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UNIVERSITY
DEPARTMENT OF
PROPAEDEUTIC OF INNER
DISEASES
PNEUMONIA
LUNG ABSCESS
Acute pneumonia
Definition
Pneumonia is an acute inflammatory
process of infectious origin affecting the
pulmonary parenchyma.
Types of pneumonia
1.
2.
3.
4.
Community-acquired pneumonia
Hospital-acquired (nosocomial)
pneumonia
Aspiration pneumonia
Pneumonia in the
immunocompromised host
(including AIDS)
Types of pneumonia
Typical pneumonia
(usually lobar, pleuropneumonia)
Atypical pneumonia
(usually bronchopneumonia)
Primary pneumonia
Secondary pneumonia
Morphologic variants of
pneumonia
Variant
Lobar
Bronchopneumon
ia
Causative
organism
Most frequently
Pneumococcus
Characteristics
Many organisms
(Staph. Aureus,
Haemophilus
influenza,
Klebsiella, Strep.
pyogenes)
Acute
inflammatory
infiltrates
extending from
bronchioles into
adjacent alveoli
Patchy distribution
involving one or
more lobes.
Predominantly
intra-alveolar
exudate resulting
in consolidation.
May involve entire
lobe.
Community acquired
pneumonia
This form is
responsible for over
1000 000
admissions per
year.
Mortality: 6-20%
Increasingly common
with age
Community acquired
pneumonia.
Etiology
Common organisms:
Str. Pneumoniae
70% (50-80%)
Chlamidia pneum.
10%
Mycoplasma pneum.
9%
Legionella pneum.
5%
Uncommon organisms:
Haemophilus influenzae
3%
Staphyl. Aureus
<1%
Chlamidia psittaci
<1%
Klebsiella pneum.
<1%
Primary viral pneumonia:
Influenza, parainfluenza, measles
Community acquired
pneumonia.
Transmission
Transmission
Hospital acquired
pneumonia (nosocomial)
Refers to a new episode of
pneumonia occurring at least 2
days after admission to the
hospital.
The term includes post-operative
and certain forms of aspiration
pneumonia.
Hospital acquired
pneumonia
Predisposing factors
Hospital acquired
pneumonia
Predisposing factors
2. Aspiration of nasopharyngeal or
gastric secretion:
Immobility or reduced conscious
level.
Vomiting, dysphagia, achalasia or
severe reflux.
Nasogastric intubation.
Hospital acquired
pneumonia
Predisposing
factors
3. Bacteria introduced into lower
respiratory tract:
Endotracheal intubation / tracheostomy.
Infected ventilators / nebulisers /
bronchoscopes.
Dental or sinus infection.
4. Bacteraemia:
Abdominal sepsis.
Intravenous cannula infection.
Infected emboli.
Hospital acquired
pneumonia
Etiology
Pneumonia in the
immunocompromised
patient
Lobar pneumonia
Homogeneous consolidation of one ore more
lobes, associated with pleural inflammation.
Lobar
Lobar pneumonia
Main syndromes
1.
2.
3.
4.
5.
6.
7.
Lobar pneumonia
Morphology
4 stages:
1. Congestion
2. Red hepatization
3. Grey hepatization
4. Resolution
Lobar pneumonia
Morphology
Lobar pneumonia
Morphology
CONGESTION
1) Hyperemia of the lung tissue.
2) Exudation.
3) Obstruction of capillary patency.
4) Stasis of the blood.
Lobar pneumonia
Morphology
RED HEPATIZATION
1) Massive confluent
exudation with red cells
and neutrophils and
fibrin filling the alveolar
spaces.
2) The lobe now appears
distinctly red, firm, and
airless with a liver like
consistency.
Continues from 1 to 3
days.
Lobar pneumonia
Morphology
GRAY HEPATIZATION
1) Progressive disintegration
of red cells.
2) The alveoli (containing
fibrin) become filled with
leucocytes
3) Persistence of
fibrosuppurative
exudates, giving the gross
appearance of a grayish
brown, dry surface.
Lobar pneumonia
Morphology
RESOLUTION
The consolidated exudate within
the alveolar spaces undergoes
progressive enzymic digestion to
produce a granular, semifluid
debris that is resorbed, ingested
by macrophages, or coughed up.
Lobar pneumonia
Clinical stages
1.
2.
morphological stage)
3.
Clinical symptoms
I stage (onset of the
disease)
Shaking chills
(persist for 1-3 hours) or rigor
Complaints:
(imply bacteraemia).
