Understanding Pneumonia: Causes, Types, and Treatment Approaches

1. PNEUMONIA

2. PNEUMONIA IS INFLAMMATION OF THE PARENCHYMA OF THE LUNGS. MOST CASES OF PNEUMONIA ARE CAUSED BY MICROORGANISMS.

3. NONINFECTIOUS CAUSES of PNEUMONIAE • -ASPIRATION OF FOOD AND OR GASTRIC • ASID • FOREIGN BODIES • - HYDROCARBONS • LIPOID SUBTANCES • HYPERSENSITIVITY REACTIONS • DRUG • - RADIATION MAY INDUCED PNEUMONIAE

4. PNEUMONIA HAS BEEN CLASSIFIED ON AN ANOTOMIC BASIS AS A LOBAR, ALVEOLAR OR LOBULAR, OR INTERSTITIAL PROCESS

5. 1. LOBAR PNEUMONIA-ALVEOLAR STREPTOCOCCUS PNEUMONIAE

6. 2. LOBULAR-BRONCHOPNEUMONIAE STREPTOCOCCUS PNEUMONIAE HAEMOPHILUS INFLUENZAE KLEBSIELLA SP. GROUP B STREP E.COLI S.AUREUS

7. 3. INTERSTITIAL PNEUMONIAE VIRAL PNEUMONIAE RSV CMV ADENOVIRUS INFLUENZA A.B

8. CLASSIFICATION OF PNEUMONIA WITH RESPECT TO AGE NEW BORN GROUP B STREPTOCOCCI (SEROTYPES I, II) L.MONOCYTOGENES H.INFLUENZAE (NONTYPABLE) GRAM-NEGATIVE ENTERIC BACILLI

9. NOSOCOMIAL PNEUMONIA P.AEROGINOSA E.COLI GRAM-NEGATIVE BACILLI C.TRACHOMOTIS

10. 1 MONTH-6 YEAR S.PNEUMONIA (1.3.6A.14.18C, 19F, 23F) H.INFLUENZAE (HIB) GROUP A STREPTOCOCCI S.AUREUS M.CATARHALIS

11. OVER 6 YEARS OF AGE AND ADOLESCENTS S.PNEUMONIA M.PNEUMONIA ATYPICAL PNEUMONIA C. PNEUMONIA

12. IMMUNOCOMPETENT IMMUNOCOMPROMISED BACTERIAL S.PNEUMONIAE PSEUDOMONAS SP H.INFLUENZA ENTEROBACTERIACEAE S.AUREUS L.PNEUMOPHILIA GROUP A STREP NOCARDIA SPP M.CATARHALIS RHODOCOCUS EQUI Y.PESTIS ACTINOMYCES BRUCELLA SP ANAEROBIC BACTERIA FRANCISELLA TULARENSIS ENTEROCOCCUS SP N.MENENGITIDIS SALMONELLA SPP BACTERIA- LIKE AGENTSM.PNEUMONIAE C.PNEUMONIAE C.TRACHOMATIS C.PSITTACI COXIELLA BURNETI RICKETTSIA RICKETTSII

13. PROTECTING MECHANISM OF THE LUNG • FILTRATION OF THE PARTICLES IN THE • NARES 5-20 Μm • PREVENTION OF ASPIRATION BY THE EPIGLOTTAL REFLEX • EXPULSION OF ASPIRATED MATERIAL BAY THE COUGH REFLEX • ENTRAPMENT AND EXPULSION OF ORGANISM BY MUCUS SECRETING AND CILIATED CELLS

14. PROTECTING MECHANISM OF THE LUNG 4. ENTRAPMENT AND EXPULSION OF ORGANISM BY MUCUS SECRETING AND CILIATED CELLS 5. INGESTION AND KILLING OF BACTERIA BY ALVEOLAR MACROPHAGES 6. NEUTROLIZATION OF BACTERIA BY LOCAL IMMUN SUBSTANCES. LACTOFERRIN, LYZOZIM, INTERFERON, IgG, IgA 7. TRANSPORT OF PARTICLES FROM THE LUNGS BY LYMPHATIC DRAINES

