This document discusses a case of lung consolidation seen in a patient. It provides definitions and causes of lung consolidation, including pneumonia, malignancy, and infarction. Differential diagnoses for consolidation are discussed. The document also contains sections on carcinoma of the lung, bronchial carcinoma, clinical features, investigations, management, and classifications of pneumonia by pathogen, anatomy, presentation, duration, and environment.

1. Lung consolidation
Ca lung
Pneumonia
DR.Bilal Natiq Nuaman,MD
C.A.B.M.,F.I.B.M.S.,D.I.M.
2018
1

2. Lung consolidation
a “solidification” of the lung tissue due to accumulation
of solid and liquid material in the air spaces that would
have normally been filled by gas.
causes:
1-pneumonia
2-malignancy
3-infarction
2

3. When making a diagnosis of consolidation, use other
signs to provide an underlying cause. the best thing is to
provide a list of differential diagnoses for consolidation:
(a) Pneumonia (pyrexia, purulent sputum, hemoptysis)
(b) Malignancy (cachexia,clubbing.nicotine
stainlng,lympahdenopathy,productive cough).
(c) Infarction (signs of pulmonary hypertension. deep
venous thrombosis)'
3

5. Carcinoma of lung
Primary lung cancer
Lung cancer is the most common cause of cancer death in the world, with more
than 1 million deaths occurring annually.
Smoking is thought to be directly responsible for at least 90% of
lung carcinomas, the risk being directly proportional to the
amount smoked and the tar content of cigarettes. Risk falls
slowly after smoking cessation, but remains above the risk in
nonsmokers for many years.
A number of industrial materials (e.g. asbestos and silica) are
associated with lung cancer
4

6. Bronchial carcinoma
This tumor arises from the bronchial epithelium.
The common cell types are
squamous (35%),
adenocarcinoma (30%),
small cell (20%) and
large cell (15%).
Lung cancer presents in many different ways. If the
tumor arises in a large bronchus, symptoms arise
early, but tumors originating in a peripheral
bronchus can grow large without producing
symptoms.
Peripheral squamous tumors may cavitate.
5

7. Local spread may occur into the mediastinum and
invade or compress the pericardium, oesophagus,
superior vena cava, trachea, or phrenic or left
recurrent laryngeal nerves.
Lymphatic spread to supraclavicular and mediastinal
lymph nodes is also frequently observed.
Blood borne metastases most commonly affect liver,
bone, brain, adrenals and skin. Even a small primary
tumor may cause widespread metastatic deposits;
this is a particular characteristic of small cell lung
cancers.
6

8. Clinical features
Cough: This is the most common early symptom.
Hemoptysis: This occurs especially with central tumors.
Bronchial obstruction:
Complete obstruction causes collapse of a lobe or lung,
with breathlessness, mediastinal displacement, dullness
to percussion and reduced breath sounds.
Partial obstruction may cause unilateral wheeze that fails
to clear with coughing, and may also impair the drainage
of secretions, causing pneumonia or lung abscess.
Persistent pneumonia in a smoker suggests an underlying
bronchial carcinoma.
Stridor (a harsh inspiratory noise) occurs when the
trachea or larynx is narrowed by tumor or nodes. 7

9. Breathlessness: Cancer may present with breathlessness
by causing collapse, pneumonia or pleural effusion, or by
compressing a phrenic nerve and leading to diaphragmatic
paralysis.
Pain and nerve entrapment: Pleural pain usually indicates
malignant pleural invasion or distal infection.
Apical carcinoma may cause :
Horner’s syndrome (ipsilateral partial ptosis ,
enophthalmos, myosis and hypohidrosis of the face) due to
involvement of the sympathetic nerves in the neck.
Pancoast’s syndrome (pain in the inner aspect of the arm,
sometimes with weakness or wasting in the hand) indicates
involvement of the brachial plexus by an apical tumor.
8

10. Mediastinal spread:
Involvement of the oesophagus may cause dysphagia.
Pericardial involvement may lead to arrhythmia or effusion.
Superior vena cava obstruction by malignant nodes causes
suffusion and swelling of the neck and face, conjunctival
edema, headache and dilated veins on the chest wall.
Involvement of the left recurrent laryngeal nerve by tumors
at the left hilum causes voice alteration and a ‘bovine’
cough.
Metastatic spread: This may lead to
focal neurological defects, epileptic seizures, personality
change,
jaundice,
bone pain or
skin nodules.
Lassitude, anorexia and weight loss usually indicate meta-
9
static spread.

