PNEUMONIA IS INFLAMMATION OF THE

PARENCHYMA OF THE LUNGS.

MOST CASES OF PNEUMONIA ARE CAUSED

BY MICROORGANISMS.

NONINFECTIOUS CAUSES of PNEUMONIAE

-ASPIRATION OF FOOD AND OR GASTRIC ASID

-FOREIGN BODIES

- HYDROCARBONS

-LIPOID SUBTANCES

-HYPERSENSITIVITY REACTIONS

-DRUG

- RADIATION MAY INDUCED PNEUMONIAE

PNEUMONIA HAS BEEN CLASSIFIED ON AN

ANOTOMIC BASIS AS A LOBAR, ALVEOLAR

OR LOBULAR, OR INTERSTITIAL PROCESS

1. LOBAR PNEUMONIA-ALVEOLAR1. LOBAR PNEUMONIA-ALVEOLAR

STREPTOCOCCUS PNEUMONIAE

2. LOBULAR-BRONCHOPNEUMONIAE2. LOBULAR-BRONCHOPNEUMONIAE

STREPTOCOCCUS PNEUMONIAE

HAEMOPHILUS INFLUENZAE

KLEBSIELLA SP.

GROUP B STREP

E.COLI

S.AUREUS

3. INTERSTITIAL PNEUMONIAE VIRAL3. INTERSTITIAL PNEUMONIAE VIRAL

PNEUMONIAE

RSV

CMV

ADENOVIRUS

INFLUENZA A.B

CLASSIFICATION OF PNEUMONIA WITHRESPECT TO AGE

NEW BORNNEW BORN

GROUP B STREPTOCOCCI

(SEROTYPES I, II)

L.MONOCYTOGENES

H.INFLUENZAE (NONTYPABLE)

GRAM-NEGATIVE ENTERIC BACILLI

NOSOCOMIAL NOSOCOMIAL

PNEUMONIAPNEUMONIA

P.AEROGINOSA

E.COLI

GRAM-NEGATIVE BACILLI

C.TRACHOMOTIS

1 MONTH-6 YEAR1 MONTH-6 YEAR

S.PNEUMONIA (1.3.6A.14.18C, 19F,

23F)

H.INFLUENZAE (HIB)

GROUP A STREPTOCOCCI

S.AUREUS

M.CATARHALIS

OVER 6 YEARS OF AGE AND OVER 6 YEARS OF AGE AND

ADOLESCENTSADOLESCENTS

S.PNEUMONIA

M.PNEUMONIA ATYPICAL PNEUMONIA

C. PNEUMONIA

IMMUNOCOMPETENT IMMUNOCOMPETENT IMMUNOCOMPROMISEDIMMUNOCOMPROMISED BACTERIALBACTERIAL 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-BACTERIA-LIKE AGENTSLIKE AGENTS M.PNEUMONIAE

C.PNEUMONIAE C.TRACHOMATIS C.PSITTACI COXIELLA BURNETI RICKETTSIA RICKETTSII

PROTECTING MECHANISM OF THE LUNG

FILTRATION OF THE PARTICLES IN THE

NARES 5-20 Μm

1. PREVENTION OF ASPIRATION BY THE EPIGLOTTAL REFLEX

2. EXPULSION OF ASPIRATED MATERIAL BAY THE COUGH REFLEX

3. ENTRAPMENT AND EXPULSION OF ORGANISM BY MUCUS SECRETING AND CILIATED CELLS

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

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)

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

CLINICAL FEATURES

A) NONSPESIFIC SIGNS AND SYMPTOMS

FEVER VOMITING

CHILLS ABDOMNAL DISTANTION

HEAD ACHE DIARRHEA

IRRITABILITY ABDOMINAL PAIN

APPREHENSION

B) PULMONARY SIGNS

NASAL FLARING

TASYPNEA

DYSPNEA

APNEA

USE OF ACCESORY INTERCOSTAL MUSCLES AND ABDOMINAL MUSCLES

COUGH IS INITIALLY DRY, LATER PRODUCTIVE

OF PURULENT OR EVEN BLODDY SPUTUM

C) EXTRA PULMONARY SIGNS

ABSCESSES OF SKIN

ABSCESSES OF SOFT TISSUE

ROENTGENOGRAPHIC FINDINGS:

PATCHY INFILTRATES (IN INFANCY)

SEGMENTAL OR S. PNEUMONIAELOBAR CONSOLIDATION H.

