Lung consolidation Ca lung

Pneumonia

DR.Bilal Natiq Nuaman,MD C.A.B.M.,F.I.B.M.S.,D.I.M. 2016-2017

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a “solidification” of the lung tissue due to accumulation of solid and liquid material in the air spaces that would have normally been filled by gas. causes: 1-pneumonia 2-malignancy 3-infarction

Lung consolidation

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When making a diagnosis of consolidation, use other signs to provide an underlying cause. the best thing is to provide a list of differential diagnoses for consolidation:

(a)Pneumonia (pyrexia, purulent sputum, hemoptysis)

(b) Malignancy (cachexia,clubbing.nicotine stainlng,lympahdenopathy,productive cough).

(c) Infarction (signs of pulmonary hypertension. deep venous thrombosis)'

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Carcinoma of lung

Primary lung cancer

Lung cancer is the most common cause of cancer death in the world, with more than 1 million deaths occurring annually. Smoking is thought to be directly responsible for at least 90% of lung carcinomas, the risk being directly proportional to the amount smoked and the tar content of cigarettes. Risk falls slowly after smoking cessation, but remains above the risk in nonsmokers for many years. A number of industrial materials (e.g. asbestos and silica) areassociated with lung cancer

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Bronchial carcinoma This tumor arises from the bronchial epithelium. The common cell types are squamous (35%), adenocarcinoma (30%), small cell (20%) and large cell (15%). Lung cancer presents in many different ways. If the tumor arises in a large bronchus, symptoms arise early, but tumors originating in a peripheral bronchus can grow large without producing symptoms. Peripheral squamous tumors may cavitate.

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Local spread may occur into the mediastinum and invade or compress the pericardium, oesophagus, superior vena cava, trachea, or phrenic or left recurrent laryngeal nerves.

Lymphatic spread to supraclavicular and mediastinal lymph nodes is also frequently observed.

Blood borne metastases most commonly affect liver, bone, brain, adrenals and skin. Even a small primary tumor may cause widespread metastatic deposits; this is a particular characteristic of small cell lung cancers.

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Clinical featuresCough: This is the most common early symptom.

Hemoptysis: This occurs especially with central tumors.

Bronchial obstruction: Complete obstruction causes collapse of a lobe or lung, with breathlessness, mediastinal displacement, dullness to percussion and reduced breath sounds. Partial obstruction may cause unilateral wheeze that fails to clear with coughing, and may also impair the drainage of secretions, causing pneumonia or lung abscess. Persistent pneumonia in a smoker suggests an underlying bronchial carcinoma. Stridor (a harsh inspiratory noise) occurs when the trachea or larynx is narrowed by tumor or nodes.

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Breathlessness: Cancer may present with breathlessness by causing collapse, pneumonia or pleural effusion, or by compressing a phrenic nerve and leading to diaphragmatic paralysis. Pain and nerve entrapment: Pleural pain usually indicates malignant pleural invasion or distal infection. Apical carcinoma may cause : Horner’s syndrome (ipsilateral partial ptosis , enophthalmos, myosis and hypohidrosis of the face) due to involvement of the sympathetic nerves in the neck. Pancoast’s syndrome (pain in the inner aspect of the arm, sometimes with weakness or wasting in the hand) indicates involvement of the brachial plexus by an apical tumor.

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Mediastinal spread: Involvement of the oesophagus may cause dysphagia. Pericardial involvement may lead to arrhythmia or effusion. Superior vena cava obstruction by malignant nodes causes suffusion and swelling of the neck and face, conjunctival edema, headache and dilated veins on the chest wall. Involvement of the left recurrent laryngeal nerve by tumors at the left hilum causes voice alteration and a ‘bovine’ cough.

Metastatic spread: This may lead to focal neurological defects, epileptic seizures, personality change, jaundice, bone pain or skin nodules. Lassitude, anorexia and weight loss usually indicate meta-static spread.

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Investigations The main aims of investigation are to: ●Confirm the diagnosis. ●Establish the histological cell type. ●Define the extent of the disease.

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Biopsy and histopathology: Central lung tumors can be biopsied at bronchoscopy. For peripheral tumors, percutaneous needle biopsy under CT or US guidance is the preferred way to obtain tissue.

Combined CT and PET is used increasingly to detect metastases. Head CT, radionuclide bone scanning, liver USS and bone marrow biopsy are reserved for patients with clinical or biochemical evidence of spread to these sites.

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Surgical resection carries the best hope of long-term survival. Unfortunately, most cases (>85%) have un-resectable disease

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The treatment of small cell carcinoma with chemotherapy, some times in combination with radiotherapy, can increase median survival from 3 months to well over a year. Chemotherapy is generally less effective in non small cell bronchial cancers.

