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  • Continuing with the definition : Acquired by a patient in the following settings: 1. In a hospital or long-term-care facility after being admitted for >48 hours or 2. <7 days after a patient is discharged from the hospital with the caveat that the patient’s initial hospirtalization should be  3 days duration.
  • Let me start with the disease definition of Acute Nosocomial bacterial pneumonia which is broadly defined as a pneumonia characterized by a new cough with auscultatory findings of pneumonia in conjunction with a new inflitrate or progressive infiltrate or infiltrates on chest radiograph accompanied by: fever or hypothermia, leukocytosis and sputum production which could be purulent , caused by polymicrobial organisms

    1. 1. PNEUMONIAS By Dr Bashir Ahmed Dar Chinkipora Sopore Kashmir Associate Professor Medicine Email [email_address]
    2. 7. NOTE <ul><li>The purpose of this presentation is to take full detailed history in case of pneumonia to arrive at correct diagnosis. </li></ul><ul><li>The presentation has been made very easy for undergraduate as well as for post graduate medical students. </li></ul><ul><li>Description of various organisms and x-rays have made the task very simple. </li></ul>
    3. 8. Definition of Pneumonia <ul><li>Pneumonia is defined as inflammation of lung parenchyma </li></ul><ul><li>The term pneumonitis is synonymous but is best avoided </li></ul><ul><li>During the process of inflammation of alveoli there occurs inflammatory exudate that fill up air spaces and result in consolidation of lung. </li></ul>
    4. 9. Primary Pneumonia <ul><li>There is no pre-existing abnormality of respiratory system. </li></ul>
    5. 10. Secondary Pneumonia <ul><li>is characterized by </li></ul><ul><li>Absence of specific pathogenic organism in the sputum but presence of some pre-existing abnormality of respiratory system. </li></ul>
    6. 11. Secondary Pneumonia <ul><li>Examples are </li></ul><ul><li>1.Aspiration of pus from any foci,vomitus,gastric contents </li></ul><ul><li>2.Inhalation of septic matter during tonsilectomy and dental procedures. </li></ul><ul><li>3.Ineffective coughing as in post-traumatic,post-operatiive,paralysis of larynx or pharynx. </li></ul><ul><li>4.Partial bronchial obstruction. </li></ul>
    7. 12. Classifications by (causative agents) Pneumonia <ul><li>Classifications by (causative agents) </li></ul><ul><li>Viral pneumonia </li></ul><ul><li>Bacterial Pneumonia </li></ul><ul><li>Fungal pneumonia </li></ul><ul><li>Rickettsial pneumonia </li></ul><ul><li>Protozoal pneumonia </li></ul><ul><li>Radiation pneumonia </li></ul><ul><li>Chemical pneumonia </li></ul><ul><li>Aspiration pneumonia </li></ul><ul><li>Hypostatic pneumonia </li></ul>
    8. 13. Viruses that cause acute pneumonia
    9. 14. Rev Tran &Protease
    10. 15. Re transcriptase Protease
    11. 16. <ul><li>Viruses that cause acute pneumonia </li></ul><ul><ul><ul><ul><ul><li>Adenovirus </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Coronavirus </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>influenza A and B viruses </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>parainfluenza virus </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>respiratory syncytial virus </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>coxsackievirus A21 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Rhinovirus </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>viruses that cause rubella and measles </li></ul></ul></ul></ul></ul><ul><li>often self limiting but can be complicated </li></ul>
    12. 17. Features of viral Pneumonias <ul><li>The clinical features differ from that of bacterial pneumonia. </li></ul><ul><li>Symptoms are more than the chest signs and x-ray signs </li></ul><ul><li>Viral pneumonia often goes unrecognized because the person may not appear very ill. </li></ul><ul><li>Disease is mild and self limiting and resolves by 7-10 days time. </li></ul>
    13. 18. Features of viral Pneumonias <ul><li>It usually starts with a dry (nonproductive) cough </li></ul><ul><li>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. </li></ul>
    14. 19. Features of viral Pneumonias <ul><li>Occurs primarily in the cold and winter and tends to be more serious in people with cardiovascular or lung disease . </li></ul><ul><li>* Leucocyte count is usually normal or low </li></ul><ul><li>* The x ray may show features of interstitial or. </li></ul><ul><li>atypical pneumonia </li></ul><ul><li>* Diagnosis confirmed by isolation of virus and </li></ul><ul><li>serological tests. </li></ul>
    15. 20. BACTERIA THAT CAUSE PNEUMONIA <ul><li>GRAM POSITIVE COCCI </li></ul><ul><li>1.Streptococcus Pneumoniae </li></ul><ul><li>the most common </li></ul><ul><li>2. Streptococcus Pyogenes </li></ul><ul><li>3. Streptococcus Agalactiae </li></ul>