INFLUENZAE

HILAR LYMPHNODUS H. INFLUENZAES.AUREUS

PNEUMOTOCELE S.AUREUSKLEBSIELLA

PLEVRAL EFFUSION S. AUREUSPNEUMOTORAX KLEBSIELLA

ROENTGENOGRAM CLEARS WITH IN 3-4

WEEKS 80 PERCENT OF CASES

IN S.AUREUS PNEUMONIA THIS DURATION

MUCH LONGER

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

PLEVRAL FLUID (EXUDATE)

PROTEIN> 3.0 GR/DL

↓ GLUCOSE BELOW 40 MG/L

LACTIC DEHYDROGENASE 1000 IU/L

Ph BELOW 7.20

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%

PHYSICAL EXAMINATION

FINE CRACKLING RALES

DIMINISHED OR TUBULAR BREATH SOUND

DULLNESS ON PERCUSSION (PLEVRAL EFFUSION )

LIVER MAY SEEM ENLARGED EMPYEMA

DIFFERENTIAL DIAGNOSIS

- FOREIGN BODY

- ALLERGIC ALVEOLITIS

- ATELECTASIS

- TBC PNEUMONIAE

- CYSTIC FIBROZIS

- ACUTE EXACERBATIONS OF BRONCHIECTASIS

- PULMONARY ABSCESS

- ACUTE ABDOMEN

COMPLICATIONS

EMPYEMA

PNEUMOTORAX

LUNG ABCESS

MIDDLE EAR INFECTIONS

PERICARDIAL EFFUSION

OSTEOMYELITIS

ABSCESSES OF SOFT TISSUE

TREATMENT

GROUP B STEP.

DURING THE FIRST 24-48 HOURS OF LIFE

AGGRESSIVE CARDIOVASCULAR AND

VENTILATORY SUPPORT IS REQUIRED

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

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

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

PREVENTION:

CHILDREN IN HIGH RISK GROUPS

2 YEAR OR OLDER

0.5 ML 23 VALANT PNEUMOCOCCAL/VACCINE

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.

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 MONTHS4-8 WEEKS INTERVAL

2 DOSES

1 YEAR LATER 1 DOSES

1-5 YEARS 1 DOSES

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/DAYORNEUTROMYCIN 40 MG/KG/DAY 4X1

IF S. AUREUS IS REZISTANT TO METHICILLINIV VANCOMYCIN 40 MG/KG/DAY 4X1

TREATMENT IS GIVEN 6-10 WEEKS

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

LARYNGITIS

TRACHEOBRONCHITIS URTI

PNEUMONIAE

RECURRENT M.PNEUMONIAE ARE QUITE

COMMON IN INFANCY AND CHILDHOOD

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

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

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

PHYSICAL EXAMINATION

BRONCHIAL BREATH SOUND

RHONCHI

LOCALIZED CREAKLES

WHEEZING

FLEURAL PAIN

CHEST FILMS

• LOCALIZED INFILTRATES (BRONCHOPNEUMONIAE)

• LOBAR CONSOLIDATION

• BILATERAL DIFFUSE INFILTRATES

• SMALL PLEURAL EFFUSION

EXTRAPULMONARY MANIFESTATIONS

CEREBELLAR ATAXIA ENCEPHALOPATHY

PERIPHERAL NEUROPATHIES

CARDIOMYOPATHY

MYOSITIS

PANCREATITIS

HEMOLYTIC ANEMIA

E. MULTIFORME

STEVENS-JOHNSON SYNDROME

HEPATOSPLENOMEFALY

LABORATORY FINDINGS

WBC: N

COLD HEMAGGLUTININ ASSAY 1/64↑(+)

COMPLEMENT FIXATION ASSAY (+)

PCR (POLYMERASE CHAIN REACTION) TO

DETECT

ANTIGEN IN RESPIRATORY SECRETION

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

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

PNEUMONIAS OF VIRAL ORIGIN

• RSV

• PARAINFLUENZACORONOVIRUSES

• ADENOVIRUSES HERPES VIRUSES

• INFLUENZAENTEROVIRUSES

• CMV

• RHINOVIRUSES

CLINICAL MANIFESTATIONS

RHINITISCOUGH

FEVERTACHYPNEAINTERCOSTALSUBCOSTALSUPRASTERNALNAZAL FLARINGUSE OF ACCESSORY MUSCLE

CYANOSISRESPIRATORY FATIQUE

URTI

RETRACTIONS

IN SEVERE CASES

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)

LABORATORY

WHITE BLOOD CELL N OR SLIGHTLY

ELEVATED

<10.000 mm3

LYMPHOCYTES ↑

ESR

CRP

ISOLATION OF THE VIRUS FROM ISOLATION OF THE VIRUS FROM NASOPHARYNGIALNASOPHARYNGIAL

SECRETIONS (+)SECRETIONS (+)

N OR SLIGHTLY ELEVATED

PNÖMONİLERE AİT BÜTÜN AKCİĞER

GRAFİLERİ HASTA HAKLARI AÇISINDAN

DERS SLAYTLARINDAN ÇIKARILMIŞTIR.