Pneumonii virale

• Agresiune virala asupra structurilor cardiace

• Incluse in pneumoniile atipice
• Este necesara diferentierea lor de celelalte
pneumonii atipice, diferentiere uneori dificila, pe
criterii clinice, radiologice, microbiologice.Datele
clinice si radiologice sunt sugestive, dar dg
etiologic precis se va face numai pe baza
studiilor virusologice. Chiar si astfel organismul
nu poate fi identificat la 50-80% dintre pacientii
simptomatici.
 Etiologia
• Adenoviridae (adenoviruses)
• Coronaviridae (coronaviruses)
• Bunyaviridae (arboviruses) - Hantavirus
• Orthomyxoviridae (orthomyxoviruses) - Influenza virus
• Paramyxoviridae (paramyxoviruses) - Parainfluenza virus (PIV), respiratory
syncytial virus (RSV), human metapneumovirus (HMPV), measles virus
• Picornaviridae (picornaviruses) – Enteroviruses, coxsackievirus, echovirus,
enterovirus 71, rhinovirus
• Reoviridae (rotavirus)
• Retroviridae (retroviruses)- Human immunodeficiency virus (HIV), human
lymphotropic virus type 1 (HTLV-1)
• Herpes simplex virus 1 (HSV-1) and herpes simplex virus 2 (HSV-2), also
called human herpesvirus 1 (HHV-1) and human herpesvirus 2 (HHV-2),
respectively
• Varicella-zoster virus (VZV)
• Cytomegalovirus (CMV)
• Epstein-Barr virus (EBV)
 Patogeneza
• Transmitere prin picaturile de saliva : influenza virus, PIV, RSV,
measles virus, adenovirus, severe acute respiratory syndrome (SARS)
virus, Hantavirus, and enterovirus.
• Factori de mediu (adenovirus, enterovirus, rhinovirus), contact direct cu
obiecte contaminate (VZV), transplant (CMV) or transfuzii (CMV),
aspiratie in tractul aerian a virusurilor din saliva (CMV, HSV),
reactivarea unei infectii latente (HSV, CMV), diseminare hematogena
(CMV), transmitere prin personalul medical (SARS, measles,
adenovirus, PIV, RSV).
• Personalul medical din anumite institutii prezinta un risc crescut pentru
infectii nosocomiale (SARS coronavirus).
• Adenoviruses, influenza virus, measles virus, PIV, RSV, rhinoviruses,
and VZV, sunt transmise relativ usor intraspitalicesc (70% dintre
pneumoniile virale nosocomiale).
• Virusurile se multiplica in epiteliul cailor aeriene si infecteaza secundar
plamanul prin secretii si diseminare hematogena. Unele virusuri sunt
predominant citopatice, altele actioneaza printr-o inflamatie secundara
excesiva.
 Mecanismele de aparare ale gazdei
• (1) bariera mecanica, (2) imunitatea umorala, (3) fagocitoza celulara, (4)
imunitatea mediata celular
• Bariera mecanica: perii nazali, clearance-ul mucociliar, angulatia bronsiilor
centrale (filtreza particulele peste 5-10 microni).
• Imunitatea umorala este reprezentata de IgA ale mucoasei, Ig M alveolare
si IgG din transudatul plasmatic.
• Celulele fagocitare constau in polymorfonucleare, macrofage (alveolare,
interstitiale, intravasculare) si celule dendritice respiratori. Macrofagele
alveolare reprezinta primul mecanism in inglobarea cu degradarea
patogenilor virali, prin producerea de opsonina.
• Celulele respiratorii dendritice se matureaza, devin active si migreaza in ggl
regionali secundar expunerii la virus. Expuse la antigen sunty implicate in
activarea celulelor T CD8.
• Imunitatea mediata celular reprezinta cel mai important mecanism de
aparare impotriva patogenilor virali intracelulari : productie de Ac, de
citokine, activitate citotoxica.
 Incidenta
In SUA pneumoniile virale se inregistreaza la 13% dintre pacientii
de peste 65 de ani, spitalizati. O suprainfectie bacteriana este
prezenta la o mare proportie a acestora. De aceea la aceste grupe
de varsta se recomanda asocierea la vaccinarea antigripala si a
vaccinului antipneumococic.
Adenovirus pneumonia
• 10% dintre pneumoniile la copii sunt cauzate de adenovirus.
Aspecte asemanatoare la militarii tineri.
• CMV pneumonia
Incidenta pneumoniei cu virus citomegalic post transplant de
maduva este de 10-50% .
• EBV pneumonia
• La 25% dintre copii infectati cu , virusul EB poate cauza pneumonii
interstitiale.
• Pneumonia prin Hantavirus
Mai frecvent intalnita in SUA (400 cazuri in
ultimii ani), America de Sud si Canada
• HMPV pneumonia
Pneumonia prin virusul metapneumonic uman
HMPV reprezinta aproximativ 10% dintre
infectiile respiratorii neelucidate la copii si la
pacientii transplantati.
(HMPV was originally described in 6- to 12-month-old infants from
the Netherlands with respiratory infections. Evidence suggests that
virtually all children in the Netherlands are exposed by the age of 5
years and that the virus has been circulating for more than 50 years
in humans. A Canadian series showed that symptomatic infections
appear to cluster among the young (35% in those <5 y) or the
elderly (46% in those >65 y). A 25-year follow-up study of pediatric
patients with respiratory tract infection showed a 20% incidence of
HMPV in infections of unknown etiology affecting the upper tract
and a 12% incidence among all lower respiratory tract infections).
• Pneumonia cu virusul herpes simplex HSV
Survine in special la persoane imunocompromise. (la 70% dintre transplantele de
maduva daca nu se preactica profilaxia cu aciclovir.

