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Pneumonia

Title               

Ñ    Pneumonia

Definition

Ñ    Pneumonia may be defined as:

Ñ    Inflammation of the lung parenchyma:

·          Alveoli

·          Interstitial tissue

Aetiology

Bacteria

Ñ    Streptococcus pneumoniae

Ñ    Staphylococcus aureus

Ñ    Haemophilus influenzae

Ñ    Chlamydia pneumoniae

Ñ    Chlamydia psittaci

Ñ    Moraxella catarrhalis

Ñ    Legionella pneumophilia

Ñ    Klebsiella pneumoniae

Mycoplasma

Ñ    Mycoplasma pneumoniae

Viruses

Ñ    Influenza A

Ñ    Influenza B

Ñ    Varicella-zoster

Higher bacteria  

Ñ    Nocardia

Ñ    Actinomyces

Mycobacteria

Ñ    Mycobacterium tuberculosis

Ñ    Mycobacterium kansasii

Ñ    Mycobacterium avium-intracellulare

Fungi

Ñ    Histoplasma capsulatum

Ñ    Coccidioides immitis

Ñ    Blastomyces dermatidis

Ñ    Cryptococcus neoformans

Ñ    Aspergillus fumigatus

Ñ    Pneumocystis carinii

Ricketsiae

Ñ    Coxiella burnetii

Pathogenesis

Sites

Ñ    Lobar pneumonia:

Affects an entire lobe

Ñ    Segmental pneumonia:

Segment of a lobe

Ñ    Bronchopneumonia:

Bronchi and contiguous alveoli

Ñ    Interstial pneumonia:

Interstitial tissue

Predisposing factors

RS

Ñ    Upper respiratory viral infections

Ñ    Exposure to infective agents

Ñ    Chronic obstructive pulmonary disease

Ñ    Bronchiectasis

Ñ    Bronchial obstruction

Toxins

Ñ    Alcoholism

Ñ    Cigarette smoking

CVS

Ñ    Heart failure

E&M

Ñ    Debility

HS

Ñ    Immunocompromised individuals

CNS

Ñ    Impaired level of consciousness

GIT

Ñ    Aspiration

Age

Ñ    Extremes of age

Social circumstances

Ñ    Institutionalisation

Pathological Process

Ñ    Infective agent triggers an inflammatory response

Ñ    Neutrophilic inflammatory exudate fills alveoli and small airways

Clinical Features

History

E&M

Ñ    Fever

Ñ    Malaise

RS

Ñ    Cough

Ñ    Sputum production

Ñ    Pleuritic chest pain

Ñ    Haemoptysis

GIT

Ñ    Anorexia

CNS

Ñ    Headache

Examination

RS

Ñ    Tachypnoea

Ñ    Reduced chest expansion

Ñ    Increased vocal fremitus

Ñ    Dull percussion note

Ñ    Bronchial breathing

Ñ    Increased vocal resonance

Ñ    Whispering pectoriloquy

Ñ    Crepitations

Ñ    Pleural rub

CVS

Ñ    Tachycardia

IS

Ñ    Herpes labialis

HS

Ñ    Hepatomegaly

Ñ    Splenomegaly

Complications

IS

Ñ    Conjunctivitis

Ñ    Erythema nodosum

RS

Ñ    Lung abscess

Ñ    Pleural effusion

Ñ    Empyema

CVS

Ñ    Endocarditis

Ñ    Pericarditis

LMS

Ñ    Septic arthritis

CNS

Ñ    Meningitis

Ñ    Brain abscess

GIT

Ñ    Hepatitis

Ñ    Peritonitis

HS

Ñ    Haemolytic anaemia

Investigations

Fluids

Sputum

Microbiology

Ñ    Culture:

Blood

Haematology

Ñ    Neutrophilia 

Ñ    Elevated inflammatory markers:

ESR, CRP, PV

Biochemistry

Ñ    Hyponatraemia

Ñ    Hypoalbuminaemia

Microbiology

Ñ    Culture

Urine

Ñ    Pneumococcal antigen

Ñ    Legionella antigen

Imaging

Chest s-ray

Ñ    Consolidation

Management

Cure

Drugs

Antibiotics

Ñ    Outpatient  (not severe):

Amoxycillin and erythromycin or clarithromycin

Ñ    Inpatient  (not severe):

Oral amoxycillin and clarithromycin or erythromycin

Or

Fluoroquinolone with enhanced pneumococcal activity:

Levofloxacin or moxifloxacin

Or

Intravenous ampicillin or benzylpenicillin plus erythromycin or clarithromycin

Ñ    Inpatient   (severe):

Intravenous co-amoxiclav or cefuroxime or cefotaxime or ceftriaxone

Plus

Erythromycin or clarithromycin

Or

Fluoroquinolone with enhanced pneumococcal activity

Plus

Benzylpenicillin

Support

Respiratory         

Ñ    Oxygen therapy

Ñ    NIPPV (non invasive positive pressure ventilation)

Ñ    Intubation and ventilation

Prognosis

CURB-65 score

This system may be used to determine severity of the disease

Ñ    Confusion

Ñ    Urea > 7 mmol/L

Ñ    Respiratory rate ³ 30 /min

Ñ    Blood pressure:

Systolic < 90 mm Hg

Diastolic £ 60 m Hg

Ñ    Age ³ 65 years

One point for each of the above

Score

Ñ    3 or more:     

Severe pneumonia

High risk of death

Ñ    2:

Increased risk of death

Ñ    1or 0:

Low risk of death

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