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IDL presentation #ISNC

TuQa Al-Harazi

on 5 April 2013

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Transcript of Pneumonia

Etiologic Types

Infective :

2- Bacterial
4- tuberculosis

Non Infective :

Aspiration classification of pneumonia : Community-Acquired Acute Pneumonia Streptococcus pneumoniae : The Pneumonia Syndromes The clinical examination varies according to the immune state of the patient and the infecting agent that cause pneumonia disease : Haemophilus influenza
small gram-negative bacillai organism .

This bacterium is a ubiquitous colonizer of the pharynx, where it exists in two forms: encapsulated (5%) and unencapsulated (95%).
Although there are six serotypes of the encapsulated form (types a to f), type b, which has a polyribosephosphate capsule, used to be the most frequent cause of severe invasive disease.

Before a vaccine became widely available, H. influenzae was a common cause of suppurative meningitis in children up to 5 years of age. H. influenzae also causes an acute, purulent conjunctivitis (pink eye) in children and, in predisposed older patients, may cause septicemia, endocarditis, pyelonephritis, cholecystitis, and suppurative arthritis. H. influenzae is the most common bacterial cause of acute exacerbation of COPD. PNEUMONIA Pneumonia in the Immunocompromised Host Pneumonia is defined as an inflammation of the substance
of the lungs. It is usually caused by bacteria. Clinically it :
usually presents as an acute illness with cough, purulent
sputum and fever together with physical signs or radiological
changes compatible with consolidation of the lung. The
advent of antibiotics has dramatically decreased the mortality
from pneumonia among young people but it remains a
dangerous condition and is a major cause of death over the
age of 70 years. The causative agents are the same as
found in community-acquired pneumonia in
healthy people. Community-Acquired Acute Pneumonia
Community-Acquired Atypical Pneumonia
Nosocomial Pneumonia
Aspiration Pneumonia
Chronic Pneumonia
Pneumonia in the Immunocompromised Host going on the details about each agents !
Moraxella catarrhalis is being increasingly recognized as a cause of bacterial pneumonia, especially in the elderly. It is the second most common bacterial cause of acute exacerbation of COPD. Along with S. pneumoniae and H. influenzae, M. catarrhalis constitutes one of the three most common causes of otitis media in children. Moraxella catarrhalis :
Staphylococcus aureus is a bacterium commonly found on the skin and in the nose of healthy people. The major habitats of the pathogen are the nasal membrane and skin of warm-blooded animals. it characterized by
Gram positive cocci, arranged in grape-like clusters.
Catalase and coagulase positive. Facultative anaerobes,

Diagnosis of it by Chest x-rays nearly always reveal a lung abscess. Treatment of it by requires antibiotics. Staphylococcus aureus
Legionella pneumophila is a motile, rod-shaped, gram-negative, aerobic, bacterium. It requires complex nutritional requirements such as high cysteine levels and low sodium levels to grow. Legionella pneumophila have always been found in non-marine aquatic environments such as lakes and ponds
Legionella bacteria has been recovered from a wide range of both human-made and natural aquatic habitats, from lakes and streams to air-conditioning cooling towers, fountains, and spa baths. It diagnosis by Blood tests , A chest X-ray, which doesn't confirm Legionnaires' disease but can show the extent of infection in your lungs , is treated with antibiotics. The sooner therapy is started, the less likely the chance of serious complications or death. Legionella pneumophila
-Klebsiella pneumoniae is a Gram-negative bactiria.
- The organism can be found in the sputum or in the blood.
-occurs in elderly people with a history of heart or lung disease, diabetes, alcohol excess or malignancy.
- The onset is sudden, with severe systemic upset.
-The sputum is purulent, gelatinous or bloodstained. The upper lobes are more commonly affected.
- There is often swelling of the infected lobe.
cephalosporin is usually optimal Klebsiella pneumoniae Pseudomonas aeruginosa It is found in soil, water, skin flora
occurs in in patients with cystic fibrosis or those with reduced immunity
is also seen in patients with neutropenia following cytotoxic chemotherapy
The isolation of P. aeruginosa from sputum must be interpreted with care

