A 38-year-old patient with Mycoplasma pneumonia. Chest

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APPROACH TO DIAGNOSIS AND MANAGEMENT OF ATYPICAL
PNEUMONIA

• DR.K.B.GUPTA
• TB AND RESPIRATORY /PULMONARY MEDICINE
• POST GRADUATE INSTITUTE OF MEDICAL SCIENCES
• UNIVERSITY OF HEALTH AND MEDICAL EDUCATION
  ROHTAK-HARYANA

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GREETINGS FROM HARYANA
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POST GRADUATE INSTITUTE OF MEDICAL SCIENCES,
ROHTAK
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PNEUMONIA

• Common cause of infection related mortality and
  is one of the most important challenges in
  clinical medicine.

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DEFINITION

• Inflammation of pulmonary parenchyma caused by
  an infectious agent.

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CAP

• Assessed for severity by PORT Pneumonia outcome
  resource team Severity Index PSI North
  American Practice Guidelines
• 50--No pathogen is identifiedAtypical
  pneumonia.
• 15--Atypical pathogens identified.
• Undiagnosed CAP--Atypical /Aspiration

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PNEUMONITIS

• Infectious
• Non-infectious
• VARIETY OF EPONYMS attached with various
  pneumonia reflect the epidemiology of the process
  and likely causative organism e.g.
• CAPTypical Pneumonia/Atypical Pneumonia/Aspiratio
  n Pneumonia
• Pneu. in elderly
• Nosocomial--VAP/HAP/Health care facility
  pneumonia
• IC Host
• Cystic Fibrosis and Anatomical disorders

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MORTALITY

• 10-15 -due to predisposing factors
• Alcohol
• Elders
• Leucopenia
• CHF
• CAD
• DM
• IC
• Neurological diseases
• Active malignancy
• Hemodynamic instability
• Hypothermia
• Hypoalbuminemia
• Liver diseases

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CLINICAL SUSPECTS OF ATYPICAL PNEUMONIA

• A subgroup of CAP having S/A presentation, milder
  clinical S/S i.e. minimal sputum
• Does not reveal a predominant microbiology on
  routine smear like Grams stain or ZN staining or
  culture.
• Patchy infiltration/interstitial pattern on
  skiagram
• Lesser leuKocytosis
• Afebrile or mild fever

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CLINICAL SUSPECTS OF ATYICAL PNEUMONIA contd.

• 60CAP-Atypical Pneumonia
• Consists of heterogeneous entities
• 25-Mycoplasma
• 30-Resp viruses
• 25-Chlymadia
• Depends upon season and prevalence of resp
  viruses

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ATYPICAL

• Atypical organisms
• Atypical clinical presentation
• Atypical radiological presentation
• Atypical clinical course- slowly resolving
• -non resolving
• Atypical population and age group

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ATYPICAL PNEUMONIA

• Atypical pathogens
• --inability to grow on routine bacterial culture
• --prominence of nonproductive cough
• --response to macrolide therapy

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CAUSES

• Mycoplasma- M.Pneumoniae
• Chlamydophila-
• C.psittaciPsittacosis,
• C.pneumoniae
• Resp tract virus-
• influenza,
• adenovirus,
• RSV,
• Parainfluenzae virus
• Bacteria-
• Legionella,
• F. Tularemia,
• Coccidiodes,
• Pneumocystis.

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CAUSES contd.

• Aspiration pneumonitis- Sterile or mixed upper
  respiratory and oral flora
• Other viral agents
• Varicella zoster, measles,
• E.B.Virus,
• CMV,
• Metopneumo virus,
• Hantavirus.
• Rickettesia- C. Burnetti Q fever

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CLINICAL FEATURES

• COMMON SYMPTOMS
• -Chills
• -fever-mild
• -cough-dry/min expt
• -heamoptysis
• -muscle stiffness and aching
• -rapid breathing
• -shortness of breath
• -loss of appetite
• -malaise
• -confusion(specially with Legionella)
• -rash(Mycoplasma)
• -diarrhoea(Legionella)

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ATYPICAL PNEUMONIA-SIGNS

• Minimal
• Few crackles
• Rhonchi
• Exhaustion
• Low grade fever

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ATYPICAL PNEUMONIA-LAB TESTS

• FBC
• Mild elevated WBC
• U Es
• low serum Na(Legionella)
• Deranged LFTs
• ?ALT
• ?Alk Phos
• Cold aggulitinins (Mycoplsma)
• Atypical serology

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CHLAMYDIA- WALKING PNEUMONIA

• 12-21 of Atypical Pneumonia
• Spread from persons to person
• Young age
• Onset- gradual, mild, malaise, fever,
• headache, sore throat, skin rashes and dry
  cough and bullous myringitis
• Long incubation period
• Chl. tracomatis-newborns

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CHLAMYDIA-WALKING PNEUMONIA contd.