• Pneumonia gripala
Poate surveni la 4-8% dintre adultii sanatosi, respectiv la 10-20% in caz de epidemii.

• Pneumonia cu virusul rujeolic

Poate survenii la 3-7% dintre cazurile de rujeola. Mai frecvent la copii nevaccinati sau
la imunodeprimati.

• Pneumonia paragripala PIV

Dupa virusul sincitial respirator, virusul paragripal reprezinta a doua cauza de infectii
respiratorii joase la sugari si adultul tanar. Pneumonia survine mai frecvent
primavara. (PIV pneumonia causes 250,000 emergency visits annually, resulting in
70,000 admissions).
18% dintre copii spitalizati cu infectii respiratorii in SUA au pneumonie cu virus
paragripal . Incidenta creste la imunocompromisi.
.
Pneumonia cu rinovirus
• Reprezinta dupa unii autori pana la 30% dintre pneumoniile virale. Al doilea
agent etiologic in pneumoniile si bronsiolitele virale la copii. Cauza de
acutizare a astmului bronsic.
• (A study from the Netherlands showed that rhinoviruses cause 32% of all lower respiratory tract
infections with an identified pathogen in the elderly (>60 y) symptomatic population. Rhinoviruses
were identified more frequently than coronaviruses (17%) or influenza viruses (7%).
• Pneumonia cu virusul sincitial respirator (VSR)
• VSR este cea mai frecventa cauza de infectii ale tractului respirator inferior
la copii (<25% dintre pneumoniile la copii). Principala cauza de spitalizare
in infectiile respiratorii ale copiilor. (In 1980, about 100,000 children were hospitalized in
United States because of RSV pneumonia. RSV pneumonia is responsible for an average of
80,000 pediatric hospitalizations and 500 deaths every year).
• Dupa virusul gripal, cea mai frecventa cauza de pneumonii virale la adulti.
(4.4% vs 5.4%). La varstnicii institutionalizati incidenta pneumoniei cu VSR
este egala cu cea gripala, (21%), dar mortalitatea e mai mare.
Pneumonia cu virusul SARS
Acest coronavirus cauzeaza pneumonii la 6.6% si bronsiolite la 10% dintre
persoanele infectate.
In 2003, the World Health Organization (WHO) a raportat 8422 de infectii cu o
mortalitate de 916 cazuri. (11%). 1725 cazuri au interesat personalul medical
(20%)
A series of 262 patients from Hong Kong showed an inpatient mortality rate of 11.7% and an overall
mortality rate of 12.3%. Other studies demonstrated a 13% case fatality rate for patients younger
than 60 years and 43% for those aged 60 years or older. Data from Canada and Singapore
confirmed the severity of the disease.
SARS seems to be far less common in children than in adults, with a rate of 5% in Hong Kong as of
May 2003.
Pneumonia cu virusul varicelo-zoosterian (VVZ)
Incidenta este de 0.32-1.36 cazuri la 100,000 de locuitori/an.
 Mortalitate
Pneumonia cu adenovirus
• 2 decese in 2000.
• Pneumonia CMV
• 31% mortality rate la transplantatii de maduva tratati si 75% la
imunosuprimatii netratati.
• Pneumonia cu Hantavirus
• Mortalitate de 38% chiar la tineri, sanatosi .
• Pneumonia cu virus gripal
Mortalitate de pana la 8% (Between 1972 and 1992, 426,000 deaths related to
influenza pneumonia were reported in United States. Individuals 85 years or older were 16 times
more likely than those aged 65-69 years to die from influenza).
• Pneumonia cu virusul rujeolic
2 decese la copii cu HIV in 86-87 Mortalitatea prin BP este de 28%,
chiar de 40-70% in SIDA sau cc.
• Pneumonia cu virus paragripal
• Poate atinge 15-30% la copii imunodeprimati.
• Pneumonia cu VSR
• Este responsabila de 80,000 de spitalizari pediatrice si 500
decese pe an in SUA. In healthy children, the reported mortality
rate is 0.5-1.7% and higher in immunosuppressed patients
(<80-100% in untreated HSCT recipients vs 22% in treated
control subjects).
• SARS-virus pneumonia
• La 262 pacienti din Hong Kong mortalitatea a fost de 11.7% .
Este de 13% pentru cei sub 60 de ani si de 43% pentru cei
peste.
• Pneumonia cu virusul varicelo-zoosterian
• Mortalitatea a scazut de la 19% (range, 10-30%) in 1960-1970
la 6%.
 Pneumonia din gripa