-4-quinolone antibiotic
- ceftazidime
- Ticarcillin
-piperacillin are active against these bacilli
These penicillins usually given in combination with an aminoglycoside Community-Acquired Atypical Pneumonia : Mycoplasma pneumonia
The family Chlamydiaceae consists of two genera. One species of Chlamydia and two of Chlamydophila .
•Chlamydia trachomatis
•Chlamydophila pneumoniae
•Chlamydophila psittaci
the Chlamydiaceae are small obligate intracellular parasites and were formerly considered to be viruses . chlamydia group Coxiella burnetti (Q fever) syncytial virus (RSV) Respiratory syncytial virus (RSV), which causes infection of the lungs and breathing passages, is a major cause of respiratory illness in young children.
Respiratory illness caused by RSV — such as bronchiolitis or pneumonia — usually lasts about a week, but some cases may last several weeks.
Symptoms: In adults, it may only produce symptoms of a common cold, such as a stuffy or runny nose, sore throat, mild headache, cough, fever, and a general feeling of being ill. But in premature babies and kids with diseases that affect the lungs, heart, or immune system, RSV infections can lead to other more serious illnesses.
mode of transmition: RSV is highly contagious and can be spread through droplets containing the virus when someone coughs or sneezes. Almost all kids are infected with RSV at least once by the time they're 2 years old / Diagnose: Doctors typically diagnose RSV by taking a medical history and doing a physical exam. Nosocomial Pneumonia
Nosocomial, or hospital-acquired, pneumonias are defined as pulmonary infections acquired in the course of a hospital stay. The specter of nosocomial pneumonia places an immense burden on the burgeoning costs of health care, besides the expected adverse impact on illness outcome. Nosocomial infections are common in hospitalized persons with severe underlying disease, immune suppression, or prolonged antibiotic therapy. Those on mechanical ventilation represent a particularly high-risk group, and infections acquired in this setting are given the distinctive designation ventilator-associated pneumonia. Gram-negative rods (Enterobacteriaceae and Pseudomonas spp.) and S. aureus are the most common isolates; unlike community-acquired pneumonias, S. pneumoniae is not a major pathogen in nosocomial infections. Aspiration Pneumonia Definition of Aspiration pneumonia: Aspiration pneumonia occurs in markedly * debilitated patients or * those who aspirate gastric contents either while during repeated vomiting or unconscious , as in stuporous alcoholics, anesthetized patients and people subject to seizures or after a stroke .

* The resultant pneumonia is partly chemical, resulting from the extremely irritating effects of the gastric acid, and partly bacterial. Although it is commonly assumed that anaerobic bacteria predominate, recent studies implicate aerobes more commonly than anaerobes (Anaerobic oral flora (Bacteroides, Prevotella, Fusobacterium, Peptostreptococcus), admixed with aerobic bacteria (S. pneumoniae, S. aureus, H. influenzae, and Pseudomonas aeruginosa)).

* This pneumonia is often necrotizing and is a frequent cause of death in persons predisposed to aspiration. In those who survive, abscess formation is a common complication. chronic pneumonia cont. Nocardia asteroids
most commonly cause chronic but clinically localized pulmonary disease in immunocompetent individuals .
In the United States, strains implicated most frequently include :
M. avium complex , M. kansasii , and M. abscessus.
It is not uncommon for nontuberculous mycobacteria to present as upper lobe cavitary disease
The presence of chronic pulmonary disease (COPD, cystic fibrosis ) is an important risk factor associated with nontuberculous mycobacterial infection.

In immunosuppressed individuals ( HIV-positive patients ), M. avium complex presents as disseminated disease, associated with systemic symptoms (fever, night sweats, weight loss) and Hepatosplenomegaly .
Pulmonary involvement is often indistin-guisha-ble from tuberculosis in AIDS patients .