11. 10

12. Investigations
The main aims of investigation are to:
● Confirm the diagnosis.
● Establish the histological cell type.
● Define the extent of the disease.
11

13. Biopsy and histopathology:
Central lung tumors can be biopsied at bronchoscopy.
For peripheral tumors, percutaneous needle biopsy under
CT or US guidance is the preferred way to obtain tissue.
Combined CT and PET is used increasingly to detect
metastases.
Head CT, radionuclide bone scanning, liver USS and bone
marrow biopsy are reserved for patients with clinical or
biochemical evidence of spread to these sites.
12

14. Surgical resection carries the best hope of long-
term survival. Unfortunately, most cases (>85%)
have un-resectable disease
13

15. The treatment of small cell carcinoma with chemotherapy,
some times in combination with radiotherapy, can increase
median survival from 3 months to well over a year.
Chemotherapy is generally less effective in non small cell
bronchial cancers.
Malignant pleural effusions should be drained if the patient
is symptomatic and pleurodesis performed.
Overall the prognosis in bronchial carcinoma is very poor,
with ~70% of patients dying within 1 yr of diagnosis and <
8% of patients surviving 5 yrs after diagnosis.
14

16. Secondary (metastatic) tumors of the lung
The most common tumors that metastasize to the lung are
those of the breast, kidney, uterus, ovary, testes and
thyroid, often with multiple deposits.
Lymphatic infiltration (lymphangitis) may develop in
patients with carcinoma of the breast, stomach, bowel,
pancreas.
15

17. Pneumonia is defined as an
inflammatory disease of the
parenchyma of the lung, caused by
Infectious agent , associated with
recently developed radiological
pulmonary shadowing which may be
segmental, lobar or multilobar.
16

18. Epidemiology
❖The morbidity and mortality of pneumonia
are high especially in old people.
❖Leading cause of death until 1936
Due to Discovery of sulfa drugs and
penicillin
❖Now it is the 6 th leading cause of death
❖Average mortality 14%
17

19. Classification of pneumonia
• Classification by Pathophysiology
• Classification by pathogen
• Classification by acquired environment
• Classification by anatomy
• Classification by presentation
• Classification by duration
18

20. Pneumonia Pathophysiology
Microbial pathogens enter the lung by:
• 1-Inhalation of Infectious Aerosols (inhalational
pneumonia)
• Influenza, Legionella, Psittacosis,
Histoplasmosis, TB,Mycoplasma,
• 2-Hematogenous Dissemination (hematogenous
pneumonia)
• Staph aureus in osteomyelitis
19

21. • 3-Aspiration of organisms (aspiration pneumonia)
• More common in patients with impaired level of
consciousness: alcoholics, seizures, stroke,
anesthesia, swallowing disorders.
• more likely with hospitalization, debility,
alcoholism, DM, and advanced age
• From oropharynx
Gram positive and anaerobes:
Strep pneumo, H influenza, Moraxella,, S.
pyogenes,
From stomach (mendelson syndrome-chemical
pneumonitis)
Gram negatives:
•
20

22. Classification by pathogen
• Bacterial pneumonia :
(1) Aerobic Gram-positive bacteria,such
as streptococcus pneumoniae, staphy-
lococcus aureus, Group A hemolytic
streptococci
(2) Aerobic Gram-negative bacteria, such
as klebsiella pneumoniae, Hemophilus
influenzae, Escherichia coli
(3) Anaerobic bacteria 21

23. • Atypical bacterial pneumonia :
Including Legionnaies pneumonia , Mycoplasma
pneumonia , chlamydia pneumonia.
• Viral pneumonia :
may be caused by adenoviruses, respiratory
syncytial virus, influenza, cytomegalovirus, herpes
simplex , SARS .
• Fungal pneumonia :
Fungal pneumonia is commonly caused by
histoplasma , aspergilosis and pneumocystis
jiroveci (previously named pneumocystis carinii)
22

24. Classification by anatomy
1- Lobar: Involvement of an entire lobe
2- Lobular: Involvement of parts of the lobe
only, segmental or of alveoli contiguous to
bronchi (bronchopneumonia).
3- Interstitial
23

25. 24

26. Lobar pneumonia Bronchopneumonia
Interstitial pneumonia
25

27. Classification by presentation
• “Typical” (classical) pneumonia: (85%)
sudden onset of fever, cough productive of
purulent sputum, pleuritic chest pain
• “Atypical”: (15%) gradual onset, dry cough,
prominence of Extrapulmonary symptoms:
headache, myalgias, fatigue, sore throat,
nausea, vomiting
26

28. Typical pneumonia
• Mainly due to the following microorganisms:
• Streptococcus (pneumococcal ) pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis
27

29. Atypical pneumonia
Atypical organisms:
• are not revealed on ordinary Gram stain and
culture media.
• Are not affected by common antibiotics such
as sulfonamide and beta-lactams (penicillin).
28

30. The most common causative organisms of atypical
pneumonia are (often intracellular living) bacteria:
• Chlamydophila pneumoniae ( previously : Chlamydia
pneumoniae ) Mild form of pneumonia with relatively mild
symptoms.
• Coxiella burnetii Causes Q fever. Transmitted through
cattle, sheep, goats causing severe pneumonia with hepatitis
and endocarditis
• Mycoplasma pneumoniae Usually occurs in younger age
groups and may be associated with neurological and
systemic (e.g. rashes) symptoms.
29