15. PATHOLOGY AND PATHOGENESIS PATHOGENES REACH THE LRT BY ASPIRATION BY HEMATOGENEOUS OR LOCAL SPREAD RESPIRATORY PATHOGENES WHEN REACH THE THERMINAL BRONCHIOLES AND BEYOND ↓ EDEMA FLUID INTO THE ALVEOLI ↓ LEUKOCYTES INFILTRATION ↓ LOBULAR, SEGMENTAL OR LOBAR INFLAMMATION ↓ MACROPHAGES (REMOVE CELLULER AND BACTERIAL DEBRIS)

16. IN S.AUREUS PNEUMONIA, PULMONARY INVOLVEMENT FOLLOWS THE DISTRIBUTION OF AFFECTED AREA. AS THE INFECTION PROGRESSES IT DESTROYS THE WALL OF THE ALVEOLI WITH THE FORMATION OF AIR FILLED CAVITES WHICH ARE CALLED PNEUMATOCELES PNEUMATOCELE ↓ MAY RUPTURE ↓ PYOPNEUMOTORAX

17. CLINICAL FEATURES • NONSPESIFIC SIGNS AND SYMPTOMS • FEVER VOMITING • CHILLS ABDOMNAL DISTANTION • HEAD ACHE DIARRHEA • IRRITABILITY ABDOMINAL PAIN • APPREHENSION

18. B) PULMONARY SIGNS NASAL FLARING TASYPNEA DYSPNEA APNEA USE OF ACCESORY INTERCOSTAL MUSCLES AND ABDOMINAL MUSCLES

19. COUGH IS INITIALLY DRY, LATER PRODUCTIVE • OF PURULENT OR EVEN BLODDY SPUTUM • EXTRA PULMONARY SIGNS • ABSCESSES OF SKIN • ABSCESSES OF SOFT TISSUE

20. ROENTGENOGRAPHIC FINDINGS: PATCHY INFILTRATES (IN INFANCY) SEGMENTAL OR S. PNEUMONIAE LOBAR CONSOLIDATION H. INFLUENZAE HILAR LYMPHNODUS H. INFLUENZAE S.AUREUS PNEUMOTOCELE S.AUREUS KLEBSIELLA PLEVRAL EFFUSION S. AUREUS PNEUMOTORAX KLEBSIELLA

21. ROENTGENOGRAM CLEARS WITH IN 3-4 WEEKS 80 PERCENT OF CASES IN S.AUREUS PNEUMONIA THIS DURATION MUCH LONGER

22. LABORATORY FINDINGS: THE BLOOD CELL↑ 15.000 – 40.000 CELLS/MM3 PMN↑ SPUTUM CULTURE (+) BLOOD CULTURE (+) 10-15 PERCENT OF CASES COUNTER IMMUNOELECTROPHORESIS BACTERIAL LATEX PATICLE ANTIGEN (+) AGLUTINATION

23. PLEVRAL FLUID (EXUDATE) PROTEIN> 3.0 GR/DL ↓ GLUCOSE BELOW 40 MG/L LACTIC DEHYDROGENASE 1000 IU/L Ph BELOW 7.20

24. PROGNOSIS MORTALITY RATE IS VERY LOW (LESS THEN 1 PERCENT) in LOBAR PNEUMONİAE DEATH IS SEEN WITH AN UNDERLYING DISEASE OR WITH A COMPLICATED COURSE S. AUREUS PNEUMONIA MORTALITY RANGES 10-30%

25. PHYSICAL EXAMINATION FINE CRACKLING RALES DIMINISHED OR TUBULAR BREATH SOUND DULLNESS ON PERCUSSION (PLEVRAL EFFUSION ) LIVER MAY SEEM ENLARGED EMPYEMA

26. DIFFERENTIAL DIAGNOSIS • FOREIGN BODY • ALLERGIC ALVEOLITIS • ATELECTASIS • TBC PNEUMONIAE • CYSTIC FIBROZIS • ACUTE EXACERBATIONS OF BRONCHIECTASIS • PULMONARY ABSCESS • ACUTE ABDOMEN

27. COMPLICATIONS EMPYEMA PNEUMOTORAX LUNG ABCESS MIDDLE EAR INFECTIONS PERICARDIAL EFFUSION OSTEOMYELITIS ABSCESSES OF SOFT TISSUE