    16. 21. BACTERIA THAT CAUSE PNEUMONIA <ul><li>Streptococcus Pneumoniae generally resides in the nasopharynx and is found in approximately 50% of healthy individuals. </li></ul><ul><li>Pneumococci infect type II alveolar cells. </li></ul><ul><li>As the pneumococci reach the alveolar spaces they come in contact with epithelium of alveolus and produce alveolar lesions.. </li></ul>
    17. 22. BACTERIA THAT CAUSE PNEUMONIA <ul><li>The pneumonic lesion progresses as pneumococci multiply in the alveolus and invade further alveolar epithelium. and start spreading from alveolus to alveolus through the pores of Kohn, thereby producing inflammation and consolidation along larger areas of the lung.The damage may result in rust coloured sputum. </li></ul>
    18. 23. BACTERIA THAT CAUSE PNEUMONIA <ul><li>Streptococcus agalactiae bacterium is usually found in genital tract of females 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. </li></ul>
    19. 24. BACTERIA THAT CAUSE PNEUMONIA <ul><li>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 (&quot;pneumatoceles&quot;), </li></ul>
    20. 25. BACTERIA THAT CAUSE PNEUMONIA <ul><li>Abcess formation is very common.in staphylococcal infection. </li></ul><ul><li>The abcesses are thin walled,multiple and commonly bilateral giving rise to patchy bronchopneumonia. </li></ul>
    21. 26. BACTERIA THAT CAUSE PNEUMONIA <ul><li>Since multiple sites are involved bilaterally simultaneously a scattered appearance of heterogeneous opacities is the usual result. </li></ul><ul><li>Eventually more and more alveoli may be affected and ultimately a homogeneous opacification simulating lobar pneumonia may be observed. </li></ul>
    22. 27. BACTERIA THAT CAUSE PNEUMONIA <ul><li>Due to these small abcesses the staphylococcus aureus produces purulent (pus-laden) sputum that often appears creamy and may be bloodstained. </li></ul>
    23. 28. BACTERIA THAT CAUSE PNEUMONIA <ul><li>Staphylococcal organism can also cause </li></ul><ul><li>Boils </li></ul><ul><li>Abscesses </li></ul><ul><li>Styes </li></ul><ul><li>Carbuncles </li></ul><ul><li>Cellulitis </li></ul><ul><li>Impetigo </li></ul>
    24. 29. BACTERIA THAT CAUSE PNEUMONIA <ul><li>Septic shock. </li></ul><ul><li>septic arthritis </li></ul><ul><li>osteomyelitis </li></ul><ul><li>Internal abscesses anywhere within the body </li></ul><ul><li>meningitis </li></ul><ul><li>endocarditis </li></ul>
    25. 30. BACTERIA THAT CAUSE PNEUMONIA <ul><li>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. </li></ul>
    26. 31. BACTERIA THAT CAUSE PNEUMONIA <ul><li>Bacteria gram positive rods </li></ul><ul><li>Bacillus anthracis is Anthrax or Wool-Sorters disease Associated with wool sorting, with animal handlers, and veterinarians, and produces eschar on skin. </li></ul>
    27. 32. BACTERIA THAT CAUSE PNEUMONIA <ul><li>2. Nocardia & Actinomyces </li></ul><ul><li>Beaded filamentous rod shaped bacteria, causing rib destruction, cutaneous sinuses, cavitation, and spreads to pleura and chest wall. </li></ul>
    28. 33. BACTERIA THAT CAUSE PNEUMONIA <ul><li>Actinomyces israeli ,an anaerobic organism occuring in mouth as commensal </li></ul><ul><li>When local defences break then can cause </li></ul><ul><li>three forms of disease. </li></ul><ul><li>1.Cervicofacial with discharging sinuses </li></ul><ul><li>Abdominal actinomycosis with discharging sinuses. </li></ul>
    29. 34. BACTERIA THAT CAUSE PNEUMONIA <ul><li>And pulmonary actinomycosis with widespread suppurative pneumonia with discharging chest wall sinuses. </li></ul><ul><li>The pus from sinuses contain sulphur granules. </li></ul>
    30. 35. BACTERIA THAT CAUSE PNEUMONIA <ul><li>Bacteria Gram Negative cocci </li></ul><ul><li>Neisseria meningitidis (meningococci) cause epidemics in military recruits,schools,young adults,overcrowded places. </li></ul><ul><li>Moraxella catarrhalis </li></ul>
    31. 36. BACTERIA THAT CAUSE PNEUMONIA <ul><li>Bacteria gram negative rods </li></ul><ul><li>Klebsiella pneumoniae (friedlanders bacillus) produces blood stained Current Jelly sputum. </li></ul><ul><li>Upper lobes being most affected with massive lobar consolidation. </li></ul>
    32. 37. BACTERIA THAT CAUSE PNEUMONIA <ul><li>Bulging of interlobar fissure is a characteristic finding in Klebsiella pneumoniae </li></ul>
    33. 38. BACTERIA THAT CAUSE PNEUMONIA <ul><li>2.Pseudomonas aeruginosa produces green sputum as well as Haemophilus. </li></ul><ul><li>3. Acinetobacter often found on respiratory therapy equipment and on human skin </li></ul><ul><li>very difficult to treat due to multiple drug resistance. </li></ul><ul><li>4. Burkholderia pseudomallei occurs with exposure to contaminated soil </li></ul>
    34. 39. BACTERIA THAT CAUSE PNEUMONIA <ul><li>6. Yersinia Pestis,causes </li></ul><ul><li>three forms of Plague Disease </li></ul><ul><ul><li>Pneumonic </li></ul></ul><ul><ul><li>Bubonic </li></ul></ul><ul><ul><li>Septicemic </li></ul></ul><ul><li>via flea bites and ticks due to animal contacts like rats,rodents. </li></ul>