In AIDS patients it tends to occur late and that's when CD4 counts have fallen below 100 cells/mm3 . Nontuberculous Mycobacterial Disease
*Cytomegalovirus infections
Cytomegalovirus (CMV), a member of the herpesvirus family, may produce a variety of disease manifestations.
Cells infected by the virus exhibit gigantism of both the entire cell and its nucleus.
The owl's eye appearance of CMV-infected cells can easily be seen in tissue or organ preparations from any part of the body.
Transmission of CMV can occur by several mechanisms, depending on the age group affected:
A fetus can be infected transplacentally from a newly acquired or primary infection in the mother.
Preschool children, especially in day care centers, can acquire it through saliva.
Toddlers so infected readily transmit the virus to their parents. In individuals over 15 years of age. Cytomegalovirus Infections
P. jiroveci (formerly known as P. carinii), an opportunistic infectious agent long considered to be a protozoan, is now believed to be more closely related to fungi. Serologic evidence indicates that virtually all persons are exposed to Pneumocystis during the first few years of life, but in most the infection remains latent. Reactivation and clinical disease occurs almost exclusively in those who are immunocompromised. Indeed, P. jiroveci is an extremely common cause of infection in persons with AIDS, and it may also infect severely malnourished infants and immunosuppressed individuals (especially after organ transplantation or in individuals receiving cytotoxic chemotherapy or corticosteroids). Pneumocystis Pneumonia
Candida albicans is the most frequent disease-causing fungus. It is a normal inhabitant of the oral cavity, gastrointestinal tract, and vagina in many individuals. Even though systemic candidiasis (with associated pneumonia) is a disease that is restricted to immunocompromised patients, we will consider the protean manifestations of Candida species in this section. In tissue sections, C. albicans demonstrates yeastlike forms (blastoconidia), pseudohyphae, and true hyphae . Pseudohyphae are an important diagnostic clue for C. albicans and represent budding yeast cells joined end to end at constrictions, thus simulating true fungal hyphae. The organisms may be visible with routine hematoxylin and eosin stains, but a variety of special "fungal" stains (Gomori methenamine-silver, periodic acid-Schiff) are commonly used to better highlight the pathogens. Opportunistic Fungal Infection How we can discover the infectious agents Laboratory Tests for Diagnosing Infection and Identifying Bacteria
Although current antibiotics can destroy a wide spectrum of organisms, it is best to use an antibiotic that targets the specific one making a person sick. Unfortunately, people carry many bacteria, and sputum and blood tests are not always effective in distinguishing between harmless and harmful kinds.
In severe cases, a doctor needs to use invasive diagnostic measures to identify the cause of the infection. Standard lab tests used to help diagnose pneumonia include: Sputum Tests The color of the mucus (sputum) sample coughed up from the lungs can reveal the severity of the disease. Only a sputum sample will reveal the organism causing the infection.
The patient coughs as deeply as possible to bring up mucus from the lungs, since a shallow cough produces a sample that usually only contains normal mouth bacteria. Some people may need to inhale a saline spray to produce an adequate sample. In some cases, a tube will be inserted through the nose into the lower respiratory tract to trigger a deeper cough. Blood Tests. The following blood tests may be performed:
•White blood cell count (WBC). High levels indicate infection.
•Blood cultures. Cultures are done to determine the specific organism causing the pneumonia, but they usually cannot distinguish between harmless and dangerous organisms.
•Detection of antibodies to S. pneumoniae. Antibodies are immune
factors that target specific foreign invaders.

Polymerase Chain Reaction (PCR). In some difficult cases, PCR may be performed. The test makes multiple copies of the genetic material (RNA) of a virus or bacteria to make it detectable.

