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Pneumonia in Plab
Introduction
Pneumonia is defined as inflammation of the substance of the lungs.
It is usually caused by bacteria but can also be caused by viruses and fungi.

Symptoms and signs

symptoms sings
Cough Dyspnea and increased RR
Purulent sputum, Sometimes hemoptysis Coarse Crepitations and brochial breathing
Breathlessness Cyanosis with severe pneumonia
Fever confusion
Pleuritic chest pain Subtle features in elderly

Beware! Lower lobe pneumonia sometime present as epigastric pain

Classification
1. Community aquired pneumonia
• Pneumonia in healthy person
• No underlying immunosuppression or malignancy

2. Hospital aquired pneumonia

• Defined as new onset of pneumonia, in patients who are beyond 2 days of their initial admission
to hospital OR who have been treated in a hospital within the last 3 months.
• So, the onset of pneumonia either inside or outside the hospital.

3. Pneumonia in immunocompromised patients

• Pneumonia in Patient with HIV and immunosuppressive therapy.

Community acquired pneumonia

Risk factors just read once...

• Age: <16 or >65 years – common in extreme of ages
• Co-morbidities: HIV infection, diabetes mellitus, chronic kidney disease, malnutrition, recent viral
respiratory infection
• Other respiratory conditions-. cystic fibrosis, bronchiectasis, COPD, Lung Ca.
• lifestyle: cigarette smoking, excess alcohol, intravenous drug use
• Iatrogenic-. immunosuppressant therapy (including prolonged corticosteroids)
Beware! Even immunocompromised patients can have community acquired pneumonia.
If a mcq says a lobar pneumonia with consolidation in a HIV patient and ask for most likely cause –
Go for Pneumococcus. Examinor tricks you in this way to choose TB or Pneumocystis pneumonia.
(With TB- apices involved, with Pneumocystis- No lobar consolidation)

Commonest cause for community acquired pneumonia is Pneumococcus (30-50%) which is a gram
positive diplococci.

Investigations
Saturation, WBC, Blood urea, electrolytes, Chest x-ray, sputum culture , blood culture, ABG

Management
Severity of pneumonia assessed by CURB65.
So, the management of pneumonia depend on CURB65 score.

Memorize CURB-65 for all exams

CURB-65 SCORE points
C Confusion Present 1
U Urea >7mmol/l 1
R Respiratory rate >30/min 1
B Blood pressure Sys<90 mmHg; dias <60 mmHg 1
65 Age >65 1
0-1- treat outpatient 2 -admit to hospital 3+ admit ITU iv antibiotics
Mortality <3% Mortality 3-15% >15%

With CURB 0-1

• can be treated outpatient
• Oral amoxicillin 500mg X 3times daily
• with penicillin allergy Oral clarythromycin 500mg X 2times daily or Oral doxycycline 100mg
X 2times daily (give loading dose 200mg doxycycline at the beginning)

With CURB 2
• Admit
• Oral amoxicillin 500mg-1000mg X 3times daily PLUS Oral/iv clarythromycin 500mg X 2times
daily
• with penicillin allergy Oral Levofloxacin 500mg X 2times daily or Oral doxycycline 100mg X
2times daily

With CURB 3-5

• Admit to ITU
• ABCD
• Oxygen target saturation 94-98%. Known COPD 88-92%
• Give antibiotics as soon as possible; Within 4hrs. Cultures must be taken before
• Co-amoxiclav 1.2g x3 daily IV PLUS clarithromycin 500 mg x2 daily IV (fluoroquinolone if
legionnaire's disease suspected)
• With penicillinallergy IV cephalosporin(e.g. cefuroxime iv) PLUS clarithromycin 500mg x2
daily
 • With penicillin allergy or macrolide intolerance – Give Levofloxacin or doxycycline

Now we look at some community acquired pneumonia by some specific organisms…..

Pneumococcal Pneumonia
(All points below are tested in mcqs regarding pneumococcus)
• Streptococcus pneumoniae is a gram positive diplococci
• Commonest cause for community acquired pneumonia
• Pneumonia often associated with cold sores ( around the mouth) or reactivation of labial herpes.
• Cough with rusty sputum
• Causes lobar pneumonia with consolidation
• Highly sensitive to penicillin

Chest x-rays in adults with consolidation repeated 6 weeks after the treatment in order to exclude the
underlying malignancy

Mycoplasma
(Highly tested facts, everything important)
• Around 10% of community acquired pneumonia due to mycoplasma
• Commonest cause for atypical pneumonia
• Children and young adult often affected often with contact history. Outbreak in an instituition.
• Headache, malaise, Myalgia are important mcq description
• Hemolytic anemia with positive cold antigens.
• Chest x-ray: Diffuse, Patchy infiltration in both lungs
• It is an intracellular organism- so, No culture test.
• Micoplasma IgM antibody or PCR of throat swab/Sputum is confirmatory
• WCC usually normal. Direct coomb test positive at <37° C (cold)
• Erythema multiforme, meningoencephalitis and peri-myocarditis are complications.
• Treatment: Erythro/Clarythromycin or tetracycline

Typical mcq for mycoplasma: Young patient presents with unresolved pneumonia even after the
amoxycillin therapy. Many other contacts have similar symptoms. In addition to cough ,patient
describes severe headache an myalgia. CXR- patchy infiltration bilateral

