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    Pneumonia in Plab PDF

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    Beaulah
    1. Pneumonia is inflammation of the lungs that is usually caused by bacteria such as Streptococcus pneumoniae but can also be caused by viruses or fungi. 2. Symptoms include cough, sputum production, fever, and shortness of breath. Pneumonia can be classified as community-acquired, hospital-acquired, or occurring in immunocompromised patients. 3. Community-acquired pneumonia is the most common type and has many potential causes including bacteria, viruses, and fungi. It is important to consider a patient's risk factors, examine imaging and sputum/blood tests, and use severity scores like CURB-65 to guide treatment.

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    Pneumonia in Plab PDF

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    Beaulah
    120 views6 pages
    1. Pneumonia is inflammation of the lungs that is usually caused by bacteria such as Streptococcus pneumoniae but can also be caused by viruses or fungi. 2. Symptoms include cough, sputum production, fever, and shortness of breath. Pneumonia can be classified as community-acquired, hospital-acquired, or occurring in immunocompromised patients. 3. Community-acquired pneumonia is the most common type and has many potential causes including bacteria, viruses, and fungi. It is important to consider a patient's risk factors, examine imaging and sputum/blood tests, and use severity scores like CURB-65 to guide treatment.

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    1. Pneumonia is inflammation of the lungs that is usually caused by bacteria such as Streptococcus pneumoniae but can also be caused by viruses or fungi. 2. Symptoms include cough, sputum production, fever, and shortness of breath. Pneumonia can be classified as community-acquired, hospital-acquired, or occurring in immunocompromised patients. 3. Community-acquired pneumonia is the most common type and has many potential causes including bacteria, viruses, and fungi. It is important to consider a patient's risk factors, examine imaging and sputum/blood tests, and use severity scores like CURB-65 to guide treatment.

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    120 views6 pages

    Pneumonia in Plab PDF

    Uploaded by

    Beaulah
    1. Pneumonia is inflammation of the lungs that is usually caused by bacteria such as Streptococcus pneumoniae but can also be caused by viruses or fungi. 2. Symptoms include cough, sputum production, fever, and shortness of breath. Pneumonia can be classified as community-acquired, hospital-acquired, or occurring in immunocompromised patients. 3. Community-acquired pneumonia is the most common type and has many potential causes including bacteria, viruses, and fungi. It is important to consider a patient's risk factors, examine imaging and sputum/blood tests, and use severity scores like CURB-65 to guide treatment.

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    PLABMASTER

    Learn With Logic


    www.plabmaster.com
    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.

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