• C.psittacis- Avian-Human parakeet and parrot
• BRADICARDIA AND HEPATOSPLENOMEGALY
• HEPATIC DYSFUNCTION

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CHLAMYDIA-WALKING PNEUMONIA contd.

• DIAGNOSIS
• -Serological tests preferred diagnostic
  result is 4 fold rise in titers from acute to
  convalescent stage
• - PCR test- not standardized
• - cell culture- not routinely available
• TREATMENT
• -Doxycycline, macrolide or a fluoroquinolone

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A 40-year-old patient with Chlamydia pneumonia
a 45-year-old patient with Chlamydia pneumonia
Illustrations from emedicine Radiology
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Q FEVER

• Abnormal transmission from contaminated
  placental and birth fluids of cattle
• Acute onset
• Long incubation period
• Clinical hepatitis

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LEGIONELLA

• Rare 2-4
• Outbreak-summer
• Use of A/C, Cooler, etc
• Acute onset, High mortality
• Extra pulmonary symptoms-bradycardia, diarrhoea,
  confusion, renal dysfunction, acute
  rhabdomyolysis, hepatic dysfunction, chills and
  rigors

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LEGIONELLA contd.

• Risk factors
• -smoking
• -chronic lung disease
• -immunosupression
• -surgery-transplant pts

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LEGIONELLA contd.

• Diagnosis
• --Culture -definitive diagnostic test
• -specialized medium
• -- Legionella urine antigen test
• -rapid
• -inexpensive
• -sensitivity 70 and specificity95
• --Direct fluororescent antibody test
• --Serologic Tests
• --PCR assay-serum, urine, BAL fluid

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LEGIONELLA contd.

• TREATMENT
• Delayed treatment increases mortality
• Macrolides, Quinolones
• Rifampin in combination with Macrolides or
  Quinolones in severily ill patients
• Duration 10-14 days(21 days for immunosupressed)

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A 53-year-male with severe Legionella pneumonia.
a 66-year-old patient with Legionella pneumonia
Illustrations from emedicine Radiology
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MYCOPLASMA PNEUMONIA

• Prevalence 2-30
• Endemic, punctuated by epidemic occurring at
  4-7yrs intervals
• Highest prevalence in child 5-9yrs
• Outbreaks military bases, summer camps and
  schools

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MYCOPLASMA PNEUMONIA contd.

• Clinical features
• Prodromal symptoms
• Pulmonary
• -tracheobronchitis,
• -sore throat, headache, chills, coryza,
• -hemorrhagic bullous myringitis
• -cough nonproductive/min productive
• -transient bronchial hyperreactivity

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MYCOPLASMA PNEUMONIA contd.

• Extrapulmonary
• -CNS-cranial nerve palsies, cerebral ataxia,
  meningoenchephalitis, peripheral neuropathy and
  transverse myelitis.
• -Hematologic - IgM antibodies
• -Dermatologic- rash, maculopapular or vesicular,
  S J Syndrome
• -Cardiac-myocarditis, pericarditis, CHF,
  hemopericardium
• -GI Nausea and vomiting , diarrhea,
  pancreatitis

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MYCOPLASMA PNEUMONIA cont.

• Diagnosis-
• Culture-limited utility, fastidious growth
  requirements, long incubation period
• Cold agglutinin titers- gt164 support diagnosis
• lacks sensitivity and specificity, response
  develops in 7-10 days after onset of symptoms and
  peaks at 3wks
• PCR

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MYCOPLASMA PNEUMONIA cont.