• Etiopatogenie: tipuri de virusuri A, B, C . Gr A este

raspunzatoare de cea mai mare morbiditate, complicatii,
decese, determina epidemii, dupa variatii ale proteinelor
de suprafata ale virusului.
• Infectia virala se transmite pe cale respiratorie prin
particule sub 10 microni, ca aerosoli
• Infectia afecteaza mucoasa, diferite structuri respiratorii
• Manifestari respiratorii
• 3 tipuri de pneumonii
 Pneumonia virala primara

• La varstinici, in afectiuni pulmonare cr, cardiopatii,

gravide
• Clinic la 24-36h de la debutul gripal
• Ex lab
• Rgr opacitati infiltrative, extensive interstitiale si alveolare
cu iradiere din hili.
• Tratament O2, cortizon, sol macromoleculare, antibiotice
 Pneumonia bacteriana secundara
• Etio: stafilococul auriu, pneumococul, Haemophilus,
streptococi, E coli, Klebsiella, coci anaerobi.
• Clinic evolutie difazica
• Dg
• Tratament
 Pneumonia mixta virala si bacteriana

• Evolutie severa
• Mortalitate mare
• Tratament : amantadina 200 mg/zi
rimantadina
ribavirina
 Pneumonia cu v paragripal
• La persoane cu imunodepresie
• Manifestari clinice PIV 3 cauzeaza pneumonia.
 Pneumonia din varicela

• Forma usoara
• Forma moderata
• Forma grava
• Tratament aciclovir iv.
 Pneumonia din rujeola

• Interstitiala virala
• Bacteriana sec
 Pneumonia cu adenovirus

• Serotipurile patogene sunt: subgroup B (3, 7, 21), C (1,

2, 5), and E4. Subgroupul B 11 si 35 pot produce
pneumonii neonatale fatale.
• Pneumonia este mult mai grava la copii mici : letargie,
diaree, varsaturi . Adultii tineri pot prezenta sindrom de
detresa respiratorie. subgroup E type 4 and B type 7
• Pacientii post transplant de MO pot prezenta pneumonii
cu adenovirus la 30-100 zile.
• Complicatiile pe termen lung includ bronchiolita
obliteranta, bronsiectazie, suprainfectii bacteriene.
 Pneumonia cu CMV

• Virusul este patogen pt toate varstele. O data infectata, persoana ramane

purtatoare pe toata viata, cu virus latent in leucocite si alte celule.
• Virusul se transmite transfuzional si prin transplant de organe. Infectia
castigata este asimptomatica, exceptand persoanele cu neoplazii, SIDA,
posttransplant.
• Pneumonia survine posttransplant de MO, rinichi, cord-plaman, chirurgie
cardiaca, in hemopatii, SIDA
• Debut cu malaise, febra, mialgii, s. de hepatocitoliza, cu evolutie usoara la
persoane sanatoase.
• Tabloul clinic sever la imunodeprimati, posttransplant sau SIDA.
• Ex radiologic: opacitati interstitiale difuze, mai proeminente in lobii inf.
• Virusul poate fi identificat in sputa, urina, secr traheale.
• Dg de certitudine prin biopsie pulmonara.
• Tratament: ganciclovir 5mg/kg x 2 , 14z, ulterior intretinere
• Fosfonoformat de Na (foscarnet) inhib de AND polimeraza virala.
 Pneumonia cu VSR

• Mai frecvent infectii respiratorii sup, dar si

pneumonii
• Clinic febra, tuse, otalgii, anorexie,
dispnee
 Pneumonia cu virusul EB