31. • Legionella pneumophila Causes a severe form of
pneumonia with a relatively high mortality rate, known
as legionellosis or Legionnaires' disease is transmitted by
inhalation of aerosolized water .
it is not transmitted from person-to-person.
Sources include hot-water tanks, cooling towers, and evaporative
condensers of large air-conditioning systems, and showers
Hyponatremia (serum sodium <130 meq/L) occurs significantly
more frequently in Legionnaires' disease than in pneumonias of
other etiologies
30

32. Clinical clues for the diagnosis of Legionnaires'
disease
Presence of gastrointestinal symptoms, especially diarrhea
Neurologic findings, especially confusion
Fever >39ºC
Hyponatremia
Hepatic dysfunction
Hematuria
Failure to respond to beta-lactam and/or aminoglycoside antibiotics
treatments of choice
are the respiratory tract quinolones (levofloxacin, moxifloxacin, ) or
newer macrolides (azithromycin, clarithromycin, ).
31

33. Viral
• Influenza A and B, including avian flu and swine flu
• severe acute respiratory syndrome (SARS) due to
coronavirus
Fungal
• Pneumocystis jiroveci (previously : pneumocystis carinii) it
can cause a severe lung infection in people with a weakened
immune system due to:
Cancer
Chronic use of corticosteroids or other medications that
weaken the immune system
HIV/AIDS
Organ or bone marrow transplant
32

34. 33

35. Classification by acquired environment
◆ Community acquired pneumonia. CAP
◆ Hospital acquired pneumonia. HAP
34

36. Hospital-acquired (nosocomial) pneumonia
is defined as pneumonia developing 2 or more days after
admission to hospital for some other reason.
the most common pathogens in hospital-acquired
pneumonia are as follows:
• Gram-negative bacteria:50%
• Staphylococcus aureus: 20%
• Streptococcus pneumonia:15%
• Anaerobes and fungi:10%
• Other(e.g.Legionella pneumophila):5%
35

37. Community Acquired Pneumonia
Definition:
Lower respiratory tract infection in a non hospitalized person
that is associated with symptoms of acute infection with or
without new infiltrate on chest radiographs
36

38. S. pneumoniae classically presents with sudden rigor,
fever, and cough productive of rust-colored sputum
Legionella presents as a severe pneumonia with high-
spiking fevers accompanied by diarrhea, and in some
cases, relative bradycardia despite high fevers.
Hyponatremia may be more common with Legionella
than with other etiologic agents
Mycoplasma infection presents as a paroxysmal,
nonproductive cough, often with minimal findings on
CXR
37

39. 3

40. 3

41. 40

42. 41

43. Chest radiograph
The primary role of the chest radiograph is to differentiate
pneumonia from other conditions that produce opacities
(e.g. atelectasis, pleural effusion, pulmonary embolus,
pulmonary contusion, mass lesions).
The chest radiograph is also helpful in :
following the progress of pneumonia,
evaluating the response to therapy, and
detecting complications (e.g., pleural effusion, empyema,
congestive heart failure).
42

44. The key-findings on the chest X-ray are:
1-ill-defined homogeneous opacity obscuring vessels
2-Silhouette sign: loss of lung/soft tissue interface
3-Air-bronchogram
4-Extention to the pleura or fissure, but not crossing it
5-No volume loss
43

45. 44

46. 4

47. 46

48. 4

49. Management
The most important aspects of management are oxygenation, fluid
balance and antibiotic therapy.
In severe or prolonged illness, nutritional support may be
required.
Oxygen
Oxygen should be administered to all patients with tachypnea,
hypoxemia, hypotension or acidosis,
with the aim of maintaining the SaO2 at or above 92%.
High concentrations(35% or more), preferably humidified, should
be used in all patients who do not have hypercapnia
associated with COPD.
48

50. 4

51. Indications for referral to ICU
• CURB score 4-5 failing to respond rapidly to
initial management .
• Persisting hypoxia PaO2<60 mmHg despite
high conc. O2 .
• Progressive hypercapnea .
• Severe acidosis .
• Shock .
• ↓ consciousness
50

52. How Long Should You Treat?
• A generally accepted approach for outpatients and non-ICU
inpatients:
• S. pneumoniae, H. influenzae and other “typical ” bacterial organisms
(to include gram negative organisms) - treat for 7 to 10 days
• Mycoplasma, Chalmydia and Legionella species ”atypical bacteria“ -
treat for 10 to 14 days (Macrolide )
51

53. 52

54. Classification by duration
A-ACUTE PNEUMONIA
Duration of symptoms days to weeks
B-CHRONIC PNEUMONIA
Duration of symptoms weeks to months
53

55. Chronic Pneumonia
➢ These pneumonia develop gradually over a period of weeks - months and
are caused but numerous microorganisms.
❖Common causes
❖ M.tuberculosis
❖ Entamoeba histolytica
❖ Echinococcus granulosus
54

56. Recurrent “pneumonias
Causes
• Pulmonary
• Neoplasm
• Foreign body
• Bronchiectasis
Neurological dysfunctions
• Seizures
Gastrointestinal Problems
GERD
Zenker’s diverticula
Achalasia
Immune deficiency
Multiple Myeloma
Chronic lymphocytic leukemia
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HIV

57. THANKS
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