This document describes a case of pneumonia in a 68-year-old male smoker who presented with cough, fever, and chest pain. On examination, he appeared tired and underweight with decreased breath sounds on the right lung. A chest x-ray showed right middle lobe pneumonia. He was treated as an outpatient with antibiotics, but a follow-up x-ray found a right hilar mass and sputum testing demonstrated atypical cells, indicating a more serious condition. The document provides answers to questions about identifying problems in the history, significant physical findings, likely causative organisms, how the specific diagnosis is established, appropriate treatment, and expected duration of treatment.

1. Pneumonia Cases
Dr. Sameh Ahmad Muhamad abdelghany
Lecturer Of Clinical Pharmacology
Mansura Faculty of medicine

2. Pneumonia

3. CAS(1)

4. CHIEF COMPLAINT
4
 Cough and fever for four days.

5. HISTORY
5
 Mr. Alcot is a 68 year old man who developed a tough, productive cough four
days prior to being seen by a physician. The sputum is thick and yellow with
streaks of blood. He developed a fever, shaking, chills and malaise along with
the cough. One day ago he developed pain in his right chest that intensifies
with inspiration. The patient lost 7 kilograms over the past few months but
claims he did not lose his appetite. "I just thought I had the flu." Past history
reveals that he had a chronic smoker's cough for "10 or 15 years" which he
describes as being mild, non-productive and occurring most often in the early
morning. He smoked 2 packs of cigarettes per day for the past 50 years.

6. PHYSICAL EXAMINATION
6
 The patient is an elderly man who appears tired weak and underweight. His
complexion is pale. He coughs continuously. Sitting in a chair, he leans to his right
side, holding his right chest with his left arm. Vital signs are as follows: blood pressure
152/90, apical heart rate 112/minute and regular, respiratory rate 24/minute and
somewhat labored, temperature 39.2 ° Celsius. Both lungs are resonant by percussion
with one exception: the right mid-anterior and right mid-lateral lung fields are dull.
Auscultation reveals bilateral diminished vesicular breath sounds. Bronchial breath
sounds, rhonchi and late inspiratory crackles (are heard) in the area of the right mid-
anterior and right mid-lateral lung fields. The remainder of the lung fields is clear.
Percussion and auscultation of the heart reveals no significant abnormality.

7. LABORATORY
7
 WBC 17,000/mm3; neutrophils 70%, bands 15%,
lymphocytes 15%.

8. COURSE OF ILLNESS
8
 Following a chest x-ray PA
view and Lateral which
revealed an acute pneumonia
in the right middle lobe, the
patient was treated with
antibiotics as an outpatient.

9. COURSE OF ILLNESS
9
 During the 10 days of treatment the patient's fever abated
and he felt somewhat better. A post-treatment (follow up)
chest x-ray reveals a right hilar mass. Sputum cytology
demonstrates atypical cells.

10. Questions
10
 Q1:Identify the problems from the history?
 Q2:Identify and explain the significance of physical findings?
 Q3:Review the lab findings. What is your diagnosis?
 Q4:What do you understand by the terms "hospital acquired"
and "community acquired " pneumonia.? Which type of
pneumonia does our patient have?
 Q5:What organisms are likely to be causing his
pneumonia?

11. Questions
11
 Q6: How is the specific diagnosis established?
 Q7: What antimicrobial agents would you prescribe for this
patient? Would you use or avoid penicillin, and why?
 Q8:What is the duration of treatment?

12. Answer of Question 1
12
 Acute febrile illness
 Cough with Yellow sputum, with streaking of blood
 Pain in chest
 Shaking chills
 weight loss
 Chronic bronchitis
 Smoker
 Hypertension
Back

13. Answer of Question 2
13
 BP, Temp, Respiratory rate
 Labored breathing
 Supraclavicular node
 Dullness with bronchial breathing over right mid anterior
lung field.
Back

14. Answer of Question 3
14
 Lobar Pneumonia
Back

15. Answer of Question 4
15
 Oropharyngeal colonization is different in the community
and hospital setting.
 This makes a difference in the etiology of pneumonia.
 This patient has community acquired pneumonia.
Back

16. Answer of Question 5
16
 The patient has community-acquired pneumonia.
 The most common organisms are
1. Streptococcus pneumoniae (30%)
2. Hemophilus influenzae (10%)
3. Mycoplasma pneumoniae (10%)
4. Chlamydia pneumoniae (8%)
5. influenza virus (7%)
6. Legionella species (3%)
7. gram negative Enterobacteriaceae (3%)
8. Chlamydia psittaci (1%)
Back

17. Answer of Question 6
17
 Gram stain: The diagnosis is suggested by the
demonstration of large numbers of PMN’s and gram-
positive diplococci in a gram stained sputum specimen.
 Sputum culture: The diagnosis is confirmed by
identification of Streptococcus pneumoniae in sputum
culture.
Back

18. Answer of Question 7
18
 Penicillin has been the standard drug to treat pneumonococcal
pneumonia. Procaine penicillin G, amoxicillin, cefazolin, and
erythromycin are effective.
 Trimethoprim-sulfamethoxazole should be avoided as up to 20%
isolated from day care centers are resistant.
 In penicillin – allergic patients, erythromycin is an alternative.
 The emergence of penicillin resistant strains is of great concern .
Where the incidence of resistance of high, Ceftriaxone or
erythromycin are the agents of choice.
Back