• In fibroza chistica, SIDA, post transplant

de MO
 Pneumonia cu Hantavirus

• Cel mai recent identificat este Sin Nombre virus (the sixth
organism), care cauzeaza pneumonii fulminante. Incubatia este de
9-35 zile. Evol in 3 etape
• Prodrom
• Et cardiopulmonara
• De recuperare
• Exista 2 forme
• A fulminanta
• Moderata
Pneumonia
cu HIV
Pneumonia cu v herpes simplex HSV

• La pers imunodeprimate
 Pneumonia cu rinovirus

• Exacerbari in BPOC, astm, fibroza chistica

 Pneumonia cu v SARS
• SARS-associated coronavirus
• Incubatie de 2-7 z.
• Varsta avansata – f de risc
• BPOC, cc, cardiopatii, diabetul – f de risc 1
• Evol clinica in 2 faze:
• Prodrom
• Faza respiratorie

• Several clinical trials of adult SARS patients from Canada or Hong Kong reported
similar manifestations: fever (99-100%), dyspnea (60-80%), cough (49-80%), malaise
(70%), headache (30-70%), myalgia (20-50%), and chills (74%). One study reported
infiltrates on chest radiographs in 100% of its patients.

• .
 Diagnostic paraclinic

• Teste virusologice
• Culturi virale
• Detectia Ag virale
• Teste serologice
• polymerase chain reactions (PCRs

• PCR is limited by the fact that the results cannot completely rule out contamination of
the specimens. In some immunocompromised patients, who shed the virus for long
periods, the diagnosis can be of little clinical significance. This limitation is overcome
by using quantitative PCR, which shows the level of viral load; the findings can also
help in differentiating active infection from contamination
 Diagnostic diferential
• Acute Respiratory Distress Syndrome
Asbestosis
Aspergillosis, Thoracic
Aspiration Pneumonia
Asthma
Atelectasis, Lobar
Blastomycosis, Thoracic
Bronchiectasis
Bronchiolitis Obliterans Organizing Pneumonia
Extrinsic Allergic Alveolitis
Histoplasmosis, Thoracic
Lung Cancer, Non-Small Cell
Lung Cancer, Small Cell
Lung, Carcinoid
Lung, Drug-Induced Disease
Lung, Metastases
Lung, Nontuberculous Mycobacterial Infections
Lung, Postprimary Tuberculosis
Lung, Primary Tuberculosis
Mesothelioma, Malignant
Pneumonia, Atypical Bacterial
Pneumonia, Neonatal
Pneumonia, Pneumocystis Carinii
Pneumonia, Typical Bacterial
Pulmonary Edema, Noncardiogenic
Radiation Pneumonitis
Sarcoidosis, Thoracic
Silicosis and Coal Worker Pneumoconiosis
 Radiologie

• 2 aspecte radiologice

• F insidioasa
• F rapid progresiva

The chest radiograph shows the rapid confluence of patchy, unilateral or bilateral
consolidations and ground-glass opacity or poorly defined centrilobular nodules
 Adenovirus pneumonia

• diffuse bilateral bronchopneumonia and

severe overinflation. Lobar collapse and
atelectasis is a frequent complication; right
upper-lobe atelectasis is most common in
infants, and left lower-lobe collapse is
common in older children. Radiologic
changes resolve in 2 weeks in
uncomplicated cases.
 CMV pneumonia

• In 1 series of lung transplant recipients with

proven CMV pneumonitis, only one third of
patients had abnormal radiographs. When
abnormal, chest radiographs reveal an interstitial
pattern of disease, which is usually diffuse and
which involves the bases. The interstitial pattern
consists of accentuation of Kerley A and Kerley
B lines or of diffuse, hazy, ground-glass
opacities.
 Coxsackievirus pneumonia

• the radiographic pattern consists in fine

perihilar infiltration. In the cases with
pleurodynia, parenchymal consolidation in
the lung bases may be observed.
 EBV pneumonia

• Chest radiographic analysis :

• hilar lymph node enlargement (13%), a
diffuse reticular pattern indicating
interstitial disease (5%), and bilateral or
unilateral pleural effusions.
 Hantavirus pneumonia

• Chest radiographs show interstitial edema

with or without progression to airspace
disease, with a central or bibasilar
distribution and common pleural effusions.
Pulmonary capillary leak syndrome of
hantaviral infection may be secondary to
the associated renal failure.
 HIV pneumonia