• TREATMENT
• Macrolide/Tetracycline
• 2-3weeks therapy

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A 38-year-old patient with Mycoplasma pneumonia.
Chest computed tomography scan in the same
patient shows the ill-defined, airspace
infiltrate in the left lower lobe better than
skiagram chest does. .
Illustrations from emedicine Radiology
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BACTERIAL ATYPICAL Pn

• Tularemia, Plague, Anthrax -Uncommon, epid.
  Exposure.
• Tularemia-Contact with tissue of an infected
  animal(rabbit),animal bites(cat),infected
  aerosol, tick bite, deerfly bite or ingestion
  of water and poorly cooked meat.
• Plague- H/O visit to an endemic area
• septicemia
• painful localized LAP with fever
• H/O bite by rodent fleas or handling of
  tissue of infected animals
• 10-15Pneumonia in plague
• Primary inhalation plague is very rare
• 3. Anthrax- inhalation of aerosol from any
  infected animal

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PULMONARY MYCOSIS-AMERICA

• HISTO-
• -Endemic area of U.S.A.(Travel)
• -Soil contaminated with bat, pigeon,chicken
  excreta
• -Aerosol
• BLASTO-
• -Endemic
• -Extra pulmonary manifestation-ulcerative
  skin lesion
• -Aerosol

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PULMONARY MYCOSIS-AMERICA

• Coccidio-
• -Endemic
• -Aerosol-arthrospore
• -Archeological Digs
• -Erythroderma nodosum
• Paracoccidiomycosis-
• Bragil, Columbia,Argentina,Venejuala

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ASPIRATION PNEUMONIA

• Gradual onset
• Gastric aspirate
• Bronchial aspirate
• Predisposing factors-
• -alcohol
• -nocturnal acid reflux
• -pyorrhea
• -prolonged session in dental chair
• -epilepsy
• -chronic sinusitis

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ASPIRATION PNEUMONIA Contd

• Progress to necrotizing pneumonia if left
  untreated Putrid Empyema
• Usually anaerobes or mixture of aerobes and
  anaerobes
• Rarely actinomycosis
• Bronchogenic carcinoma
• Klebssiella p neumonia
• Other gram negative bacteria

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PNEUMONIA IN ELDERLY

• gt60yrs
• Home
• N. home
• HCAP-Nosocomial infection with increased rate of
  antibiotic resistance

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CLINICAL FEATURES

• Gradual onset
• Weakness
• Mental confusion
• Less fever / CE

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FLORA

• S.Pneumoniae
• H. influenzae
• M.catarrhalis

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ATYPICAL PNEUMONIA IN CHILDHOOD

• Mycoplasma-
• -- gt80of all pneumonia in school age group
• --Diagnosis by R.T. PCR
• --Common in crèches/day care centers under
  5yrs age group
• --Extra pulmonary skin lesion- mild rashes
  to fatal SJ Syndrome, CNS,
  Blood dyscrasia, cardiac, hepatic,
  joints
• --Sickle cell anemic children acute chest
  syndrome
• --Cold agglutinins
• --Increased IgM

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ATYPICAL PNEUMONIA IN CHILDHOOD contd.

• Chlamydia- 10in lt5yrs age
• -Milder
• -Pharyngitis
• Legionella- (2-52)
• -IC Host

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DIAGNOSIS

• Direct isolation of the organism- not performed
• .Due to specialized culture technique
• .Hazardous nature of the some organisms
• except Legionella DIETERLE silver stain and
  direct fluorescent antibody staining. Can be
  culture routinely

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DIAGNOSIS contd.

• Serological Tests-definitive diagnosis
• 1. M.pneumoniaecomplement fixation test, IgM by
  latex agglutination or ELISA, cold agglutinins.
• 2. L.pneumophila rapid microagglutination test,
  test for Legionella antigen in the urine.
• 3. Chlamydia spp.microimmunoflourescence, ELISA
• 4.Coxiella burnetticomplement fixation test
• Four fold rise in titer between acute and
  convalescent phase is confirmatory.

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DIAGNOSIS contd.

