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ATYPICAL PNEUMONIAS: THE BASICS

ATYPICAL PNEUMONIAS: THE BASICS. Nilesh Patel, DO October 8, 2008 St. Joseph’s Regional Medical Center. QUESTIONS WE WILL ANSWER???. What is an atypical pneumonia? What are the organisms that compromise atypical pneumonias? How do we test for atypical pneumonias; does it matter?

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ATYPICAL PNEUMONIAS: THE BASICS

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  1. ATYPICAL PNEUMONIAS: THE BASICS Nilesh Patel, DO October 8, 2008 St. Joseph’s Regional Medical Center

  2. QUESTIONS WE WILL ANSWER??? • What is an atypical pneumonia? • What are the organisms that compromise atypical pneumonias? • How do we test for atypical pneumonias; does it matter? • What are the antibiotic choices? • What should we think about when HIV patients present with pneumonia?

  3. OBJECTIVES • We will discuss…. • Mycoplasma pneumoniae • Legionella sp. • Chlamydia pneumoniae • Chlamydia psittaci • Viral pneumonias • Pneumonia in the setting of HIV/AIDS--PCP

  4. ATYPICAL PNEUMONIA: WHAT IS IT??? • Infection of pulmonary parenchyma • Community-acquired • Classically—do not show up on Gram stain • Characteristics • “Atypical” presentation/symptoms/diagnostics • Insidious onset • Nonproductive cough • Constitutional symptoms • Interstitial pattern on CXR • Smoldering course • The lines are “blurred” • Similar to typical organisms clinically and radiographically

  5. ORGANISMS • Mycoplasma pneumonia • Viral pneumonias • RSV • Parainfluenza • Adenovirus • Influenza • Other • Chlamydia pneumonia • Chlamydia psittaci • Legionella pneumophila • Coxiella burnetti (Q fever pneumonia) • Francisella tularensis (Tularemia)

  6. EPIDEMIOLOGY • 4 million cases CAP/year • 20-60% typical organisms • 10-40% atypical organisms • Hard to quantify these organisms

  7. PATHOPHYSIOLOGY

  8. MYCOPLASMA PNEUMONIA • Smallest free living organisms • Prokaryotes • No cell wall • Most common cause of atypical pneumonia • “Walking” pneumonia • Community acquired • Usually occur in young to middle aged patient • Clinical symptoms • Insidious onset, protracted course • Constitutional symptoms (fevers, chills, myalgias, body aches) • Sore throat, HA • Dry cough • Chest pain/SOB

  9. MYCOPLASMA: DIAGNOSTICS • CXR • Consolidation • Patchy infiltrates • Interstitial pattern • Pleural effusion • Labs • WBC • Cold agglutinin assays • Other serum assays • Cultures • Blood • Sputum

  10. MYCOPLASMA: TMT • Macrolides • Azithromycin • Erythromycin • Clarithromycin • Doxycycline

  11. LEGIONELLA • Gram negative intracellular rods • Fastidious • Multiple serotypes • Legionella pneumophila • Community acquired • Legionnaire’s disease • Transmission from contaminated water sources • Warm water environments • No person to person transmission • Outbreaks….Sporadic cases • High mortality if not treated

  12. LEGIONELLA • Natural water habitats • Water distribution systems • Cooling towers • Hot tubs/Spas • Respiratory equipment • Humidifiers • Etc…… • Travel • Hotels • Large Events • Floods/Natural Disasters

  13. LEGIONELLA: SYMPTOMS • Incubation period: 2-10 days • Clinical symptoms • Pulmonary • Cough • Chest pain • Dyspnea • Extrap-pulmonary • Constitutional symptoms • GI symptoms—diarrhea, abd pain, n/v • Neuro symptoms—HA, change in mental status

  14. LEGIONELLA: DIAGNOSTICS • CXR—variable • Consolidation • Patchy infiltrates/Interstitial infiltrates • Pleural effusions • Multi-lobar • Labs • CBC, SMA-7 (Hyponatremia, Elevated LFTs, ARF) • CPK • Urine antigen tests • Serum legionella antibodies • PCR • Cultures • Sputum gram stain/culture; DFA sputum • Blood cultures

  15. LEGIONELLA: TMTS • Fluoroquinolones • Levaquin • Avelox • Macrolides • Zithromax • Doxycycline • Bactrim • Rifampin • Extended course • Initial IV therapy