    35. 40. BACTERIA THAT CAUSE PNEUMONIA <ul><li>7. Francisella tularensis ,Tularemia Infection is via tick bite or contact with contaminated rabbits. </li></ul><ul><li>8. Hemophilus influenzae more commonly seen in patients with COPD, alcoholics, and the elderly. </li></ul><ul><li>9. Bordetella pertussis is Whooping cough </li></ul><ul><li>common in children. </li></ul>
    37. 42. BACTERIA THAT CAUSE PNEUMONIA <ul><li>There are other bacteria or Bacteroides that are anaerobes and usually found in aspirationn pneumonia and are as follows. </li></ul><ul><li>11.Fusobacterium </li></ul><ul><li>12.Porphyromonas </li></ul><ul><li>13.Prevotella </li></ul><ul><li>14.Proteus </li></ul><ul><li>15.Serratia </li></ul>
    38. 43. ANAEROBIC BACTERIA <ul><li>Other anaerobic bacteria are </li></ul><ul><li>• Actinomyces </li></ul><ul><li>• Bifidobacterium </li></ul><ul><li>• Clostridium </li></ul><ul><li>• Peptostreptococcus </li></ul><ul><li>• Propionibacterium </li></ul><ul><li>These are bacteria that do not live or grow in the presence of oxygen. </li></ul>
    39. 44. Gram-Negative Bacteria <ul><li>There are many Gram-Negative bacteria such as Cyanobacteria, Spirochaetes, E-coli, Salmonella, Pseudomonas, Moraxella, Helicobacter, Stenotrophomonas, Legionella,Hemophilus influenzae, Neisseria Meningitidis, Moraxella Catarrhalis, Neisseria Gonorrhoeae, Acinetobacter Baumanii . </li></ul>
    40. 45. Gram-Negative Bacteria <ul><li>People most likely to get sick with Gram-negative germs are those who: </li></ul><ul><li>• are seriously ill </li></ul><ul><li>• are in the hospital for a long time </li></ul><ul><li>• have taken many antibiotics or drugs </li></ul><ul><li>• have a disease that prevents the body </li></ul><ul><li>from fighting infection </li></ul><ul><li>• have been in a nursing home or long-term </li></ul><ul><li>care setting </li></ul><ul><li>• are on a ventilator or breathing machine </li></ul><ul><li>Old,alcoholic, and in diabetic </li></ul>
    41. 46. Clinical Features of Bacterial Pneumonia <ul><li>Onset is often sudden </li></ul><ul><li>High grade fever </li></ul><ul><li>Rigors and chills </li></ul><ul><li>Sputum is rusty coloured or blood stained </li></ul>
    42. 47. Features of Bacterial Pneumonias <ul><li>In fact, the preceding viral infection may predispose to bacterial pneumonia, by damaging some of the lung's defenses against infection or may occur without preceding viral infection.One important clue to this diagnosis is deterioration after initial improvement. </li></ul>
    43. 48. Signs of Pneumonia <ul><li>Decreased chest movements </li></ul><ul><li>Dull on percussion </li></ul><ul><li>VF/VR increased </li></ul><ul><li>Bronchial breathing </li></ul><ul><li>Bronchophoney,aegophony and whispering pectoriloquy may be present </li></ul><ul><li>Crepitations </li></ul>
    44. 49. Fungal Pneumonia <ul><li>Fungi that can cause pneumonia are </li></ul><ul><ul><li>Histoplasmosis </li></ul></ul><ul><ul><li>Blastomycosis </li></ul></ul><ul><ul><li>Cryptococcosis </li></ul></ul><ul><ul><li>Sporotrichosis - primarily a lymphocutaneous disease, but can involve the lungs as well </li></ul></ul><ul><li>Aspergillus </li></ul><ul><li>Candida </li></ul><ul><li>Coccidiodomycosis </li></ul>
    45. 50. Fungal Pneumonia <ul><li>Histoplasmosis H/O of contact with Chickens, bats, river valleys and excavation. </li></ul><ul><li>Coccidioidomycosis may occur after exposure to a wind or rain storm in an endemic area. </li></ul>
    46. 51. <ul><li>HISTOPLASMOSIS </li></ul>
    47. 52. Clinical features of fungal Pneumonias <ul><li>Occurs in a particular setting </li></ul><ul><li>History of immunosupression like in AIDS,malignancy,Corticosteroid theraphy,radiation theraphy,antimalignant drugs. </li></ul><ul><li>Debilitated bed ridden people,malnutrition. </li></ul><ul><li>Has chronic serious pre-existing disease. </li></ul>
    48. 53. Clinical features of fungal Pneumonias <ul><li>People working in agriculture lands,caves,old buildings,places of bird droppings,soil. </li></ul><ul><li>The disease runs a chronic course. </li></ul>
    49. 54. Protozoal Pneumonia <ul><li>Parasites causing pneumonia are </li></ul><ul><li>1.Toxoplasma gondii </li></ul><ul><li>2.Strongyloides stercoralis </li></ul><ul><li>3.Ascariasis. </li></ul><ul><li>4.Cryptosporidia </li></ul><ul><li>5.Hookworms </li></ul>
    50. 55. Protozoal or Parasitic Pneumonia <ul><li>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. </li></ul>
    51. 56. Rickettsial Pneumonia <ul><li>Typhus fevers (epidemic and endemic) </li></ul><ul><li>Rocky mountain spotted fever,scrub typhus, rickettsialpox </li></ul><ul><li>Louse-borne </li></ul><ul><li>flea-borne through rats and mouse fleas </li></ul>
    52. 57. Rickettsial Pneumonia <ul><li>Q fever </li></ul><ul><li>Acute, self-limited, systemic disease that spreads rapidly in cows, sheep, and goats, slaughter houses, research facilities, where handling of animals or their birth products is a source of exposure. Hepatosplenomegaly is a common finding. </li></ul>