PCR is useful for identifying certain atypical bacteria strains, including mycoplasma and Chlamydia pneumoniae, and possibly, Haemophilus influenzae type b, but it is expensive. One study found that using a real-time PCR test may help quickly diagnose Pneumocystitis pneumonia in HIV-positive patients. Urine Tests Urine antigen tests for Legionella pneumophila (Legionnaires' disease) and Streptococcus pneumoniae may be performed.The S. pneumoniae test takes only 15 minutes and may identify up to 77% of pneumonia cases and rule out S. pneumoniae infection in 98% of patients. It may not be useful in children.
In critically-ill patients with ventilator-associated pneumonia, doctors have tried sampling fluid taken from the lungs or trachea. These techniques enabled the physicians to identify the pneumonia-causing bacteria and start the appropriate antibiotics. However, this made no difference in the length of stay in the ICU or hospital, and there was no significant difference in outcome. Invasive Tests.
X-Rays. A chest x-ray is nearly always taken to confirm a pneumonia diagnosis. X-rays are a form of electromagnetic radiation (like light). They are of higher energy, however, and can penetrate the body to form an image on film. Structures that are dense (such as bone) will appear white, air will be black, and other structures will be shades of gray depending on density. X-rays can provide information about obstructions, tumors, and other diseases, especially when coupled with the use of barium and air contrast within the bowel. Chest X-Rays and Other Imaging Techniques Treatment: The approach to treating patients with pneumonia generally involves:
•Deciding who can be treated at home and who needs to be in the hospital
•Deciding whether a patient needs antibiotics, and which antibiotics are appropriate
•Providing appropriate supportive care
•Deciding what follow-up and preventive care are needed
Whether patients are treated at home or admitted to the hospital, receiving their first dose of antibiotics quickly improves the outcome of the illness and the speed at which they get better. Determining the Need for Hospitalization
Studies indicate that many patients do not need to be hospitalized for pneumonia, and can be safely treated at home. Likewise, many patients who are admitted to the hospital could be released sooner.
A variety of guidelines and tools have been developed to help determine who can safely be treated at home and who cannot. The more of these risk factors that are present, the less likely that the patient can be safely treated at home.
Some of the important factors used to make a decision include:
•Patients who have been living in a nursing home or other residential facility are of greater concern.
•Elderly patients and infants, particularly infants who are less than 1 month old, are more likely to be admitted. Home Treatment
The following tips are suggested:
•Drink plenty of liquids.
•Do not suppress a cough. Coughing is an important reflex for clearing the lungs. Some doctors advise taking expectorants, such as guaifenesin (Breonesin, Glycotuss, Glytuss, Hytuss, Naldecon Senior EX, Robitussin) to loosen mucus. However, there is no proof that any of these products make much difference in a patient's outcome.
•Mild pain can be treated with aspirin (in adults only), acetaminophen (Tylenol), or ibuprofen (Advil, Motrin).
•For severe pain, codeine or another stronger pain reliever may be prescribed. It should be noted, however, that codeine and other narcotics suppress coughing, so they should be used with care in pneumonia. Such pain relievers often require monitoring. Chronic pneumonia is localized lesion in an immunocompetent person, There is typically granulomatous inflammation, which may be due to bacteria (e.g., M. tuberculosis) or fungi. those with debilitating illness or with human immune deficiency virus (HIV) infection , there is usually systemic dissemination of the causative organism, accompanied by widespread disease.

# Glaucomatous: mycobacterium tuberculosis :
- Transmitted by droplet infection.
- Serious cause of morbidity and mortality (6% of all deaths worldwide).
- It's treatment are very different from the other infective agents.
-Tuberculosis is by far the most important entity within the spectrum of chronic pneumonias.
Domain (Bacteria); Phylum (Actinobacteria); Class (Actinobacteridae); Order (Corynebacterineae); Family (Nocardiaceae); Genus (Nocardia) ; species (Nocardia asteroids) .
Species of Nocardia genus are Gram –positive.
Nocardia asteroides are found worldwide and they are saprophytes.
Nocardia may also colonize the respiratory tract of immunocompetent individuals with compromised pulmonary function, such as those with asthma . morphological types :


duration :

chronic clinical :
primary/ secondary
Typical / Atypical
community /hospital Typical pneumonia This type of pneumonia typically comes on very quickly. However, chest pain associated with typical pneumonia can also be a sign of other serious medical conditions . Symptoms of typical pneumonia include: chest pain, which is usually worse with breathing or coughing
high fever
shaking chills
short of breath
sore chest when you touch or press it
yellow or brown sputum Atypical pneumonia “walking pneumonia”, typically come on gradually. Unlike cases of typical pneumonia, you may not experience any chest pain and body temperature is usually lower, while shaking chills are less likely. Older people can experience confusion or a change in mental abilities as a sign of pneumonia or other infection. Other Symptoms of typical pneumonia include: abdominal pain
another preceding illness
a cough that only produces a little sputum
body aches
dry cough
joint pain Infecting agent:
Pneumocystis jiroveci (it is a yeast-like fungus),it cannot be grown in culture.

Symptoms include:
Cough – Fever--Rapid breathing--Shortness of breath

Diagnosis :
Blood gases--Bronchoscopy (with lavage)--Lung biopsy-
X-ray of the chest--Sputum exam to check for fungus that causes the infection

· Antibiotics can be given by mouth (orally) or through a vein (intravenously), depending on the severity of the illness.
· People with low oxygen levels and moderate to severe disease are often prescribed corticosteroids as well.
· PCP does not respond to antifungal treatment.

Cc cont.
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