Malignant pleural effusions should be drained if the patient is symptomatic and pleurodesis performed. Overall the prognosis in bronchial carcinoma is very poor, with ~70% of patients dying within 1 yr of diagnosis and < 8% of patients surviving 5 yrs after diagnosis.

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Secondary (metastatic) tumors of the lung

The most common tumors that metastasize to the lung are those of the breast, kidney, uterus, ovary, testes and thyroid, often with multiple deposits.

Lymphatic infiltration (lymphangitis) may develop in patients with carcinoma of the breast, stomach, bowel, pancreas.

Pneumonia is defined as an inflammatory disease of the parenchyma of the lung, caused by Infectious agent , associated with recently developed radiological pulmonary shadowing which may be segmental, lobar or multilobar.

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Epidemiology❖The morbidity and mortality of pneumonia are high especially in old people. ❖Leading cause of death until 1936

Due to Discovery of sulfa drugs and penicillin

❖Now it is the 6 th leading cause of death ❖Average mortality 14%

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Classification of pneumonia• Classification by Pathophysiology • Classification by pathogen • Classification by acquired environment • Classification by anatomy • Classification by presentation • Classification by duration

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Pneumonia PathophysiologyMicrobial pathogens enter the lung by:

• 1-Inhalation of Infectious Aerosols (inhalational pneumonia) • Influenza, Legionella, Psittacosis,

Histoplasmosis, TB,Mycoplasma,

• 2-Hematogenous Dissemination (hematogenous pneumonia) • Staph aureus in osteomyelitis

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• 3-Aspiration of organisms (aspiration pneumonia)

• More common in patients with impaired level of consciousness: alcoholics, seizures, stroke, anesthesia, swallowing disorders.

• more likely with hospitalization, debility, alcoholism, DM, and advanced age

• From oropharynx Gram positive and anaerobes: Strep pneumo, H influenza, Moraxella,, S.

pyogenes, From stomach (mendelson syndrome-chemical

pneumonitis) Gram negatives:

•

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Classification by pathogen• Bacterial pneumonia : (1) Aerobic Gram-positive bacteria,such as streptococcus pneumoniae, staphy- lococcus aureus, Group A hemolytic streptococci (2) Aerobic Gram-negative bacteria, such as klebsiella pneumoniae, Hemophilus influenzae, Escherichia coli (3) Anaerobic bacteria 21

• Atypical bacterial pneumonia : Including Legionnaies pneumonia , Mycoplasma

pneumonia , chlamydia pneumonia.

• Viral pneumonia : may be caused by adenoviruses, respiratory

syncytial virus, influenza, cytomegalovirus, herpes simplex , SARS .

• Fungal pneumonia : Fungal pneumonia is commonly caused by

histoplasma , aspergilosis and pneumocystis jiroveci (previously named pneumocystis carinii)

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Classification by anatomy

1- Lobar: Involvement of an entire lobe

2- Lobular: Involvement of parts of the lobe only, segmental or of alveoli contiguous to bronchi (bronchopneumonia).

3- Interstitial

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Lobar pneumonia Bronchopneumonia Interstitial pneumonia

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Classification by presentation

• “Typical” (classical) pneumonia: (85%) sudden onset of fever, cough productive of purulent sputum, pleuritic chest pain

• “Atypical”: (15%) gradual onset, dry cough, prominence of Extrapulmonary symptoms: headache, myalgias, fatigue, sore throat, nausea, vomiting

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Typical pneumonia• Mainly due to the following microorganisms: • Streptococcus (pneumococcal ) pneumoniae • Haemophilus influenzae • Moraxella catarrhalis

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Atypical pneumoniaAtypical organisms: • are not revealed on ordinary Gram stain and

culture media. • Are not affected by common antibiotics such

as sulfonamide and beta-lactams (penicillin).

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The most common causative organisms of atypical pneumonia are (often intracellular living) bacteria:

• Chlamydophila pneumoniae ( previously : Chlamydia pneumoniae ) Mild form of pneumonia with relatively mild symptoms.

• Coxiella burnetii Causes Q fever. Transmitted through cattle, sheep, goats causing severe pneumonia with hepatitis and endocarditis

• Mycoplasma pneumoniae Usually occurs in younger age groups and may be associated with neurological and systemic (e.g. rashes) symptoms.