    53. 58. Rickettsial Pneumonia <ul><li>Rickettsia pneumonia usually gives rise to atypical pneumonia.Vasculitis of small vessels is basic underlying pathology in rickettsial infections. </li></ul><ul><li>Rickettsial infections usually present with fever, skin rash and eschar. </li></ul><ul><li>Common fleas such as cat and dogs fleas and rat fleas are reported worldwide, as are their transmitted rickettsial diseases. </li></ul>
    54. 59. Features of Rickettsial infection <ul><li>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. </li></ul>
    55. 60. Features of Rickettsial infection <ul><li>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.Poor environmental hygiene conditions </li></ul><ul><li>such as inadequately managed rubbish collection points and wet markets was a risk factor for contracting murine typhus. </li></ul>
    56. 61. Features of Rickettsial infection <ul><li>At the site of entry commonly skin the organisms localize in endothelial cells and enter into the cells. It proliferates intracelluarly. A papule may be formed that 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. </li></ul>
    57. 62. ATYPICAL BACTERIA <ul><li>Are organisms that do not fit in virus,bacteria or fungus. </li></ul><ul><li>Thus these bacteria are called atypical and produce atypical pneumonia. </li></ul><ul><li>These organisms also do not stain with gram stain. </li></ul>
    58. 63. ATYPICAL BACTERIA <ul><li>Following organisms constitute atypical bacteria. </li></ul><ul><li>Legionella </li></ul><ul><li>Mycoplasma </li></ul><ul><li>Chlamydia trachomatis an afebrile pneumonia, usually seen in 2 wk to 6 months of age </li></ul><ul><li>Chlamydia psittaci </li></ul><ul><li>Chlamydia pneumoniae </li></ul><ul><li>Chlamydia trachomatis is a sexually transmitted disease that may also cause pneumonia and bronchitis and conjuctivitis in early infancy by passing through contaminated genital tract, but it may occur in adults too. </li></ul>
    59. 64. ATYPICAL BACTERIA <ul><li>Other organisms that cause atypical pneumonia are </li></ul><ul><li>Coxiella burnetii (Q-fever) ingestion of comtaminated milk, or inhalation of contaminated aerosols from barnyard animals </li></ul><ul><li>Mycobacterium tuberculosis and other Mycobacterium </li></ul><ul><li>And some species of fungi ,viruses and protozoa </li></ul>
    60. 65. Classification of Pneumonias <ul><li>BY SITE </li></ul><ul><li>LOBAR PNEUMONIA </li></ul><ul><li>BRONCHOPNEUMONIA </li></ul><ul><li>INTERSTITIAL OR ATYPICAL PNEUMONIA </li></ul>
    61. 66. Lobar Pneumonia <ul><li>Consolidation or pneumonia of whole lobe of lung is called lobar pneumonia. </li></ul>
    62. 67. Broncho-Pneumonia <ul><li>Bronchopneumonia is characterized first by inflammation of small bronchioles then of alveoli there by resulting in patchy bilaterial consolidation of lung. </li></ul>
    63. 69. <ul><li>b </li></ul>
    64. 70. Pathogenesis of Bronchopneumonia <ul><li>There is initial terminal bronchiolitis that then spreads to 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. </li></ul><ul><li>Consolidated areas are surrounded, from inside outwards, by areas of congestion,infilfamatory cells, collapse and emphysema. </li></ul><ul><li>Resolution of the exudate usually restores normal lung structure.Organization may occur and result in fibrous scarring  in some cases or Aggressive disease may produce abscesses. </li></ul>
    65. 72. Broncho-Pneumonia <ul><li>Lesions may be more extensive that often fuses together resembling lobar pneumonia (confluent bronchopneumonia). </li></ul>
    66. 73. Liver Abomasum Diaphragm These are the lungs from a cow with severe bronchopneumonia and fibrinous pleuritis.
    67. 74. This is the same lung cut open showing deposits of fibrin between sections of lung with bronchopneumonia.
    68. 75. These are lungs from a cow with severe Pasteurella bronchopneumonia.
    69. 76. This is severe bacterial bronchopneumonia and pleuritis in a pig caused by Actinobacillus pleuropneumonia .
    70. 77. This is a closer look at the same lung. Again, note the black line. The darker red tissue has severe Pasteurella bronchopneumonia. The white spots are abscesses.
    71. 78. Here is the same lung cut open to show The severe bronchopneumonia and numerous abscesses (white spots)
    72. 79. Bacterial pneumonia in a pig. Areas with inflammation are dark pink. Normal lung is light pink.
    73. 80. This is the same lung cut open showing areas of inflammation (dark pink) and Normal tissue (light pink)
    74. 81. These are the lungs from a cow with chronic bronchopneumonia. The areas with inflammation are to the right of the black lines. Within the areas of inflammation are numerous abscesses (white spots).
    75. 82. This is the same lung cut open to show areas of inflammation and abscess formation (white spots). The normal lung is the white colored region to the far right.
    76. 83. This is severe fibrinous pleuritis and pneumonia caused by aspirating foreign material into the lung.