• Skin testing
• -Histoplasmosis and Coccidiodomycosis
• -Performed only if previous skin test is
  negative

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Comparative Epidemiological features of the
Atypical Pneumonia
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Comparative Epidemiological features of the
Atypical Pneumonia contd.
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Comparative Epidemiological features of the
Atypical Pneumonia contd.
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Clinical, Radiological, and Laboratory Features
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Clinical, Radiological, and Laboratory Features
cont.
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Clinical, Radiological, and Laboratory Features
cont.
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DIFFERENTIAL DIAGNOSES

• ARDS (Acute Respiratory Distress Syndrome)
• BOOP (Bronchilitis Obliterans Organizing
  Pneumonia)
• Empyema
• Drug Induced Lung Disease
• Pulmonary Tuberculosis
• Typical
• Atypical

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DIFFERENTIAL DIAGNOSES CONT.

• Atypical Bacterial Pneumonia,
• PCP
• Typical Bacterial Pneumonia,
• Viral Pneumonia,
• Others-
• Hypersensitivity pneumonitis
• Fungal pneumonia
• Vasculitis
• Collagen vascular disease

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NON-RESOLVING AND SLOWLY RESOLVING
PNEUMONIA(INAPPARENT RESOLUTION OF PULMONARY
INFILTERATES) A DIAGNOSTIC CHALLENGE

• PREVALENCE -25 OF ALL PNEUMONIAS
• -10 0F HOSPITALIZED CAP
• -60 OF NOSOCOMIAL
• COMPONENTS-
• NO CLINICAL IMPROVEMENT
• MICROBIOLOGICAL PERSISTENT
• NO/DELAYED RADIOGRAPHIC RESOLUTION

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Contd.

• DEFINITION--
• lt50 CLEARANCE AT 2WKS OR COMPLETE CLEARANCE AT 4
  WKS
• SLOW RESOLUTION OF RADIOGRAPHIC INFILTRATE OR
  CLINICAL SYMPTOMS DESPITE 10 DAYS ADEQUATE A/B
  THERAPY
• CAUSES--
• NON-INFECTIOUS
• MIS ADVENTURES OF ANTIMICROBIAL THERAPY
• INADEQUACIES OF HOST DEFICIENCIES

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Contd.

• RISK FACTORS
• HOST ABNORMALITIES-
• ADVANCE AGE
• COPD, AND
• ALCOHOLISM
• COMORBIDITY- COPD, ASTHMA
• IMMUNOSUPRESSION
• STERIODS
• FUNGAL INFECTIONS

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DIAGNOSTIC ALGORITHM FOR EVALUATION OF
NONRESOLVING PNEUMONIA
RE-EVALUATE HOST FACTORS ELDERLY? ALCOHOL? CORTICO
STERIODS? COPD?
REVIEW MICROBIOLOGICAL DATA CULTURE
RESULTS ANTIBIOTIC SUSCEPTIBILITY DATA
REPEAT CXR
CT SCAN
REPEAT RESPIRATORY SAMPLING BRONCHOSCPIC OR
MIN-BAL
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ATYPICAL ORGANISMSIN NR/DELAYED RES PN

• LEGIONELLA- ELDERLY AND CHRONICALLY ILL PTS
• MYCOPLASMA- YOUNGER PTS
• CHLAMYDIA- AS A PART OF MIXED INFECTIONS

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CONCLUSIONS

• Atypical pneumonia is to be suspected in a group
  of CAP having sub acute presentation, min
  clinical symptoms, without predominant
  microbiology on routine smear, patchy
  infiltrates/interstitial pattern on skiagram with
  milder leukocytosis.
• Usual pathogens are Mycoplasma, Chlamydia
  ,Legionella and respiratory viruses.

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CONCLUSIONS contd.

• 3. Elderly individuals smokers, alcoholic,
• underlying chronic illness and weak immune
  system are at higher risks.
• 4. Identification of epidemiological factors
  like-
• -exposure to infected animals or their sources,
  air cooling system, viral epidemics are also
  helpful in diagnosis.
• 5. The definitive diagnosis usually requires
  retrospective serologic tests.
• Thus known epidemiologic factors and positive
  serological tests are key for diagnosis.

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CONCLUSIONS contd.

• 6.Treatment- usually responds to Macrolides,
  Fluoroquinolones and sometimes to Tetracyclines.
• 7.They may also cause delayed or non-resolution
  of pneumonia specially in elderly, alcoholics,
  pts on steroids and underlying COPD.

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THANK YOU