By
Funom Makama
Inflammation of the lung is called Pneumonia. Pneumonias may be
caused by specific pathogens like Pneumococcus or Klebsiella or by mixed
flora which reach the lungs due to aspiration of infected material from
the upper respiratory passages, stomach or exterior. The latter group
is called aspiration pneumonia. Pneumococcal pneumonia is the commonest
type in adults.
Other Organisms causing Pneumonia
Staphylococcal Pneumonia
This is more frequently seen in debilitated subjects and in hospitalized patients. Respiratory viral infections predispose to staphylococcal pneumonia. This is a dreaded complication in children with cystic fibrosis and in patients receiving immunosuppressant therapy. The organisms reach the lung through the blood stream (Pyemia) or along the respiratory passages.
Clinical features: The onset is with mild symptoms, but soon the condition worsens to produce grave toxemia, purulent and blood stained sputum and cyanosis. The lesions are generally multiple, giving rise to thin-walled abscesses. It may frequently spread to the pleura to produce emphysema or pyo-pneumothorax. Signs of lobar consolidation may not be evident. Diagnosis should be suspected from the clinical setting and the presence of toxemia fat out of proportion to the pulmonary signs. Gram-staining of sputum and culture reveal the organisms. Mortality varies from 20-25%.
Treatment: At present most strains of hospitalized-acquired staphylococci produce penicillinase. Hence penicillinase-resistant drugs such as Cephalothin, cloxacillin or vancomycin may be necessary. Early diagnosis and prompt treatment ensures cure.
Klebsiella Pneumonia (Friedlander's Pneumonia)
This is a grave illness seen in patients above the age of 40 years. Debilitating diseases, alcoholism, and malnutrition predispose this condition. Common site of involvement is the posterior segment of the upper lobe. The condition sets in with sudden chills, rigors, fever, dyspnea and cough with gelationous thick sputum streaked with blood. The course may be subacuate or fulminant and fatal. Abscess formation is a common complication. Mortality is high, ranging around 30%.
Treatment
Once the condition is suspected, urgent treatment with Cephalexin 1g, 6h, intramuscular administration should be started. Gentamicin in a dose of 5-8mg/Kg may be added as a second antibiotic. Treatment may have to be continued for 2 weeks or more to ensure cure.
Mycoplasma Pneumonia (Primary atypical pneumonia, Eaton agent Pneumonia, Cold- agglutinin-positive Penumonia)
This is caused by Mycoplasma Pneumoniae which is a bacterium devoid of cell wall. It spreads in closed communities and in families through the respiratory secretions. Clinically, it may present as
• Tracheobronchitis or
• Pneumonia (in 30%).
The disease starts insidiously with lassitude, headache, myalgia, and chest pain. Expectoration is scanty. Hemoptysis may occur. Physical examination of the chest may reveal only minimal findings. The Skiagram shows extensive lesions, not made out clinically. Over 50% of patients develop cold agglutinins in their serum in a dilution of 1:32 or more by the second week. These nonspecific antibodies agglutinate human 0 group erythrocytes at 4 degrees. These antibodies may be present for long periods. Complement fixation tests help in demonstrating specific antibodies. Tetracycline and erythromycin are effective against this organism.
Aspiration Pneumonia (Nonspecific Pneumonia)
Infective material may be aspirated into the trachea and bronchi.
Causes predisposing to aspiration
1. Conditions which suppress the cough reflexes, eg, coma, alcoholic intoxication, general anaesthesia.
2. Spillover of pus or gastric contents into the respiratory tract, eg, sinusitis, tonsillitis, achalasia cardia, pharyngeal paralysis, tracheo-oesophageal fistula.
3. Violent contraction of abdominal muscles forcing gastric contents into the respiratory tract eg, epilepsy, tetanus.
4. Aspiration from outside, eg, drowning.
Microbial flora is mixed, depending on the source of infection. The pulmonary lesion may be a localized massive pneumonia or a bronchopneumonia.
Clinical features: Aspiration of large volumes presents as pulmonary collapse or as pneumonia. In the presence of any of the predisposing factors, aspiration pneumonia should be suspected. Right lower lobe is more often affected because of the disposition of its bronchus. The upper lobe is also not infrequently involved in alcoholics and comatose subjects. If the obstruction is not removed by coughing or by other means the consolidation tends to persist and proceed to lung abscess. So also, aspiration pneumonia tends to recur if the primary cause is not removed.