    77. 84. This is the same lung cut open to show regions of the lung with severe inflammation and necrosis.
    78. 85. These are the lungs of a horse with chronic, fibrous pleuritis. Note how the fibrous material appears organized and is stuck to the surface of the lung.
    79. 86. Atypical or Interstitial or viral Pneumonia <ul><li>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. Most of viruses produce this type of pneumonia also.The inflammation is confined to interalveolar septa or interstitial spaces between alveoli and radiologically gives appearance of reticulonodular pattern.linear thread like opacities here and there in lungs. </li></ul>
    80. 87. Atypical or Interstitial or viral Pneumonia <ul><li>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,typical of interstitial pneumonia. </li></ul>
    81. 89. CAUSES OF ATYPICAL PNEUMONIA <ul><li>Following organisms constitute atypical bacteria and cause atypical pneumonia </li></ul><ul><li>Mycoplasma </li></ul><ul><li>Legionella </li></ul><ul><li>Chlamydia trachomatis </li></ul><ul><li>Chlamydia psittaci </li></ul><ul><li>Chlamydia pneumoniae </li></ul><ul><li>Q-fever </li></ul><ul><li>Tularemia </li></ul><ul><li>Anthrax </li></ul><ul><li>Viruses </li></ul><ul><li>Fungi </li></ul>
    82. 90. CAUSES OF ATYPICAL PNEUMONIA <ul><li>Others like </li></ul><ul><li>Histoplasmosis </li></ul><ul><li>Coccidiodomycosis </li></ul>
    83. 91. Mycoplasma <ul><li>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. </li></ul><ul><li>Mycoplasma pneumonia occurs in Adolescents and young adults. </li></ul>
    84. 92. Mycoplasma <ul><li>EXTRA PULMONARY MANIFESTATIONS </li></ul><ul><li>gastrointestinal </li></ul><ul><li>musculoskeletal </li></ul><ul><li>dermatologic </li></ul><ul><li>cardiac </li></ul><ul><li>neurologic symptoms </li></ul><ul><li>The most common pathogen of atypical pneumonia is Mycoplasma pneumoniae. It ranks second only to S. pneumoniae </li></ul>
    85. 93. LEGIONELLA <ul><li>Occurred first in military personnel called legionnairs while using tank water etc. </li></ul>
    86. 94. LEGIONELLA <ul><li>So in legionella pneumonia there will be history of contact with Cooling towers, condensers,Water tanks,AC coolers,washings etc. </li></ul><ul><li>There is also history of GIT disturbances. </li></ul>
    87. 95. Chlamydial infection <ul><li>Due to </li></ul><ul><li>Chlamydia trachomatis </li></ul><ul><li>Chlamydia psittaci </li></ul><ul><li>Chlamydia pneumoniae </li></ul><ul><li>Chlamydia trachomatis is a sexually transmitted disease that may also cause pneumonia and bronchitis and conjuctivitis in early infancy by passing through contaminated genital tract, but it may occur in adults too. </li></ul>
    88. 96. Chlamydial infection <ul><li>Chlamydia psittaci infection will have history of contact with pigions,pet shops and zoo. </li></ul>
    89. 97. Q- FEVER <ul><li>Q fever is common rickettsial disease that gives rise to pneumonia.In Q fever there will be history of contact with cattle, sheep, goats, contaminated milk, birthing various livestock </li></ul>
    90. 98. TULAREMIA--ANTHRAX <ul><li>Tularemia will have history of contact with Rabbits, ticks </li></ul><ul><li>Tularemia also causes lymph gland involvement. </li></ul><ul><li>Anthrax has contact with Goat hair/skin, wool, bone meal fertilizer and causes black spot on skin due to ulcer surrounded by edema called eschar. </li></ul>
    92. 100. ANTHRAX ESCHAR
    93. 101. HISTOPLASMOSIS <ul><li>People with atypical pneumonia due histoplasmosis will have history of contact with Chickens, bats, river valleys .It also produces skin leisions. </li></ul><ul><li>Coccidioidomycos </li></ul><ul><li>found in people residing in California,Southwest USA. </li></ul>
    94. 102. <ul><li>HISTOPLASMOSIS </li></ul>
    95. 103. COXIELLA BURNETII <ul><li>Coxiella burnetii: This is related to exposure to infected parturient cats, cattle, sheep, or goats. </li></ul><ul><li>Burkholderia (Pseudomonas) pseudomallei (melioidosis): This infection may result from travel to Thailand or other countries in Southeast Asia. </li></ul>
    96. 104. Atypical or Interstitial or viral Pneumonia <ul><li>In atypical pneumonia extrapulmonary symptoms, most often give some clue to the causative organism. </li></ul><ul><li>The symptoms are generally more than the sings in the chest or x-ray as already said. so this type of setting is called occult pneumonia. </li></ul>
    97. 105. CHEMICAL PNEUMONIA <ul><li>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. </li></ul><ul><li>Aspiration of gastric contents in pts with gastro-esophageal reflux disease(HCL may directly and quickly cause lung damage resulting in chemical pneumonia. </li></ul>
