A previously healthy 32-year-old male presented with a 2-day history of fever, chills, productive cough, dyspnea, and chest pain. On examination, he had tachycardia, tachypnea, and reduced breath sounds with crackles on the left side of his chest. He likely has pneumonia based on his symptoms and physical exam findings of reduced breath sounds and crackles.

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-Nov-12

3. What is your diagnosis?
2-Nov-12

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. 2-Nov-12

6. How severe is our patient’s pneumonia?
2-Nov-12

7. Applying CURB-65 Rule
2-Nov-12

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. Classification of pneumonias
• BRONCHO-pneumonia
• LOBAR pneumonia
• SEGMENTAL pneumonia
• SUBSEGMENTAL pneumonia
And
 ‘Double’ pneumonia
2-Nov-12

10. 2-Nov-12

11. Distribution of lung involvement in
lobar pneumonia and bronchopneumonia
2-Nov-12

12. 2-Nov-12

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. 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. CAP - Microbiology
Typical 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. CAP - Presentation
Typical 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. Other Pneumonias - Microbiology
What 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. 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. `
2-Nov-12

20. Streptococcus pneumoniae are Gram-positive, lancet-shaped cocci in
couples
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. Streptococcus pneumoniae
Quellung (capsular swelling)
reaction can be used to
demonstrate the presence of
a specific capsular type of the
bacterium.
2-Nov-12

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. 2-Nov-12

24. 2-Nov-12

25. 2-Nov-12

26. 2-Nov-12

27. Mycoplasma Pneumonia
Extrapulmonary 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. 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. The clinical
diagnosis of
psittacosis was
subsequently
confirmed by
serology tests. He
was treated with
intravenous
fluids, oxygen and
tetracycline and
recovered fully
2-Nov-12

30. CT scan of the chest demonstrates patchy multifocal ground glass
attenuation opacities (arrows).
2-Nov-12

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. 2-Nov-12

33. After3 weeks course of macrolide
2-Nov-12

34. Investigations in CAP
ROUTINE INVESTIGATIONS IN CAP
• Chest X-ray +/- CT chest
• Blood: CBC with reticulocytes
• Tests for microbiological identification:
2-Nov-12

35. Differential diagnosis
PULMONARY INFARCTION
PULMONARY/PLEURAL TUBERCULOSIS
PULMONARY EDEMA
NEOPLASTIC DISEASE
SUBDIPHRAGMATIC INFLAMMATION
 Subphrenic abscess, Amebic liver abscess,
cholycystitis, pancreatitis
RARE CONDITIONS
 Pulmonary eosinophilia, connective tissue
diseases, Wegener’s granuloma
2-Nov-12

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. 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. 2-Nov-12

39. 2-Nov-12

40. Klebsiella pneumoniae on a
MacConkey agar plate.
2-Nov-12

41. Klebsiella pneumonia. Downward bulging of the minor fissure (arrow)
due to massive enlargement of the right upper lobe with inflammatory
exudate.
2-Nov-12

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. 2-Nov-12

44. Production of pyocyanin, water-soluble green pigment of
Pseudomonas aeruginosa
2-Nov-12

45. Pseudomonas aeruginosa on an 2-Nov-12
agar plate.

46. Case 8
A 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. 2-Nov-12

48. PCP pneumonia in a young HIV- CT scan of the chest demonstrates
positive patient. cystic air spaces of varying sizes that
CXR demonstrates are consistent with pneumatoceles.
predominantly central airspace
disease with peripheral sparing.
2-Nov-12

49. Pneumonia in the
immunocompromised host
Mechanism Cause Organisms
 Marrow Aplasia Staph. aureus
Neutropenia  AMM Gram negative bacteria
 Marrow infiltration Candida/ Aspergillus
 AIDS Strept. pneumoniae
T cell defect  CLL H. influinzae
 Lymphoma Staph. aureus
 Immunosuppressants Gram negative bacteria
 BMT Pneumocystis carinii
 Splenectomy Myco. tuberculosis
 CLL Strept. pneumoniae
Antibody  Myeloma H. influinzae
production
2-Nov-12

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. 2-Nov-12

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. 1: 15.09.2008 2: 20.09.2008
2-Nov-12

54. 3: 12.10.2008
2-Nov-12
4: 22.10.2008

55. Complications of pneumonia
 Respiratory failure
 Septicemia/ hypotension: ARF
 Atrial fibrillation
 Pleural effusion/ empyema
 Lung abscess
 Jaundice
 Pericarditis/myocarditis/endocarditis
2-Nov-12

56. 2-Nov-12