Case 2-5 - Pneumonia - Concepts

Front 1

Describe the classical presentation of pneumonia.

Back 1

• Sudden onset of fever
• Chills (the new hypothalamic set-point for temperature makes the patient feel cold until the new set-point is reached)
• Cough with or without purulent sputum
• Pleuritic chest pain
• Dyspnea

Front 2

What organisms are the usual culprits of pneumonia?

Back 2

Usually S. pneumoniae (in both immunocompetent and immunocompromised individuals)

H. influenzae, M. catarrhalis, S. aureus or gram-negative enteric bacteria may be the culprits.

Front 3

What tests could be done in a patient with pneumonia and productive cough?

Back 3

Gram-stain of sputum. The specimen must be adequate, meaning that it has to contain greater than 25 neutrophils and less than 10 squamous cells.

Front 4

This organism is the most likely cause of bacterial pneumonia complicated by ABSCESS FORMATION.

Back 4

S. aureus. It is the most destructive to lung tissue and most likely to cause cavitary lesions.

Front 5

Normal lungs are ________ below the first major bronchial divisions.

Back 5

sterile

Front 6

__________ and ________ are examples of bacteria that are deposited directly in the lower airways through inhalation of small airborne particles (tiny bacteria).

Back 6

M. tuberculosis; L. pneumophila

Front 7

The chest x-ray in classic pneumonia shows a ________ confined to a particular lobe of the lung that correlates with location of __________.

Back 7

focal consolidation; pleuritic chest pain (pleurisy)

Front 8

Consolidation refers to?

Back 8

There is alveolar infiltrates in a region of the lung, making it more *solid* to the touch. It consists of pathogens and the inflammatory exudate which is cell rich, containing inflammatory cells and proteins.

Front 9

List all the pulmonary defense mechanisms.

Back 9

• Starts in the nose; there is abrupt change in the direction of airflow in the nose, which potentially traps pathogens.
• Cough reflex.
• Ciliated respiratory epithelium.
• Humoral factors (Lysosyme, IgA in mucus or potentially IgG + C from the blood).
• Alveolar macrophages (and potentially neutrophils via diapedesis).
• Most extensive lymphatics in the entire body (lungs)

Front 10

Atypical pneumonia results from a more ________ process and include more prominent __________ symptoms with less ________ complaints.

Back 10

indolent; constitutional; pulmonary

Constitutional symptoms: Low-grade fever, myalgias, fatigue, arthralgias, headache, sore throat, skin rash.

Front 11

The cough in atypical pneumonia is typically _________.

Back 11

non-productive

Front 12

Atypical pneumonia is most commonly caused by __________.

Back 12

Mycoplasma pneumoniae (remember, no cell wall on this one)

Front 13

What organisms can cause atypical pneumonia other than the most common type?

Back 13

• C. pneumoniae
• Legionella (infected water like shower or the fine spray of water covering vegetables in a grocery store)
• M. tuberculosis
• Viruses such as Adenovirus, Parainfluenza, RSV
• Fungus such as Aspergillus, Coccidiomycosis, Histoplasmosis, Pneumocystic jirovecii

Front 14

The gram-stain procedure in atypical pneumonia is ________.

Back 14

less diagnostic.... it contains fewer neutrophils.

Front 15

The chest X-ray in atypical pneumonia ______, but will often show ___________.

Back 15

varies; bilateral patchy/interstitial infiltrates

Front 16

Animal exposure can cause pneumonia. Which organisms can be involved?

Back 16

• C. psitacci (birds)
• C. burnetii (animals)
• Hanta virus (rodents)

These three cause acute symptoms.

• C. neoformans (birds, like PIGEONS)

Causes more subacute and chronic symptoms.

Front 17

H. capsulatum is endemic in _______.

Back 17

Endemic in Mississippi & Ohio river valleys.

Front 18

What are some general risk factors for pneumonia?

Back 18

• Elderly
• Debilitated
• Immunocompromised

Front 19

What are some specific risk factors for pneumonia?

Back 19

• Chronic lung disease
• Chronic renal failure (uremic toxins [principally] is believed to suppress leukocyte function)
• Diabetes Mellitus
• Sickle cell disease

Front 20

These people are prone to aspiration pneumonia.

