Pulmonary autoimmune rheumatic diseases (e.g., rheumatoid arthritis, SLE).
5. Drugs (busulphan, bleomycin, methotrexate, nitrofurantoin, amiodarone).
6. Other forms of DPLD, e.g., histiocytosis X (Langerhans cell histiocytosis), Goodpasture
syndrome, idiopathic pulmonary haemosiderosis, diffuse alveolar haemorrhage,
lymphangioleiomyomatosis, pulmonary alveolar proteinosis.
43. Clinical presentation
1. What are the presentations of DPLD (IPF)?
■ A: Patient is usually elderly, uncommon ,50 years.
• Cough, usually dry.
• Progressive breathlessness, usually exertional.
• Arthralgia, arthritis.
• Weakness, dizziness, giddiness.
• Cyanosis and finger clubbing (20 to 50% cases).
44. CASES
■ A 40-year-old construction worker has noted increasing shortness of breath and
cough over many years. On physical examination bilateral inspi- ratory crackles
are heard. Chest x-ray shows egg shell calcifications in hilar adenopathy and
bilateral small nodular interstitial markings in the upper lobes.
■ ANSWER SILICOSIS
45. ■ A 65-year-old who is retiring from work as a plumber has complained of a dry cough. He
has also had some shortness of breath on walking. On physical examination there are
bilateral crackling rales at both lung bases. Bilateral clubbing is also noted. On chest x-
ray, bilateral linear infiltrates are seen at the lung bases. Pleural scarring is noted on CT
scan.
■ ANS:ASBESTOSIS