19. Answer of Question 8
19
 The length of treatment will vary with the severity of illness and the
presence of underlying disease.
 Generally, 7-10 days of antibiotic should be sufficient.
 Pneumococci are no longer detected in the sputum within several hours
of the first dose of penicillin.
 Dramatic symptomatic improvement in 24 hours
 The lack of lung destruction and complete resolution of pathologic
changes on recovery, coupled with the dramatic response to penicillin,
allow for a relatively short duration of treatment.
Back

20. CAS(2)

21. Scenario
21
A 15 year old female with a history of hay fever develops fever,
headache and malaise for 4 days followed by a nonproductive
cough and scratchy throat. Despite chicken soup and orange juice,
the cough and fever persist, and her mother drags her to your
office. On examination, her temperature is 38.3° celsius, pulse 90
beats/min, BP 110/70, respiratory rate 20 beats/min Physical
examination is unremarkable except for scattered rales over the
left lower lung, and small bullae in her left tympanic membrane.
Chest x-ray reveals a patchy left lower lobe infiltrate. At your
request, she makes a great effort but is unable to produce sputum.

22. Questions
22
 Q1:What is the type of pneumonia likely to have?
 Q2:What is "atypical pneumonia"?
 Q3:What is the differential diagnosis of atypical pneumonia?
 Q4: If the causative organism was Mycoplasma pneumonia,
What antimicrobial agent(s) would you use ?

23. Answer of Question 1
23
 Atypical pneumonia.
Back

24. Answer of Question 2
24
 The term "atypical pneumonia" is applied to non-lobar
patchy or interstitial infiltrates on chest x-ray where the
causative organism is not identified on gram stain or
culture of sputum.
 Often they are not toxic, do not have shivers and do not
seek medical attention. "Walking Pneumonia“
Back

25. Answer of Question 3
25
 The pathogens causing atypical pneumonia include
o Mycoplasma pneumoniae
o Chlamydia psittaci
o Chlamydia pneumoniae
o Coxiella burnetii
o Legionella pneumophila
o viruses including influenza A and B, parainfluenza, adenovirus and
respiratory syncytial virus.
Back

26. Answer of Question 4
26
 Erythromycin and tetracycline are equally effective in treatment of M.
pneumoniae infection. They shorten the course of infection but do not
eliminate the carrier state.
 Clarithromycin and azithromycin are also effective but much more
expensive.
 Quinolones such as ciprofloxacin have in vitro efficacy against
mycoplasma, but are expensive and contra-indicated in children.
 Since mycoplasmas lack a cell wall, beta-lactam antibiotics are
ineffective for treatment.
 Therapy is generally continued for 2-3 weeks, as relapses can occur in
up to 10% cases
Back

27. CAS(3)

28. Scenario
28
A 35 year alcoholic male with a history of seizures is admitted
with a three week history of fever, generalized weakness, poor
appetite, and cough productive of green, foul - smelling sputum.
On physical examination, the temperature is 37.9 celsius degrees.
Pulse is 96 beats per minute, respiratory rate is 20 breaths per
minute, and BP is 120/80 mm. There are many missing teeth with
gingivitis and dental caries. He has rales and decreased breath
sounds over the right base. Chest x-ray shows consolidation in the
superior segment of the right lower lobe.

29. Questions
29
 Q1: What type of infection is suggested by his fowl smelling
sputum?
 Q2: What organisms could be responsible for this patient's
pneumonia?
 Q3: How would you treat this patient?
 Q4: What organisms might be the cause of a hospital acquired
aspiration pneumonia?

30. Answer of Question 1
30
 Anaerobic infection.
Back

31. Answer of Question 2
31
 Peptostreptococcus sp.
 Bacteroides sp. (B. melanogenicus, B. intermedius)
 Fusobacterium sp.
Back

32. Answer of Question 3
32
 Antibiotic therapy is the key treatment for anaerobic pulmonary infections.
 Drug of choice: Clindamycin
 Alternative agents: Penicillin, Ampicillin/sulbactam, or
Amoxicillin/clavulanic acid
 Duration of therapy will depend on radiographic clearance, and may range
as long as 2-4 months.
 Postural drainage is an important component of therapy.
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33. Answer of Question 4
33
 Patients with nosocomial aspiration pneumonia are more likely to have a
mixed aerobic-anaerobic infection, in which the aerobic component
(gram-negative bacilli) predominates.
 Aerobic organisms: Klebsiella , Enterobacter , Serratia , E. coli ,
Pseudomonas aeruginosa, Staphylococcus aureus ,
 Anaerobic organisms: Peptostreptococcus sp. , Bacteroides sp. (B.
melanogenicus, B. intermedius) , Fusobacterium sp.
 Antibiotics
o Drug of choice: Clindamycin + aminoglycoside
o Alternative agents: Ticarcillin/clavulanate, or Imipenem, or Piperacillin, or
Mezlocillin
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34. T H A N K Y O U !
A N Y Q U E S T I O N S ?