28. TREATMENT GROUP B STEP. DURING THE FIRST 24-48 HOURS OF LIFE AGGRESSIVE CARDIOVASCULAR AND VENTILATORY SUPPORT IS REQUIRED

29. ANTIBIOTIC THERAPY: AMPICILLINE or PEN. + GENTAMISIN OR AMPICILLINE or PEN + III. JEN. CEPHALOSPORIN IF THE MINIMAL BACTERICIDAL CONCENTRATION FOR PENICILLIN IS ADEQUATE GENTAMISIN CAN BE DISCONTINUED TREATMENT IS GIVEN FOR 10-14 DAYS

30. PNEUMOCOCCAL PNEUMONIA IN OLDER CHILDREN PROCAINE PENICILLIN 600.000 UNITS/DAY OR ORAL PENICILLIN U 50-250 MG/KG/DAY 200.000 U = 125 MG EVERY 4-6 HOURS OR ORAL ERYTHROMYCIN 30-50 MG/KG/DAY EVERY 6 HOURS

31. IF PATIENTS APPEAR TOXIC OR IN INFANTS, OR IN YOUNG CHILDREN PENICILLIN G 200.000-400.000 U/KG/DAYEVERY 4-6 HOURS IF S.PNEUMONIA IS REZISTANT TO PENICILLINE CEFUROXIME 20-100 MG/KG CEFTRIAXONE 25-50 MG/KG 2-3 DOSE CEFOTAXIME 50-100 MG/KG VANCOMYCIN 40 MG/KG 4X1 IF PATIENTS ALLERGIC TO PENICILLINE ERYTHROMYCIN 30-40 MG/KG (10-14 DAYS) TREATMENT IS GIVEN

32. PREVENTION: CHILDREN IN HIGH RISK GROUPS 2 YEAR OR OLDER 0.5 ML 23 VALANT PNEUMOCOCCAL/VACCINE

33. HAEMOPHILUS INFLUENZAE (HIB) TREATMENT: AMPICILLIN 100 MG/KG/DOZ 4X1 + CHLOROMPHENICAL 50-75 MG/KG/DOZ 4X1 MAX DOZ: 1,2 GR OR CEFUROXIME CEFTRIAXONE CEFOTAXIME TREATMENT IS GIVEN 10-14 DAYS.

34. PREVENTION: HIB CONJUGATED VACCINE SINGLE DOSE 12-18 MONTHS OF AGE IN HAUSEHOLD CANTACT 4 YEAR ↓ RIFAMPIN 20 MG/KG ONCE DAILY FOR 4 DAY 2-6 MONTHS 4-8 WEEK INTERVAL IM OR SC 3 DOSES 1 YEAR LATER 1 DOSES 6-12 MONTHS 4-8 WEEKS INTERVAL 2 DOSES 1 YEAR LATER 1 DOSES 1-5 YEARS 1 DOSES

35. S. AUREUS PNEUMONIA ALL PATIENT IN ALL AGES SHOULD BE HOSPITALIZED NAFCILLIN IV OXACILLIN IV 100-150 MG/KG/DAY 4X1 METHICILLIN IV OR IV CEFAZOLIN 100 MG/KG/DAY 3X1 + IV GENTAMISIN 5 – 7 MG/KG/DAY OR NEUTROMYCIN 40 MG/KG/DAY 4X1 IF S. AUREUS IS REZISTANT TO METHICILLIN IV VANCOMYCIN 40 MG/KG/DAY 4X1 TREATMENT IS GIVEN 6-10 WEEKS

36. MYCOPLASMA PNEUMONIAE ATYPICAL PNEUMONIAE M. PNEUMONIAE WAS IDENTIFED AND CHARACTERIZED AS THE ETIOLOGIC AGENT IN 1963 BY CHANOCK (PRESUMABLY A VIRUS) HIGHEST INCIDENCE OF PNEUMONIAE TO BE IN SCHOOL AGE CHILDREN FROM AGE 6 TO 18 M.P ENTIRE RESPIRATORY TRACT BY DROPLET

