Pneumonia

Pneumonia is a common disease because: The epithelial surfaces of the lung are constantly exposed to many liters of air containing various levels of microbial contaminants. Nasopharyngeal flora are regularly aspirated during sleep, even by healthy persons. Other common lung diseases render the lung parenchyma vulnerable to virulent organisms.

Pneumonia can be very broadly defined as any infection in the lung. The clinical presentation may be as an acute, fulminant or a chronic disease Acute bacterial pneumonias can manifest as one of two anatomic and radiographic patterns, referred to as bronchopneumonia and lobar pneumonia.

Bronchopneumonia implies a patchy distribution of inflammation that generally involves more than one lobe. This pattern results from an initial infection of the bronchi and bronchioles with extension into the adjacent alveoli. By contrast, in lobar pneumonia the contiguous air spaces of part or all of a lobe are homogeneously filled with an exudate.

The anatomic distinction between lobar pneumonia and bronchopneumonia can often become blurry, because: (1) many organisms cause infections that can manifest with either of the two patterns of distribution. (2) confluent bronchopneumonia can be hard to distinguish radiologically from lobar pneumonia. Therefore, it is best to classify pneumonias either by the specific etiologic agent or, if no pathogen can be isolated, by the clinical setting in which infection occurs.

* Classification of pneumonia: 1. Community-Acquired Acute Pneumonia: Streptococcus pneumonia Haemophilus influenza pneumonia Staphylococcus aureus pneumonia Legionella pneumophila pneumonia 2. Community-Acquired Atypical Pneumonia: Mycoplasma pneumonia Viral pneumonia: Respiratory syncytial virus, para-influenza virus (children); influenza A and B (adults); adenovirus.

3. Nosocomial Pneumonia. 4. Aspiration Pneumonia. 5. Chronic Pneumonia. Granulomatous: Mycobacterium tuberculosis and atypical mycobacteria. Nocardia. Actinomyces. Histoplasma capsulatum.

Community-Acquired Acute Pneumonias

Most community-acquired acute pneumonias are bacterial in origin Most community-acquired acute pneumonias are bacterial in origin. However, may follow upper respiratory tract viral infection. The onset is usually abrupt, with high fever, shaking chills, pleuritic chest pain, and a productive mucopurulent cough. S. pneumonia (i.e., the pneumococcus) is the most common cause of community-acquired acute pneumonia.

Streptococcus (Pneumococcal ) pneumonia

* Risk factors: 1. Patients with chronic diseases such as congestive heart failure, COPD, or diabetes. 2. Patients with congenital or acquired immunoglobulin defects (e.g. AIDS). 3. Patients with decreased or absent splenic function (e.g. sickle cell disease or after splenectomy). - In the last group, such infections are more likely because the spleen contains the largest collection of phagocytes and is therefore the major organ responsible for removing pneumococci from the blood. The spleen is also an important organ for production of antibodies against encapsulated bacteria.

* Morphology: Both patterns of pneumonia, lobar or bronchopneumonia, may occur. In lobar pneumonia pattern, the lower lobes or the right middle lobe is most frequently involved because lung infection usually is acquired by aspiration of pharyngeal flora (20% of adults harbor S. pneumonia in the throat). In the era before antibiotics, pneumococcal pneumonia involved entire lung lobe and evolved through four stages: congestion, red hepatization, gray hepatization, and resolution. Early antibiotic therapy alters or halts this typical progression.

- In stage of congestion (1st day): the affected lobe is heavy and red - In stage of congestion (1st day): the affected lobe is heavy and red. The alveolar capillaries are congested and the alveoli show exudate, scattered neutrophils, and many bacteria. - In the stage of red hepatization (2nd – 4th day): the lung lobe has a liver-like consistency; the alveolar spaces are packed with neutrophils, red cells, and fibrin. - In the stage of gray hepatization (5th – 8th day): the lung is dry, gray, and firm, because the red cells are lysed, while the exudate persists within the alveoli.

- In the stage of resolution: occurs in uncomplicated cases, as exudates within the alveoli are enzymatically digested to produce granular, semifluid debris that is resorbed, ingested by macrophages, coughed up, or organized by fibroblasts growing into it). - The pleural reaction (fibrinous or fibrinopurulent pleuritis) may similarly resolve or undergo organization, leaving fibrous thickening or permanent adhesions.

Gross view of lobar pneumonia with gray hepatization Gross view of lobar pneumonia with gray hepatization. The lower lobe is uniformly consolidated.

Lobar pneumonia

In the bronchopneumonic pattern, foci of inflammatory consolidation are distributed in patches throughout one or several lobes, most frequently bilateral and basal. confluence of these foci may occur in severe cases, producing the appearance of a lobar consolidation. Pleural involvement is less common than in lobar pneumonia. Histologically, the reaction consists of focal suppurative exudate that fills the bronchi, bronchioles, and adjacent alveolar spaces.