  16. CHLAMYDIA • Chlamydia 3 sp (pneumoniae, psittaci, trachomatis) • Gram negative obligate intracellular organisms (parasites) • Unique organisms • Community acquired • Chlaymydia pneumoniae • Common • Respiratory transmission (person to person) • Pneumonia • Chlaymdia psittaci • Rare • Ornithosis • Respiratory transmission (infected birds to humans) • Pneumonia/Viral illness

  17. CHLAMYDIA PNEUMONIA • Clinical symptoms • Incubation period: 1-4 weeks • Acute/subacute illness • Self limited URI/bronchitis • Fever • Constitutional symptoms • Cough • Chest pain/sob • Pharyngitis • Sinusitis • Rales/Rhonchi/Wheezing

  18. CHLAYMDIA PSITACCI • Risk Factors—Contact with birds • Clinical symptoms (incubation 5-30 days) • Acute viral illness/flu like symptoms • Fever • Relative bradycardia • Constitutional symptoms • Chest pain/sob • Multi-system • Neuro symptoms—HA, altered mental status • HSM (elevated LFTs) • Rash—Horder spots, EM, EN • Rales/Rhonchi/Wheezing/Clear lungs

  19. CHLAMYDIA: DIAGNOSTICS • Chlamydia pneumonia • CXR • Cultures • Serologic tests • Chlamydia psitacci • CXR • Cultures • Serologic tests

  20. CHLAMYDIA: TMTS • Chlamydia pneumoniae • Doxycycline/Tetracycline • Macrolides (Zithromax, Clarithromycin, E-mycin) • Quinolones (Avelox, Levaquin) • Chlamydia psitacci • Doxycycline/Tetracycline • Macrolides (Zithromax, E-mycin)

  21. VIRAL PNEUMONIAS • More common in pediatric population and elderly • Up to 15% of all CAP cases • Mild>>>>Severe • Influenza A & B • RSV • Adenoviruses • Parainfluenza • SARS • Avian flu • Varicella • CMV • Herpes virus • Hanta virus

  22. ANTIBIOTICS • Outpatient/Inpatient/ICU • Remember coverage for CAP • Mycoplasma—Macrolide, Doxy • Legionella—Quinolone, Macrolide • Chlaymydia pneumonia—Doxy, Macrolide • Chlaymida psitacci—Doxy, Macrolide • Viral pneumonias • Supportive care • Influenza—Tamiflu, think Staph coverage

  23. HIV & PNEUMONIA • Most common infectious process in HIV + patients • Broaden differential diagnosis • CD4 count & viral load important for specific organisms and prognosis • CAP most common • Other • PCP • TB • MAC • Histoplasmosis/Coccidiomycosis • Viral pneumonias

  24. PCP • Pneumocystis carinii >> Pneumocystis jiroveci • Unicellular fungus • Various morphology--cysts • Pre-HIV—few cases • Most common opportunistic infection in HIV patients • Common cause of death in HIV patients; mortality ~ 15% • Decreased incidence with prophylaxis and antiretroviral treatment • Transmission—human to human; airborne • Pneumocystis is widespread • Symptomatic disease occurs in immunosuppressed populations

  25. PCP: CLINICAL SYMPTOMS • Symptoms • SOB (exertional) • Cough • Fevers • Constitutional symptoms • Chest pain • Signs • Tachypnea/Fever/Tachycardia • Rales/RhonchiWheezing • Cachexia • Lymphadenopathy • Cyanosis

  26. PCP: DIAGNOSTICS • Labs • CBC, SMA-7 • LDH • ABG • Imaging • CXR—variable • Normal>>Diffuse b/l infiltrates>>Perihilar infiltrates>>PTX • CT scan • Diffuse b/l infiltrates>>Ground glass appearance>>Cysts • Sputum culture • BAL • Complication—PTX!

  27. PCP: TMT • Supportive treatments • Oxygen • Noninvasive/Invasive ventilation • Antibiotics (14-21 days or until clinical response achieved) • Bactrim IV • Pentamadine IV or aerosolized • Atovaquone po • Other therapies • Steroids—Hypoxemia, PaO2 < 70, Severe disease • Prophylaxis

  28. PCP: COMPLICATIONS • Hypoxemic respiratory failure • ARDS • PTX • Risk for other opportunistic infections

  29. SUMMARY • Atypical pneumonias • Mycoplasma • Legionella • Chlamydia • Viral pneumonias • HIV & pneumonia • PCP

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