Fever (39- 400C)
Pleuritic pain in the chest (on the affected side)
in lower lobe pneumonia can simulate acute
appendicitis, hepatic colics.
Dyspnoea.
Cough is first dry (in 1-2 days rusty sputum is
Clinical symptoms
I stage
General inspection:
Facies pneumonica:
Hyperemia of the cheeks, more
pronounced on the affected
side, participation of the nostrils
in breathing, herpes nasalis &
labialis.
General cyanosis
Clinical symptoms
I stage
Respiratory system
examination
Clinical symptoms
Clinical symptoms
Investigations
Blood test
Investigations
Blood test
Investigations
Sputum
Microbiological
investigations
Sputum:
Direct smear by
Gram.
Culture.
Antimicrobial
sensitivity test.
Microbiological
investigations
Serology:
Acute and convalescent titers (Mycoplasma,
Chlamidia, Legionella and viral infections).
Pneumococcal Ag in sputum, serum & urine.
Direct fluorescent Ab stain in Legionella.
Legionella Ag in urine.
Cold agglutinins positive in 50% of
patients with Mycoplasma.
Investigations
X-ray
Homogeneous
opacity
localized to the
affected lobe
Complications:
1. pulmonary
2.
extrapulmonary
Bronchopneumonia
(focal pneumonia)
Main syndromes in
bronchopneumonia
1.
2.
3.
Focal consolidation.
Respiratory insufficiency.
Intoxication.
Bronchopneumonia
Clinical symptoms
Bronchopneumonia
Clinical symptoms
Cough
Fever different: remittent, irregular
(usually subfebrile). Temperature may be
normal at aged patients.
Dyspnoea
Pain in the chest (only in involvement
of the pleura in peripheral located
inflammatory focus)
Bronchopneumonia
Clinical symptoms
Bronchopneumonia
Clinical symptoms
In presence of large focus,
if it is located peripherally
(over the limited part of the
chest):
Bronchopneumonia
Investigations
Treatment of pneumonia
Risk class
No. of points
Recommendatio
ns for site of
care
No predictors Outpatient
II
< 70
Outpatient
III
71 90
Inpatient
IV
91 130
Inpatient
>130
Inpatient
Characteristic
Points
Men
Age (years)
Women
Age (years) - 10
Nursing home
resident
+ 10
Characteristic
Points
Neoplastic disease
+30
Liver disease
+30
Heart failure
+10
Cerebrovascular disease
+10
Renal disease
+10
Characteristic
Points
+20
SBP<90 mm Hg
+20
+15
+10
Characteristic
Points
+30
+20
+20
+10
+10
Pleural effusion
+10
Pulmonary abscess
Is a purulent melting of the lung
tissue circumscribed by an
inflammatory swelling
It develops mostly as an outcome of
pneumonia or complicated
bronchoiectasis.
Pulmonary abscess
Etiology
Streptococci
Staphylococci
Pneumococci
Pulmonary abscess
Clinical symptoms
2 periods are distinguished:
1st before opening an abscess
(formation of abscess; it continues
10-12 days)
2nd after opening an abscess (begins
with the opening of the purulent
abscess into the bronchus)
Pulmonary abscess
I period
Complaints:
Weakness
Chills
Cough with meager sputum
Pain in the chest (in pleura
involvement)
Dyspnoea
Fever (remittent or hectic)
Pulmonary abscess
I period
In peripheral location of abscess
Pulmonary abscess
I period
Investigations
Pulmonary abscess
II period
Complaints:
Severe cough with sudden release of
ample offensive purulent sputum (full
mouth):
on standing separates into three layers:
mucous, serous and purulent
(from 200 ml to 1-2 L/day)
Dyspnoea
Pain in the chest
Pulmonary abscess
II period
Clinical symptoms
Unilateral thoracic
lagging
Vocal fremitus
increased
Percussion: tympanic /
metallic sound;
crackled - pot sound
Auscultation: bronchial
(amphoric / cavernous)
breathing;
resonant moist rales;
gutta cadens (falling
drop sound)
Pulmonary abscess
II period
Investigations:
Blood test:
Neutrophylic leucocytosis.
Shift to the left,
to the myelocytes.
ESR increased significantly.
Sputum:
On standing separates into
three layers: mucous, serous
and purulent.
Elastic fibers.
Leucocytes and
erythrocytes.
Dittrichs plugs (resemble
the lenticular formations
with offensive odour on
pressing )
Pulmonary abscess
II period
X-ray:
cavity with liquid
level
Pulmonary abscess
Treatment
Hospitalization
Adequate draining
Antibiotics
Desintoxication