    98. 106. Serological tests for atypical pneumonia <ul><li>1.Mycoplasma pneumoniae </li></ul><ul><li>complement fixation test, IgM by latex agglutination or ELISA test. </li></ul><ul><li>cold agglutinin test. </li></ul><ul><li>2.Legionella pneumophila </li></ul><ul><li>rapid microagglutination test </li></ul><ul><li>Test for Legionella antigen in the urine. </li></ul>
    99. 107. Serological tests for atypical pneumonia <ul><li>3.Chlamydia </li></ul><ul><li>Microimmunofluorescence </li></ul><ul><li>ELISA </li></ul><ul><li>4.Coxiella burnetii </li></ul><ul><li>complement fixation test. </li></ul><ul><li>Serologic tests. A four fold or greater rise in titer is confirmatory of an acute infection </li></ul>
    100. 108. Serological tests for atypical pneumonia <ul><li>Skin testing for histoplasmosis,coccidioidomycosis. </li></ul><ul><li>. </li></ul>
    101. 109. Classification by mode of acquiring pneumonia <ul><li>1.Community acquired pneumonia </li></ul><ul><li>2.Nosocomial pneumonia </li></ul>
    102. 110. Community acquired pneumonia <ul><li>This indicates pneumonia occuring in a person </li></ul><ul><li>in a community outside hospital . </li></ul><ul><li>Common organisms responsible are </li></ul><ul><li>Streptocccus pneumoniae </li></ul><ul><li>Haemophilus influenzae </li></ul><ul><li>Moraxella catarrhalis </li></ul><ul><li>. </li></ul>
    103. 111. Nosocomial pneumonia <ul><li>Acquired by a patient in the following settings: </li></ul><ul><ul><li>in a hospital after being admitted for >48 hours or </li></ul></ul><ul><ul><li><7 days after a patient is discharged from hospital. </li></ul></ul>
    104. 112. Nosocomial pneumonia <ul><li>new cough </li></ul><ul><li>new infiltrate or progressive infiltrate on </li></ul><ul><li>chest radiograph. </li></ul><ul><li>In wards,icu,and in patients on mechanical vetillation </li></ul>
    105. 113. ASPIRATION PNEUMONIA <ul><li>OCCUR IN FOLLOWING SETTINGS </li></ul><ul><li>Altered Level of Consciousness </li></ul><ul><li>Alcoholism </li></ul><ul><li>Seizures </li></ul><ul><li>Drugs </li></ul><ul><li>Anesthesia </li></ul><ul><li>Central nervous system disorders </li></ul><ul><li>Trauma </li></ul><ul><li>Dysphagia </li></ul><ul><li>Esophageal disorders </li></ul><ul><li>Neurological disorders </li></ul><ul><li>Mechanical Disruption of Functional Barriers </li></ul><ul><li>Nasogastric tubes </li></ul>
    106. 114. RISK FACTORS <ul><li>- Asplenia </li></ul><ul><ul><li>HIV/AIDS </li></ul></ul><ul><ul><li>Elderly </li></ul></ul><ul><li>Defective Clearing mechanism </li></ul><ul><ul><li>Cough/gag Reflex – Coma, paralysis, sick. </li></ul></ul><ul><ul><li>Mucosal Injury – smoking, toxin aspiration </li></ul></ul><ul><ul><li>Low Alveolar defense - Immunodeficiency </li></ul></ul><ul><ul><li>Pulmonary edema – Cardiac failure, embol. </li></ul></ul>
    107. 115. RISK FACTORS <ul><li>Hypogammaglubolinemia </li></ul><ul><li>Sever Neutrogena </li></ul><ul><li>Corticosteroid therapy </li></ul><ul><li>Environmental risk factors. </li></ul><ul><ul><li>Obstructions – foreign body, tumors </li></ul></ul><ul><li>- Prolonged mechanical ventilation </li></ul><ul><li>- extremes of age </li></ul>
    108. 116. RISK FACTORS THAT FORM BASIS OF SECONDARY PNEUMONIAS <ul><li>* Partial bronchial obstruction by tumour causes stasis of secretions and secondary infection distal to site of obstruction </li></ul><ul><li>Vomiting and aspiration during anaesthesia,sleep,coma,alcholism </li></ul><ul><li>Inhalation of septic matter during tonsillectomy,dental procedure,or general anaesthesia </li></ul>
    109. 117. Route of Entry <ul><li>Aspiration </li></ul><ul><li>Inhalation </li></ul><ul><li>Inoculation </li></ul><ul><li>Colonization (in patients with COPD) </li></ul><ul><li>Hematogenous spread (patients with sepsis) </li></ul><ul><li>Direct spread </li></ul>
    110. 118. Route of Entry <ul><li>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. </li></ul>
    111. 119. Route of Entry <ul><li>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. </li></ul>
    112. 120. Route of Entry <ul><li>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. </li></ul>
    113. 121. Route of Entry <ul><li>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. </li></ul>
    114. 122. Route of Entry <ul><li>Keep everything sprayed with antibacterial agent of some sort, strict hand washing,face masks and gloves for you and your children until another person is no longer contagious. </li></ul>
    115. 123. Pathogenesis and four phases of pneumonia <ul><li>are </li></ul><ul><li>1. Congestion (1-2 days) </li></ul><ul><li>2. Red hepatization (2nd-4th day) </li></ul><ul><li>3. Gray hepatization (4th-6th day) </li></ul><ul><li>4. Resolution (6th day onwards) </li></ul>
    116. 124. Congestion (1-2 days) <ul><li>Organism after entry from various routes </li></ul><ul><li>Come in contact with alveolar walls </li></ul><ul><li>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. </li></ul>