Bronchopneumonia

Bronchopneumonia

Bronchopneumonia

* Clinical course of strept. (pneumococcal pneumonia): With appropriate therapy, complete restitution of the lung is the rule for both forms of pneumococcal pneumonia, but in occasional cases complications may occur like; lung abscess formation; Empyema (suppurative material may accumulate in the pleural cavity. Lung fibrosis: due to organization of the intra-alveolar fibrinopurulent exudate. Bacteremic blood dissemination: may lead to meningitis, arthritis, or infective endocarditis.

Haemophilus influenza pneumonia Affects children, often after a respiratory viral infection and adults having chronic pulmonary diseases such as chronic bronchitis, cystic fibrosis, and bronchiectasis. H. influenza is the most common bacterial cause of acute exacerbation of COPD.

Staphylococcus aureus pneumonia S. aureus is an important cause of secondary bacterial pneumonia in children and healthy adults after viral respiratory illnesses (e.g., measles in children and influenza in both children and adults). Staphylococcal pneumonia is associated with a high incidence of complications, such as lung abscess and empyema. Staphylococcal pneumonia occurring in association with right-sided staphylococcal endocarditis is a serious complication of intravenous drug abuse.

Klebsiella pneumoniae K. pneumoniae is the most frequent cause of gram negative bacterial pneumonia. Klebsiella-related pneumonia frequently afflicts debilitated and malnourished persons, particularly chronic alcoholics. Thick and gelatinous sputum is characteristic, because the organism produces an abundant viscid capsular polysaccharide, which the patient may have difficulty coughing up.

Pseudomonas aeruginosa Pseudomonas pneumonia is common in persons who are neutropenic, usually secondary to chemotherapy; in victims of extensive burns; and in patients requiring mechanical ventilation. P. aeruginosa has a propensity to invade blood vessels at the site of infection, with consequent extra-pulmonary spread; Pseudomonas bacteremia is a fulminant disease, with death often occurring within a matter of days.

Legionella pneumophila pneumonia L. pneumophila flourishes in artificial aquatic environments, such as water-cooling towers and within the tubing system of domestic (potable) water supplies. The mode of transmission is thought to be either inhalation of aerosolized organisms or aspiration of contaminated drinking water. Legionella pneumonia is common in persons with some predisposing condition such as cardiac, renal, immunologic, or hematologic disease. Organ transplant recipients are particularly susceptible.

Community-Acquired Atypical Pneumonias

The designation atypical denotes the moderate amounts of sputum, absence of physical findings of consolidation, only moderate elevation of white cell count, and lack of alveolar exudates. Atypical pneumonia is caused by a variety of organisms: 1. Bacterial: Mycoplasma pneumonia being the most common cause. 2. Viral: influenza types A and B, the respiratory syncytial virus, adenovirus, rhinoviruses, rubeola virus, and varicella virus.

Mycoplasma infections are particularly common among children and young adults. They occur sporadically or as local epidemics in closed communities (schools, military camps, prisons). Microscopically: interstitial inflammatory reaction with necrosis of the lining alveolar cells and minimal accumulation of exudate inside the alveoli is the hallmark of atypical pneumonia.

Atypical pneumonia. The thickened alveolar walls are infiltrated with lymphocytes and some plasma cells, with occasional alveolar edema in the center.

Hospital-Acquired (Nosocomial) Pneumonias

Nosocomial, or hospital-acquired pneumonias are defined as pulmonary infections acquired in the course of a hospital stay. Nosocomial infections are common in hospitalized persons with severe underlying disease, those who are immunosuppressed, or those on prolonged antibiotic regimens. Those on mechanical ventilation represent a particularly high-risk group, and infections acquired in this setting are given the distinctive designation ventilator-associated pneumonia. * Causative agents: Gram-negative rods (Enterobacteriaceae and Pseudomonas spp.) Staph. aureus.

Aspiration Pneumonia Aspiration pneumonia occurs in debilitated patients or those who aspirate gastric contents either while unconscious (e.g., after a stroke) or during repeated vomiting. These patients have abnormal gag and swallowing reflexes that facilitate aspiration. The resultant pneumonia is partly chemical, resulting from the extremely irritating effects of the gastric acid, and partly bacterial. This type of pneumonia is often necrotizing, pursues a fulminant clinical course, and is a frequent cause of death in persons predisposed to aspiration.

Chronic Pneumonias There is typically granulomatous inflammation, which may be due to bacteria (e.g., M. tuberculosis) or fungi. Tuberculosis is by far the most important entity within the spectrum of chronic pneumonias;

Thanks