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03-18-2009, 10:37 AM
Pneumonia
Def. It is an inflammatory reaction within the lung parenchyma exudation within alveoli (consolidation)

Consolidation i.e. alveoli out of function
Alveoli full of exudates, so pneumonia considered to be an inflammatory consolidation
local defense mechanisms of the lung:
1. Epiglottis inhibits aspiration.
2. Abs: - upper respiratory tract Ig A for viral infection
- lower respiratory tract IgG for bacterial infection.
3. Ciliated epithelium disturbed function with smoking.
4. Alveolar macrophages disturbed function with smooking.
P.V.C. plethora.
Classification of pneumonia:
1- Primary pneumonia : usually community acquired (previously normal person)
a. Pneumonococcal commonest
b. Staph, legionella, mycoplasma common
c. Strept, pseudomonas, klebsiella, H. Influenza uncommon
d. Rare chlamydia, Viral.
2- 2ry pneumonia (occur in diseased lung or in diseased host)
a. Acute bronchopneumonia
b. Nosocomial
c. Aspiration.
d. Immunocompromised patient.

Pneumococcal pneumonia
Aetiology Pneumococci
In patients with low resistance Infant
Old age
It may be community acquired pneumonia
Pathology Congestion
Red hepatization severe congestion + alveoli Full of RBCs
Grey hepatization alveoli full of leucocytes+ fibrin resolution
C/P
symptom General FAHM
Local Dyspnea
Chest pain (pleurisy)
Cough & expectoration of rusty sputum.
O/E Inspection Movement, chest symmetrical.
Palpation Mediastinum is normal
TVF­­
Percussion Dullness
Auscultation Crepitation Early fine
Latecoarse with resolution
Bronchial breathing
DD of consolidation ?
1- Pneumonia 2- T.B.
3- Infarction 4- Bronchogenic carcinoma.
5- Collapse
Investigation:
1- X- ray Diagnosis
Follow up
2- Culture & Sensitivity.
3- Blood picture TLC ­, PNL ­. ESR ­­
N.B. Unresolving pneumoni
i.e.> 2wks with active pneumonia
Specific organism e.g. T.B., Legionella Resistant organism
Treatment:
1- Antibiotic
Erythromycin 500 mg/ 6hrs
Ampicillin or Amoxcillin 500 mg/6hrs.
Cephalosporines (2gm/d).
lstG. 2nd G. 3rd G.
gm+ve gm+ve & gm -ve mainly gm -ve
Velosef Cefamandole Cefotaxime.
Penicillin G injection.
Ab start with injections till clinical improvement and then give oral Antibiotic.
Course of Ab for 2 wks.
2- Expectorant K+ iodides.
3- Chest pain NSAID (for pleurisy)
Complications:
1- Post- pneumonic effusion
2- Synpneumonic effusion empyema
3- Post pneumonic lung abscess.
4- Post pneumonic fibrosis
5- Pneumooccal meningitis through paravertebral venous plexus.
Septic shock.


Special Types of pneumonia according
to the type of organism




1- Staph Pneumonia (as above +..)
Extensive cavitation.
Haemoptysis
Treatment: - Dicloxacilline 1 g/6 hrs
- Treatment for 2 wks
Oral therapy can be started when fever subsides.
2- Kliebsiella : usually apical lesion (Friedlander pneumonia)
Friedlander pneumonia
Q DD. of apical T.B
Bropnchiectasis sicca hemorrhagica
Pancoast tumor
Treatment : Ab. For gm ve (for 2wks)
3- Atypical pneumonia
Viral Mycoplasma
Influenza
Respiratory syncytial virus.
C/P Severe symptom severe toxemia.
Myalgia
marked dyspnea.
Minimal signs (minimal signs of consolidation)
Treatment Viral no specific therapy
Mycoplasma Tetracycline.
4- Legionella : (Its gram -ve Coccobacilli)
C/P As atypical pneumonia
Treatment for (2wks)
Erythromycine I.V. injection lg/6hrs
Rifampicin 600mg /12 hrs oral with Erythromycine in severe cases
5- Actinomycosis:
Formerly included amongst the fungi, now it is considered as a bacteria.
Occur in impaired local defense there is pus with sulphur granules, treated with penicillin G 2-4 gm I.V /6hrs.

Secondary pneumonia



I - Acute bronchopneumonia


Bronchial infection can be aspirated into the alveoli and result in widespread patches of consolidation.
This usually occur during the extremes of life as a complication of measles and whooping cough in children for example.
Pathology:
Acute inflammation of the bronchi and terminal bronchioles is present with consolidation of the distal alveoli, the lesions are patchy and bilateral and more in lower lobes.
C/P
As Pneumococcal pneumonia but:
Severe symptoms, onset insidious.
Signs bilateral & patchy.
X-ray bilateral mottled opacities.
Treatment:
Antibiotic as in pneumonia discussed before according to organism


Il-Pneumonia in Immunocompromised pts.
-D.M.
Patient -Pt. Under steroids or chemotherapy
-AIDS
-Leukemia. Or lymphoma.
Organisms
Fungal (Aspergillus)
C.M.V.
T.B.
Pneumocystitis Carinii.
+ Any other organism
Pneumocystitis Carinii
It is protozoa. (recently it is a fungus)
Pt. As above.
C/P Dyspnea
Cough
ARDS
investigations X-ray bilateral lesions.
Transbronchial lung biopsy
Treatment Sutrim I.V injection 120 mg/kg in divided doses
I.V. Pentamidine in resistant cases.

III-Nosocomial pneumonial

It is a hospital acquired pneumonia in a patient who has been admitted for more than 48 hrs.
Route of infection Ventilators
Endotracheal tubes
Bronchoscopy steroid
Reduced host defense post operative
Aspiration in comatosed patients.


Organism: Gm - ve mostly Klebsiella
Pseudomonas
Other (pneumo staph)
C/P
As usual Investigation
Treatment
Community acquired pneumonia (normal person)
Organis Staph, Pneumococci.
Pseudomonas
Viral
C/P investigation and treatment as usual.