    117. 125. Red hepatization (2nd-4th day) <ul><li>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”. </li></ul>
    118. 126. Gray hepatization (4th-6th day) <ul><li>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. </li></ul>
    119. 127. Gray hepatization (4th-6th day) <ul><li>Polymorphonuclear leukocytes, at this stage produce the rusty sputum since RBCs are broken down and release haemosidren mixed with sputum is rusty. </li></ul>
    120. 128. Resolution (6 th day onwards) <ul><li>The alveolar exudates is then removed and the lung gradually returns to normal. </li></ul>
    121. 129. Diagramatic pathogenesis
    122. 130. Pathogenesis how organism reaches alveoli
    123. 131. Pathogenesis of Pneumonia Congestion Red Hepatisation Grey Hepatization Resolution
    124. 132. Summary of Stages of Lobar Pneumonia: <ul><li>Four stages: </li></ul><ul><li>Congestion – vasodilatation </li></ul><ul><ul><li>Red Hepatization - Exudation+RBC </li></ul></ul><ul><ul><li>Gray Hepatization - neutro & Macrophages. </li></ul></ul><ul><ul><li>Resolution – few macrophages, normal. </li></ul></ul>
    125. 133. Complications of Pneumonia <ul><li>A painful pleuritis </li></ul><ul><li>pleural effusion </li></ul><ul><li>Pyothorax </li></ul><ul><li>Empyema </li></ul><ul><li>Fibrosis due to laying down of fibroblasts in non resolving pneumonia called carnification of lung. </li></ul><ul><li>Necrotizing lung & lung abcess </li></ul>
    126. 134. Complications of Pneumonia <ul><li>1. Pulmonary fibrosis. </li></ul><ul><li>2. Bronchiectasis </li></ul><ul><li>3. Lung abscess </li></ul><ul><li>4. Empyema </li></ul><ul><li>5. Bacteraemia with abscess in other organs </li></ul><ul><li>6.ARDS </li></ul><ul><li>7.Bacteremia </li></ul><ul><li>8.Collapse of lung </li></ul><ul><li>9.Hemoptysis </li></ul>
    127. 135. Complications of Pneumonia <ul><li>Parapneumonic effusions </li></ul><ul><li>Septic arthritis </li></ul><ul><li>Endocarditis </li></ul><ul><li>Pericarditis </li></ul><ul><li>Respiratory failure </li></ul><ul><li>Mental symptoms </li></ul>
    128. 136. Investigations of Pneumonia <ul><li>Total and differential count </li></ul><ul><li>PBF </li></ul><ul><li>Blood ,urine,sputum culture/sensitivity </li></ul><ul><li>Gram staining/stain for AFB </li></ul><ul><li>Fiberoptic bronchoscopy with bronchial washing/ brushing /biopsy </li></ul>
    129. 137. Investigations of Pneumonia <ul><li>X-ray chest </li></ul><ul><li>CT chest </li></ul><ul><li>Serological tests </li></ul><ul><li>ABG </li></ul><ul><li>Other all routine basic tests </li></ul>
    130. 138. TREATMENT OF PNEUMONIA <ul><li>Uncomplicated pneumonia </li></ul><ul><li>Erythromycin 250-500mg 6 hrly or with combination with cefuroxime or Amoxycillin or Ampicillin 500 mg 6-8 hrly x 7-10 days. </li></ul><ul><li>Azithromycin 500mg x3-5 days if pt intolerant to erythromycin </li></ul><ul><li>Consider levofloxacin 500 mg once a day if pt elderly </li></ul>
    131. 139. TREATMENT OF PNEUMONIA <ul><li>Moderately sick </li></ul><ul><li>Ceftriaxone 1-2 gram once or BD iv and erythromycin or azithromycin 500 mg daily </li></ul><ul><li>Ampicillin –clauvulanic acid plus erythromycin or azithromycin </li></ul>
    132. 140. TREATMENT OF PNEUMONIA <ul><li>Severely sick </li></ul><ul><li>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 </li></ul>
    133. 141. TREATMENT OF PNEUMONIA <ul><li>In multiresistant cases and in staphylococcal or gram negative infection can give multiresistant strains give Vancomycin 500mg to 1 gram I/V twice daily. </li></ul>
    134. 142. TREATMENT OF PNEUMONIA <ul><li>For klebsiella,legionella,actinomycosis </li></ul><ul><li>Gentamycin, ceftriaxone for two weeks even Azithromycin. </li></ul><ul><li>Rifampicin be given in legionella also </li></ul>
    135. 143. TREATMENT OF PNEUMONIA <ul><li>For actinomycosis also Benzyle penicillin 10-20 million units iv 6 hrly day. </li></ul><ul><li>In severe cases piperacillin plus tazobactam or Meropenem. </li></ul><ul><li>Clindamycin 800mg 8 hrly followed by 300 mg orally 8hrly in aspiration pneumonia. </li></ul>
    136. 144. Treatment for rickettsial infection <ul><li>Rickettsial infections respond promptly to early treatment with the antibiotics like </li></ul><ul><li>Doxycycline </li></ul><ul><li>Chloramphenicol </li></ul><ul><li>Tetracycline </li></ul>
    137. 145. Treatment for fungal infections <ul><li>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. </li></ul>
    138. 146. Treatment for fungal infections <ul><li>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. </li></ul>
    139. 147. Treatment for fungal infections <ul><li>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. </li></ul><ul><li>fatal infections may require higher dosages (1 to 1.5 mg/kg daily). </li></ul>