Legionella
• Gram negative bacteria
• middle age man
• Often there is a travel history and attending a conference to eastern european country in the
mcq.
• Exposed to contaminated showers or airconditioning
• High fever, dry cough, headache, myalgia, Hepatomegaly
• Diarrhea and abdominal pain
• Confusion is an important sign (due to hyponatremia)
• Leucocytosis, Deranged LFT, Hyponatremia, Increased creatinine kinase
• CXR- Diffuse patchy infiltrates like in mycoplama
• Diagnosis: Urinary antigens
• Treatment : iv/oral clarythromycin, Severe cases iv levofloxacin
How to differentiate Mycoplasma from Legionella in a mcq
Mycoplama Legionella
Hemolytic anemia Often travel history, attending a conference
Direct coomb positive Confusion
Erythema multiforme Hyponatremia
Guillen Barre syndrome Diarrhea

Staphylococcal pneumonia
• Often followed by viral URTI or influenza MCQ
• Cavitating lesion and abscess development. Severe pneumonia.
• Treatment iv Flucloxacillin

Chlamydia psittaci
• Acquired from birds
• Causes psittacosis: bird fancier’s lung
• Fever, cough, myalgia
• Treatment: Tetra/doxy-cycline

Chlamydia pneumoniae Not so important for the exam

• Older patients
• Extra pulmonary manifestations: Guillen Barre syndrome, Arthritis, myocarditis
• Treatment: erythromycine or tetracycline

Klebsiella pneumoniae
• Gram negative rod/bacilli
• Patients with alcohol excess, Diabetes, poor dental hygiene
• Consolidation and Cavitating pneumonia,
• Bulging fissure sign in xray MCQ MRCP
• Treatment iv Ceftazidime or iv Tazocin

Pseudomonas aeruginosa
• Gram negative rod/Bacilli
• Associated with underlying lung disease- Cystic fibrosis, Bronciectasis, COPD
• iv Tazocin in severe cases. Inhaled tobramycin in milder cases

Coxiella burnetti (Q fever)

• Farmer develops pneumonia. Then suspect Q fever
• History of contact with cattle, sheep and goat
• Associated with endocarditis

Hemophilus influenza
• Commonest cause for pneumonia in COPD patients. Also causes pneumonia in Cystic fibrosis
• Gram negative coccobacilli
• Amoxycillin or doxycycline given as treatment
Moraxella catarrhalis
• Causes pneumonia in COPD
• Amoxycillin or Doxycycline given as treatment

Viral pneumonia
1. Varicella
• severe pneumonia
• CXR- diffuse bilateral small calcified and non calcified nodules MRCP mcq
• Should be treated with IV acyclovir

2. Cytomegalovirus
• Often following organ transplantation or HIV patients (immunocompromised)
• Severe pneumonia with diffuse infiltrate
• IV Gancyclovir

3. Coxackie virus
• Causes Bornholm disease Mcq MRCP
• Pain with breathing and coughing and associated abdominal pain
• No treatment required

Measles, Influenza and RSV viruses also causes pneumonia

Childhood measles can predispose to bronchiectasis MCQ

Cavity forming pneumonia

Any severe pneumonia can cavitate. However, TB, Staph
aureus, Klebsiella and aspiration pneumonias cavitate more
frequently.
Cavitation is rare with Pneumococcus

Aspiration pneumonia
• Risk factors- Seizures, reduced consciousness, general
anesthesia, stroke
• Right lower lobe often involves. Why? Right bronchusmore
straighter than the left. Because of the position of the heart,
the left bronchus less straighter than right.
• iv cefuroxime + iv metronidazole
• Alternative: Amoxycillin+metronidazole+ gentamycin

Hospital acquired pneumonia

• Causes:- Pseudomonas, Klebsiella, Escherichia, Enterobacter, Staph. aureus
• MRSA is increasingly identified
• Mild-moderate- IV co-amoxyclave
• Severe – IV tazocin or Meropenam
Pneumonia in Immunocopmpromised patients

Pneumocystis jiroveci pneumonia So many mcqs..each and every line is important

• Most common opportunistic infection..
• It affects patients with HIV and on immunosuppressant therapy. (eg: on steroids, chemotherapy)
• associated with a high fever, breathlessness and dry cough.
• A characteristic feature on examination is rapid desaturation on exertion.
• The typical radiographic appearance is diffuse bilateral alveolar and interstitial shadowing in a
butterfly pattern.
• Other chest X-ray appearances include cavitationand pneumothorax.
• Empirical treatment is justified in very sick high-risk patients
• Diagnosis confirmed by indirect immunofluorescence on bronchoalveolar lavage fluid (BAL) or
on induced sputum.
• First-line treatment is high-dose co-trimoxazole. Second line- pentamidine

Complications of pneumonia

Paraneumonic effusion and empyema

• Pleural effusions develop 50% of patients with bacterial pneumonia. Thist is called
parapneumonic effusion.
• Parapneumonic effusions are usually sterile (not infected)
• When parapneumonic effusion get infected, empyema develops.

How we differentiate parapneumonic effusion from empyema?

Empyema suspected with ongoing fever with increasing inflammatory marker despite antibiotic
therapy.Pleural aspiration mest be done to diagnose empyema.

Empyema is suggestive if pleural aspirate shows the followings,

• Usually cloudy fluid with pus, organisms, with gram staining, culture positive
• LDH levels are very high in empyema
• Important distinctive feature is pH. If the pH is <7.2 it is highly suggestive of empyema an
pleural space drainage should be urgently done under ultrasound guidance. Continue with
antibiotcs.
• If drainage fails Do CT and refer to cardiothoracic surgeon

Lung abscess
• Commonly associated with aspiration pneumonia, Staph.aureus pneumonia, Klebsiella, and TB.
• Associated Cavity formation is common. (same micro-organisms resposible)
• Diagnosis CT
• Treatment: CT guided aspiration

Extra point.. good to know

Septic emboli usually containing staphylococci: these can cause multiple lung abscesses. The presence
of multiple lung abscesses in an injecting drug user should prompt investigation for infective
endocarditis.