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Pneumonia may be classified in different ways: etiological agent (bacterial vs. viral vs.
mycoplasmal), anatomically (lobular bronchopneumonia, lobar, interstitial), clinical presentation
(classical vs. atypical). These classifications will be discussed later.
A. Pathogenesis
Every day, our lungs are exposed to over 10 000 L of air containing many potentially disease
causing agents. However, the normal lung does not contain any bacteria because of different
effective defense mechanisms that clear or destroy bacteria:
When lung defenses are impaired, microorganisms may enter the respiratory tract via different
routes of spread:
a. hematogenous
b. from a contiguous focus
c. inhalation of aerosolized particles
d. aspiration of oropharyngeal secretions (most common)
B. Etiology
Classical community acquired pneumonia is most frequently caused by S. pneumoniae.
However, H. influenzae and M. tuberculosis become more frequent in older age groups. Gram
negative bacilli are also sometime responsible for causing pneumonia.
C. Clinical Features
Clinical features of pneumonia vary greatly according to etiologic agent responsible and
population affected.
Most patients have a cough, fever, increased heart rate, and increased respiration rate. Patients
may also experience pleuritic pain, hemoptysis, systemic upset, and confusion.
Classical community acquired pneumonia presents with abrupt onset of single shaking chill,
cough, rust-coloured sputum, and moderate fever.
Atypical community acquired pneumonia has a less severe course with more prominent systemic
symptoms and less prominent respiratory symptoms. Patients may only present with tachypnea,
dry cough, and mild fever.
D. Radiographic Patterns
Chest radiographs can rule out the possibility of pneumonia or help differentiate between
bacterial and viral pneumonias. Or, they may point to a diagnosis of presumptive pneumonia
when the patient presents with only mild symptoms, eg in the elderly.
The pattern of the chest radiograph gives clues to the etiology of pneumonia. Lobar
consolidation suggests a bacterial pathogen whereas patchy, bilateral infiltrates with little or no
pleural effusion are usually seen in atypical pneumonias.
It is important to remember that early in the course of acute bacterial pneumonias, the chest
radiographs may yield little information as they often appear normal initially. Therefore it is
important to conduct other laboratory tests, as will be discussed later.
E. Diagnosis
The use of chest radiographs in diagnosis has already been described in the previous section.
Other tests that may narrow the differential diagnosis include WBC count which tend to be
markedly elevated in bacterial pneumonia.
If the patient has a productive cough, it is important to obtain a sputum sample. Empiric therapy
for community acquired pneumonia without obtaining a sputum sample is effective in most
cases. However, this encourages the widespread and indiscriminate use of broad-spectrum
antibiotics and contributes to increases in antibiotic resistance.
A good sputum sample contains no squamous epithelial cells and at least 10-15 PMN per high
power field. If the patient is too ill to provide a sputum sample, nasotracheal or transtracheal
aspiration may be used.
The specimen should be gram stained and examined under oil immersion. This is often enough to
identify the pathogen. The presence of large numbers of PMNs and WBCs also suggests a
bacterial agent that is responsible. If only inflammatory cells and few WBC are seen, a
nonbacterial etiology should be considered.
If no clear diagnosis of bacterial pneumonia is fiound, the sample should be stained with an acid-
fast stain to indentify mycobacteria. Other less common stains are available to identify
legionnella and fungal pathogens. The sample should be cultured and tested for antibiotic
resistance.
G. Prevention
Pneumococcal pneumonia is preventable in 60-80% of patients if they are given a pneumococcal
vaccine (23 valent Pneumovax II 0.5 mL sc).