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• Legionella pneumophila Causes a severe form of pneumonia with a relatively high mortality rate, known as legionellosis or Legionnaires' disease is transmitted by inhalation of aerosolized water .

it is not transmitted from person-to-person. Sources include hot-water tanks, cooling towers, and evaporative

condensers of large air-conditioning systems, and showers Hyponatremia (serum sodium <130 meq/L) occurs significantly

more frequently in Legionnaires' disease than in pneumonias of other etiologies

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Clinical clues for the diagnosis of Legionnaires' disease

Presence of gastrointestinal symptoms, especially diarrhea Neurologic findings, especially confusion Fever >39ºC Hyponatremia Hepatic dysfunction Hematuria Failure to respond to beta-lactam and/or aminoglycoside antibiotics treatments of choice are the respiratory tract quinolones (levofloxacin, moxifloxacin, ) or

newer macrolides (azithromycin, clarithromycin, ).

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Viral • Influenza A and B, including avian flu and swine flu • severe acute respiratory syndrome (SARS) due to

coronavirus Fungal • Pneumocystis jiroveci (previously : pneumocystis carinii) it

can cause a severe lung infection in people with a weakened immune system due to:

Cancer Chronic use of corticosteroids or other medications that

weaken the immune system HIV/AIDS Organ or bone marrow transplant

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Classification by acquired environment

◆Community acquired pneumonia. CAP

◆Hospital acquired pneumonia. HAP

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Hospital-acquired (nosocomial) pneumonia is defined as pneumonia developing 2 or more days after admission to hospital for some other reason.

the most common pathogens in hospital-acquired pneumonia are as follows: • Gram-negative bacteria:50% • Staphylococcus aureus: 20% • Streptococcus pneumonia:15% • Anaerobes and fungi:10% • Other(e.g.Legionella pneumophila):5%

Community Acquired Pneumonia Definition: Lower respiratory tract infection in a non hospitalized person that is associated with symptoms of acute infection with or without new infiltrate on chest radiographs

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S. pneumoniae classically presents with sudden rigor, fever, and cough productive of rust-colored sputum

Legionella presents as a severe pneumonia with high- spiking fevers accompanied by diarrhea, and in some cases, relative bradycardia despite high fevers. Hyponatremia may be more common with Legionella than with other etiologic agents

Mycoplasma infection presents as a paroxysmal, nonproductive cough, often with minimal findings on CXR

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Chest radiograph The primary role of the chest radiograph is to differentiate pneumonia from other conditions that produce opacities (e.g. atelectasis, pleural effusion, pulmonary embolus, pulmonary contusion, mass lesions). The chest radiograph is also helpful in : following the progress of pneumonia, evaluating the response to therapy, and detecting complications (e.g., pleural effusion, empyema, congestive heart failure).

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The key-findings on the chest X-ray are:

1-ill-defined homogeneous opacity obscuring vessels 2-Silhouette sign: loss of lung/soft tissue interface 3-Air-bronchogram 4-Extention to the pleura or fissure, but not crossing it 5-No volume loss

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Air-bro

nchogram

Silhouett

e sign

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Management The most important aspects of management are oxygenation, fluid

balance and antibiotic therapy. In severe or prolonged illness, nutritional support may be required.

Oxygen Oxygen should be administered to all patients with tachypnea,

hypoxemia, hypotension or acidosis, with the aim of maintaining the SaO2 at or above 92%. High concentrations(35% or more), preferably humidified, should

be used in all patients who do not have hypercapnia associated with COPD.

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Indications for referral to ICU• CURB score 4-5 failing to respond rapidly to

initial management . • Persisting hypoxia PaO2<60 mmHg despite

high conc. O2 . • Progressive hypercapnea . • Severe acidosis . • Shock . • ↓ consciousness

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How Long Should You Treat?• A generally accepted approach for outpatients and non-ICU

inpatients: • S. pneumoniae, H. influenzae and other “typical ” bacterial organisms

(to include gram negative organisms) – treat for 7 to 10 days • Mycoplasma, Chalmydia and Legionella species ”atypical bacteria“ –

treat for 10 to 14 days (Macrolide )

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Classification by duration

A-ACUTE PNEUMONIA Duration of symptoms days to weeks B-CHRONIC PNEUMONIA Duration of symptoms weeks to months

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Chronic Pneumonia➢ These pneumonia develop gradually over a period of weeks – months and

are caused but numerous microorganisms.

❖Common causes ❖ M.tuberculosis ❖Entamoeba histolytica ❖ Echinococcus granulosus

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Recurrent “pneumoniasCauses • Pulmonary

• Neoplasm • Foreign body • Bronchiectasis Neurological dysfunctions

• Seizures Gastrointestinal Problems

GERD Zenker’s diverticula Achalasia

Immune deficiency Multiple Myeloma

Chronic lymphocytic leukemia HIV 55

THANK 56