Back 20

• People with alcoholism
• Seizure disorders
• Chronic debilitating neurologic disorders

Front 21

Patients that are immunocompromised are prone to acquiring pneumonia. What people does this group include?

Back 21

• AIDS
• Patients on steroids (corticosteroids)
• Chemotherapeutics

Front 22

What patients should be admitted to the hospital for IV antibiotics when they have pneumonia?

Back 22

Patients:

• are older than 70 and have comorbid conditions such as renal, heart or lung disease
• cannot tolerate oral antibiotics
• have failed outpatient antibiotic therapy
• patients with empyema or large parapneumonic effusion
• patients with evidence of respiratory failure or sepsis

Front 23

Pleurisy is [...]?

Back 23

Infllammation of the pleura, characterized by pain on inspiration.

Front 24

What is parapneumonic effusion and empyema?

Back 24

• Parapneumonic effusion: The exudative response to pneumonia.
• Empyema: Frank pus. A parapneumonic effusion can itself become infected and become an empyema.

Front 25

Extrapulmonary manifestations may provide clues to the etiologic agents. What agents are implicated in cases of pneumonia with pharyngitis, erythema nodosum rash and diarrhea, respectively?

Back 25

• Pharyngitis = C. pneumoniae
• Erythema nodosum rash = Fungal, Mycobacterial
• Diarrhea = Legionella

Front 26

Community-acquired pneumonia in young, healthy adults usually is caused by one of the atypical organisms, such as _________, _____ or _______.

Back 26

Mycoplasma; chlamydia; a virus

Front 27

Smokers are more likely to harbor one of the typical bacterial pathogens (than healthy individuals, who would usually acquire an atypical pneumonia) such as ______, ______ and ________.

Back 27

S. pneumoniae; H. influenzae; M. catarrhalis

Front 28

When you can't tailor the antibiotic treatment for an atypical/typical community-acquired pneumonia, what is the first-line of treatment?

Back 28

Macrolides

Front 29

Gram-positive cocci in clusters are detected in the sputum of a patient with cavitary lesions in his lungs. What is the first-line treatment?

Back 29

Nafcillin or oxacillin

Front 30

For hospital-acquired pneumonia, antibiotic coverage needs to be _______ to cover resistant strains of ________, ______, _________, _________ and _________. What agents provide good coverage for these?

Back 30

expanded; streptococcus; staphylococcus; pseudomonas; gram-negative organisms; anaerobes

Imipenem & meropenem (carbapenems) with ultra-broad coverage.

Front 31

Despite their broad coverage, these drugs should not be used as first-line agents to avoid drug resistance ...

Back 31

Carbapenems: Imipenem and meropenem.

Front 32

These drugs have anti-pseudomonal activity.

Back 32

• Third-generation cephalosporin with anti-pseudomonal activity (e.g., cefepime, ceftazidime)
• Aminoglycosides (e.g. tobramycin, gentamicin)
• Anti-pseudomonal penicillins (e.g., ticarcillin, piperacillin)

Front 33

Mnemonic for the most common pathogens in classic pneumonia.

Back 33

H. influenzae + M. catarrhalis + S. pneumoniae
H + M + S. pneumoniae
He Must Breathe (pneumo/pneuma from Gr. breath; S. pneumoniae)

Front 34

In the case of classic pneumonia, a physical exam would reveal [...]? (6)

Back 34

• Tachypnea
• Tachycardia
• Hypoxia
• Focal rhonchi (low-pitched "snoring" sound heard during inspiration or expiration; due to secretions)
• Egophony (Creek for "voice of goat"): patient saying "E" sounds like "A"
•

Front 35

Two anatomical patterns of pneumonia?

Back 35

1. Bronchopneumonia: Begins as acute bronchitis and spreads locally into the lungs. Usually involves lower lobes or right middle lobe. Lung has patchy areas of consolidation (microabscesses are present in the areas of consolidation).
2. Lobar pneumonia. Complete or almost complete consolidation of a lobe of lung.

Front 36

A severe and dangerous complication of pneumonia.

Back 36

Sepsis

Front 37

________ can cause an atypical community-acquired pneumonia in newborns.

Back 37

C. trachomatis

Front 38

This pathogen can produce pneumonia in patients with respirators.

Back 38

P. aeruginosa