Treatment: The general principles of treatment of Pneumonia are applicable. In addition, prompt attention should be given to clear the respiratory passages of obstructing material. This can be achieved by postural drainage, physiotherapy to the chest to encourage coughing, suction using a mechanical sucker, or by bronchoscopic aspiration.
Other Organisms causing Pneumonia
Staphylococcal Pneumonia
This is more frequently seen in debilitated subjects and in hospitalized patients. Respiratory viral infections predispose to staphylococcal pneumonia. This is a dreaded complication in children with cystic fibrosis and in patients receiving immunosuppressant therapy. The organisms reach the lung through the blood stream (Pyemia) or along the respiratory passages.
Clinical features: The onset is with mild symptoms, but soon the condition worsens to produce grave toxemia, purulent and blood stained sputum and cyanosis. The lesions are generally multiple, giving rise to thin-walled abscesses. It may frequently spread to the pleura to produce emphysema or pyo-pneumothorax. Signs of lobar consolidation may not be evident. Diagnosis should be suspected from the clinical setting and the presence of toxemia fat out of proportion to the pulmonary signs. Gram-staining of sputum and culture reveal the organisms. Mortality varies from 20-25%.
Treatment: At present most strains of hospitalized-acquired staphylococci produce penicillinase. Hence penicillinase-resistant drugs such as Cephalothin, cloxacillin or vancomycin may be necessary. Early diagnosis and prompt treatment ensures cure.
Klebsiella Pneumonia (Friedlander's Pneumonia)
This is a grave illness seen in patients above the age of 40 years. Debilitating diseases, alcoholism, and malnutrition predispose this condition. Common site of involvement is the posterior segment of the upper lobe. The condition sets in with sudden chills, rigors, fever, dyspnea and cough with gelationous thick sputum streaked with blood. The course may be subacuate or fulminant and fatal. Abscess formation is a common complication. Mortality is high, ranging around 30%.
Treatment
Once the condition is suspected, urgent treatment with Cephalexin 1g, 6h, intramuscular administration should be started. Gentamicin in a dose of 5-8mg/Kg may be added as a second antibiotic. Treatment may have to be continued for 2 weeks or more to ensure cure.
Mycoplasma Pneumonia (Primary atypical pneumonia, Eaton agent Pneumonia, Cold- agglutinin-positive Penumonia)
This is caused by Mycoplasma Pneumoniae which is a bacterium devoid of cell wall. It spreads in closed communities and in families through the respiratory secretions. Clinically, it may present as
• Tracheobronchitis or
• Pneumonia (in 30%).
The disease starts insidiously with lassitude, headache, myalgia, and chest pain. Expectoration is scanty. Hemoptysis may occur. Physical examination of the chest may reveal only minimal findings. The Skiagram shows extensive lesions, not made out clinically. Over 50% of patients develop cold agglutinins in their serum in a dilution of 1:32 or more by the second week. These nonspecific antibodies agglutinate human 0 group erythrocytes at 4 degrees. These antibodies may be present for long periods. Complement fixation tests help in demonstrating specific antibodies. Tetracycline and erythromycin are effective against this organism.
Aspiration Pneumonia (Nonspecific Pneumonia)
Infective material may be aspirated into the trachea and bronchi.
Causes predisposing to aspiration
1. Conditions which suppress the cough reflexes, eg, coma, alcoholic intoxication, general anaesthesia.
2. Spillover of pus or gastric contents into the respiratory tract, eg, sinusitis, tonsillitis, achalasia cardia, pharyngeal paralysis, tracheo-oesophageal fistula.
3. Violent contraction of abdominal muscles forcing gastric contents into the respiratory tract eg, epilepsy, tetanus.
4. Aspiration from outside, eg, drowning.
Microbial flora is mixed, depending on the source of infection. The pulmonary lesion may be a localized massive pneumonia or a bronchopneumonia.
Clinical features: Aspiration of large volumes presents as pulmonary collapse or as pneumonia. In the presence of any of the predisposing factors, aspiration pneumonia should be suspected. Right lower lobe is more often affected because of the disposition of its bronchus. The upper lobe is also not infrequently involved in alcoholics and comatose subjects. If the obstruction is not removed by coughing or by other means the consolidation tends to persist and proceed to lung abscess. So also, aspiration pneumonia tends to recur if the primary cause is not removed.
Treatment: The general principles of treatment of Pneumonia are applicable. In addition, prompt attention should be given to clear the respiratory passages of obstructing material. This can be achieved by postural drainage, physiotherapy to the chest to encourage coughing, suction using a mechanical sucker, or by bronchoscopic aspiration.
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