37. LARYNGITIS TRACHEOBRONCHITIS URTI PNEUMONIAE RECURRENT M.PNEUMONIAE ARE QUITE COMMON IN INFANCY AND CHILDHOOD

38. PATHOPHYSIOLOGY: SINCE HUMAN TISSUE IS RARELY OBTAINABLE (IN HAMSTER MODEL) MYCOPLASMA PNEUMONIAE ATTACH TO RECEPTORS ON CLIATED RESPIRATORY EPITHELIAL CELLS DAMAGES AND SLOUGHED THE CELLS ATELECTASIS

39. BOTH THE DURATION OF THE INFECTION AND THE TIME REQUIRED TO REGENERATE EPITHELIAL CELLS LEADS TO A PROLONGED PERIOD OF DISORDORED MUCOSAL CLEARANCE AS EVIDENCED BY THE CHRONIC COUGH

40. CLINICAL PRESANTATION INCUBATION PERIOD 2 TO 3 WEEKS CORYZA SORE THROAT MALASIE LOW-GRADE FEVER PAROXYSMAL PRODUCTIVE SHORTNESS OF BREATH DURING THE SECOND WEEK OF ILLNESS MILD CHEST PAIN URTI COUGH

41. PHYSICAL EXAMINATION BRONCHIAL BREATH SOUND RHONCHI LOCALIZED CREAKLES WHEEZING FLEURAL PAIN

42. CHEST FILMS • LOCALIZED INFILTRATES (BRONCHOPNEUMONIAE) • LOBAR CONSOLIDATION • BILATERAL DIFFUSE INFILTRATES • SMALL PLEURAL EFFUSION

43. EXTRAPULMONARY MANIFESTATIONS CEREBELLAR ATAXIA ENCEPHALOPATHY PERIPHERAL NEUROPATHIES CARDIOMYOPATHY MYOSITIS PANCREATITIS HEMOLYTIC ANEMIA E. MULTIFORME STEVENS-JOHNSON SYNDROME HEPATOSPLENOMEFALY

44. LABORATORY FINDINGS WBC: N COLD HEMAGGLUTININ ASSAY 1/64↑(+) COMPLEMENT FIXATION ASSAY (+) PCR (POLYMERASE CHAIN REACTION) TO DETECT ANTIGEN IN RESPIRATORY SECRETION

45. COURSE OF DISEASE • UNTREATED M.P EVOLUES OVER A PERIOD OF 2 TO 4 WEEKS BUT ALMOST ALWAYS RESOLVES WITHOUT RECOGNIZABLE SEQUALAE • APPROPRIATE ANTIBIOTICS ALTER THE COURSE OF DISEASE BUT NOT DRAMATICALLY • PROPHYLACTIC ANTIBIOTIC TREATMENT HAS NO PLACE IN THE MANAGEMENT OF THESE INFECTIONS

46. TREATMENT MACROLIDES ANTIBIOTICS IS EFFECTIVE IN MP AZITROMYCIN 250 mg 2-5 days CLARITHROMYCIN 250 mg 2x1 7-10 days ERYTHROMYCIN 200x3 7-10 days

47. PNEUMONIAS OF VIRAL ORIGIN • RSV • PARAINFLUENZA CORONOVIRUSES • ADENOVIRUSES HERPES VIRUSES • INFLUENZA ENTEROVIRUSES • CMV • RHINOVIRUSES

48. CLINICAL MANIFESTATIONS RHINITIS COUGH FEVER TACHYPNEA INTERCOSTAL SUBCOSTAL SUPRASTERNAL NAZAL FLARING USE OF ACCESSORY MUSCLE CYANOSIS RESPIRATORY FATIQUE URTI RETRACTIONS IN SEVERE CASES

49. AUSCULTATION: WIDE SPREAD RALES • AND WHEEZING • CHEST FILMS: • DIFFUSE INFILTRATES IN CHEST • ROENTGENOGRAM • SCATTERED INF (PI) • HYPERINFLATION (RSV, AV) • PERIHILAR AND PERIBRONCHIAL INFILTRATIONS (RSV) • ATELECTASIS (PI, RSV) • PNEUMONITIS (CMV)

50. LABORATORY WHITE BLOOD CELL N OR SLIGHTLY ELEVATED <10.000 mm3 LYMPHOCYTES ↑ ESR CRP ISOLATION OF THE VIRUS FROM NASOPHARYNGIAL SECRETIONS (+) N OR SLIGHTLY ELEVATED