• Fine reticular or reticulonodular infiltrates in the

pulmonary interstitium and coarse
reticulonodular infiltrates or opacities with
superimposed patchy alveolar infiltrates have
been described in patients with AIDS or AIDS-
related complex (ARC) and biopsy-proved
lymphocytic interstitial pneumonia. This disease
is considered a benign reaction of bronchial-
associated lymphatic tissue to HIV.
Radiographic findings are stable throughout the
course of the disease in 75% of patients.
 HSV pneumonia
• In a series of 42 patients with HSV pneumonia, all
radiographs showed abnormalities: pulmonary infiltrates
(93%), pleural effusions (29%), and atelectasis (12%).
 Pneumonia gripala

• Chest radiographic changes in influenza

pneumonia range from mild interstitial
prominence to poorly defined, 1- to 2-cm patchy
areas of consolidation to extensive airspace
disease due to hemorrhagic pulmonary edema.
Alveolar hemorrhage can be seen as small
centrilobular nodules. Pleural effusion is rare
and usually represents bacterial infection. Cavity
formation suggests bacterial superinfection with
Staphylococcus organisms.
pneumonia.

 
 
                            
 Pneumonia din rujeola

• Primary measles pneumonia results in mixed

reticular opacities and airspace consolidation.
Lymph node enlargement in the hilum can be
seen in children. The pathologic basis for these
findings is epithelial hyperplasia in bronchioles
and peribronchial alveoli, multinucleated giant
cells in the alveoli, and diffuse alveolar damage.
 Pneumonia cu VSR
• Other authors showed that the variability of lung infiltration is correlated with
the severity of infection. Atelectasis is more common in children with
positive bacterial swabs than in others.
• Lobar emphysema may be associated with RSV pneumonia.
• A study of 128 chest radiographs of children with lower respiratory infection
showed mainly lobar pneumonia, bronchopneumonia, or normal findings in
infants younger than 6 months. Children older than this had mainly
peribronchitis or interstitial pneumonia, as depicted on the chest images.
• A study performed in Germany demonstrated 3 major radiologic findings in
108 cases of confirmed RSV lower respiratory infection: normal chest
radiographic results (30%), central pneumonia (32%), and peribronchitis
(26%). Other findings were emphysema (11%), pleural effusion (6%),
bronchopneumonia (6%), atelectasis (5%), and pneumothorax (0.9%). Age-
specific differences were not confirmed. Sensitive laboratory testing to
confirm RSV infection and to rule out bacterial superinfection may explain
the differences between this study and previous ones.
 
 
                            
 Pneumonia cu virus SARS
• 3 distinctive radiographic patterns.
- the most common pattern (76.9%) was focal peripheral airspace disease at
presentation with gradual resolution. Some patients had normal radiographs
initially: 15.4% later developed focal airspace disease, and 7.7% had round
pneumonia, a rare finding confirmed with other studies. Bilateral disease
was seen in 53.8% of patients, and unilateral involvement was seen in
46.2%. All patients had mid- and lower-lung airspace disease, and 46.2%
had additional upper-lung infiltrates. No evidence of pleural thickening,
effusion, lymphadenopathy, cavities, or clinically significant airway changes
was found.
• A retrospective study of 62 children with SARS from Canada, Singapore,
and Hong Kong found normal chest radiographs in 35.5%. Prominent
radiologic findings in the remaining children were areas of consolidation
(ground-glass opacities or focal, lobar, or multifocal opacities; 45.2%), which
were often peripheral and in the lower lobes. Peribronchial thickening was
noted in 14.5%. Radiographic evidence of adenopathy was not seen.
According to the authors, radiography has 2 major roles in SARS: The first
is to depict pulmonary involvement in the suspected cases of SARS, and
the second is to show radiologic changes characteristic of other bacterial or
granulomatous diseases. Extensive pleural effusions, pneumothorax,
pneumatocele, lung abscess, cavitation, and adenopathy are uncommon
radiologic findings in SARS.
 Pneumonia cu VVZ
• The radiographic pattern is scattered, ill-defined, 5- to 15-mm
nodular opacities (acinar nodular pattern). These are confluent and
fleeting and identical in immunocompetent and
immunocompromised hosts. The nodules are seen in the lung
periphery (bases), coalescing near the hila; these probably reflect
contiguous spread from tracheobronchitis. Reticular markings,
pleural effusions, and hilar adenopathy are rarely seen.
• The radiographic manifestations usually appear 2-5 days after the
rash does. They tend to clear in 3-5 days in mild disease up to
several weeks or months in widespread disease.
• An apparently unique complication of acute VZV pneumonia
consists of the late appearance (years) of 2- to 3-mm dense
calcifications, which are well-defined, scattered, and predominant in
the lower half of the lungs. The frequency of these calcifications is
1.7-2% in adults with previous VZV pneumonia.