    140. 148. Treatment for fungal infections <ul><li>The Amphotericin B should NEVER be mixed with Normal Saline or Half Normal Saline as it will precipitate. </li></ul><ul><li>Flush I.V. line with 5% dextrose injection before and after infusion. </li></ul><ul><li>Pretreat with antihistamines, antipyretics, or corticosteroids, as prescribed. </li></ul>
    141. 149. Treatment for fungal infections <ul><li>What to Monitor in Patients Receiving Amphotericin B </li></ul><ul><li>The following should be monitored more aggressively during the initial 2 weeks of therapy. </li></ul><ul><li>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 </li></ul>
    142. 150. Treatment for fungal infections <ul><li>2. BUN, SCr </li></ul><ul><li>3. Potassium, magnesium, sodium, and other electrolytes </li></ul><ul><li>4. CBC </li></ul><ul><li>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.). </li></ul>
    143. 151. Treatment for fungal infections <ul><li>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 . </li></ul>
    144. 152. Treatment for fungal infections <ul><li>FLUCYTOSINE </li></ul><ul><li>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. </li></ul>
    145. 153. Treatment for fungal infections <ul><li>flucytosine 250,250mg capsules are also available and given as 50-150mg/kg/day 6-8 hrly x 4-6 weeks. </li></ul><ul><li>or may be 2 weeks followed by fluconazole. </li></ul>
    146. 154. Treatment for fungal infections <ul><li>so is with amphotericin x 10days or 4-6 weeks. </li></ul><ul><li>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. </li></ul>
    147. 155. Treatment for viral infections <ul><li>Acyclovir </li></ul><ul><li>The duration of intravenous therapy with Acyclovir is usually 5 days. </li></ul><ul><li>The doses recommended above (5 or 10mg/kg bodyweight or 500mg/m2 ) should be given every 12 hours. </li></ul>
    148. 156. Treatment for viral infections <ul><li>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. </li></ul><ul><li>oral dose </li></ul><ul><li>800mg 4 hrly x7-10days </li></ul><ul><li>Chronic Suppressive Therapy for Recurrent Disease: 400 mg 2 times daily for up to 12 months </li></ul>
    149. 157. Afebrile Pneumonia Syndrome <ul><li>Afebrile pneumonia syndrome (APS) is a relatively uncommon disease of neonates and infants younger than 6 months. Transmitted in female genital tract to baby by pathogens Chlamydia trachomatis, cytomegalovirus (CMV), and Ureaplasma urealyticum during delivery. </li></ul>
    150. 158. Afebrile Pneumonia Syndrome <ul><li>More recently, other potential causes of the syndrome have been recognized, including respiratory syncytial virus (RSV), parainfluenza virus, adenovirus, and Pneumocystis jiroveci. </li></ul><ul><li>Typically, infants are afebrile or have only a very little fever. </li></ul>
    151. 159. Factors that are associated with increased risk of contracting APS in infants include the following : <ul><li>Low socioeconomic status </li></ul><ul><li>Young maternal age </li></ul><ul><li>Multiple maternal sex partners </li></ul><ul><li>Unmarried maternal status </li></ul><ul><li>Exposure to other children at home or in daycare </li></ul><ul><li>Exposure to secondhand smoke </li></ul>
    152. 160. RADIOLOGY <ul><li>X-RAYS ON VARIOUS TYPES OF PNEUMONIA </li></ul>
    153. 161. Anatomy
    154. 162. Normal Chest Radiograph
    155. 163. Anatomy
    156. 164. Lobes <ul><li>Right upper lobe: </li></ul>
    157. 165. Lobes (continued) <ul><li>Right middle lobe: </li></ul>
    158. 166. Lobes (continued) <ul><li>Right lower lobe: </li></ul>
    159. 167. Lobes (continued) <ul><li>Left lower lobe: </li></ul>
    160. 168. Lobes (continued) <ul><li>Left upper lobe with Lingula: </li></ul>
    161. 169. Lobes (continued) <ul><li>Lingula: </li></ul>
    162. 170. Lobes (continued) <ul><li>Left upper lobe - upper division: </li></ul>
    163. 171. RUL pneumonia
    164. 172. RML pneumonia
    165. 173. RLL pneumonia
    166. 174. LUL pneumonia
    167. 175. LLL pneumonia
    168. 176. What’s happened here? Right upper lobe collapse
    169. 177. Bulging Fissure Sign Consolidation spreading rapidly, causing lobar expansion and bulging of the adjacent fissure inferiorly . Historically Klebsiella pneumoniae involving the right upper lobe . Friedlander pneumonia.
    170. 178. ATYPICAL PNEUMONIA <ul><li>In next slides you will thread like linear striations extending here and there in the lungs forming sort of a network.you may also see very small patchy spots nodules over or along these lines giving reticulo-nodular appearance characteristic of atypical or viral pneumonias. </li></ul>
    173. 183. Bronchopneumonia
    174. 184. <ul><li>Progressive </li></ul><ul><li>disease showing </li></ul><ul><li>Bilateral patchy </li></ul><ul><li>opacification </li></ul><ul><li>with consolidation </li></ul>
    175. 185. <ul><li>Patchy broncho pneumonia more on left side. </li></ul>
    176. 186. Thank you. Always take proper detailed history of a patient.