Pneumonia

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Pneumonia
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Definition

• Pneumonia is an acute infection of
  the
• parenchyma of the lung(???),
  caused by
• bacteria, fungi(??), virus,
  parasite(???) etc.
• Pneumonia may also be caused by
  other factors
• including X-ray, chemical,
  allergen

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Epidemiology

• The morbidity and mortality of pneumonia are high
  especially in old people.

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Etiology

• There are two factors involved in the formation
  of pneumonia , including pathogens and host
  defenses.

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Classification

• Classification of anatomy
• Classification of pathogen
• Classification of acquired environment

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?.Classification by pathogen

• Pathogen classification is the most useful
• to treat the patients by choosing
  effective
• antimicrobial agents

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Bacterial pneumonia

• (1) Aerobic Gram-positive bacteria,such
• as streptococcus pneumoniae, staphy-
• lococcus aureus, Group A hemolytic
• streptococci
• (2) Aerobic Gram-negative bacteria, such
• as klebsiella pneumoniae, Hemophilus
• influenzae, Escherichia coli
• (3) Anaerobic bacteria

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Atypical pneumonia

• Including Legionnaies pneumonia ,
• Mycoplasmal pneumonia ,chlamydia pneumonia.

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Fungal pneumonia

• Fungal pneumonia is commonly caused by
  candida(???) and aspergilosis(??).
• pneumocystis jiroveci(????)

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Viral pneumonia

• Viral pneumonia may be caused by adenoviruses,
  respiratory syncytial
• virus, influenza, cytomegalovirus,
• herpes simplex

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Pneumonia caused by other pathogen

• Rickettsias (a fever rickettsia),
• (????)
• parasites(???)
• protozoa(??)

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?.Classification by anatomy

• 1. Lobar(???) Involvement of an entire lobe
• 2. Lobular(???) Involvement of parts of the
  lobe only, segmental or of alveoli contiguous to
  bronchi (bronchopneumonia).
• 3. Interstitial(???)

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Lobar pneumonia
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Lobular pneumonia
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Interstitial pneumonia
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Classification by acquired environment

• Community acquired pneumonia,CAP
• (???????)
• Hospital acquired pneumonia,HAP ,NP
• (???????)
• Nursing home acquired pneumonia,NHAP
• (????????)
• Immunocompromised host pneumonia,(ICAP)
• (????????)

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Diagnosis(????)

• Give a definite diagnosis of pneumonia
• To evaluate the degree of the pneumonia
• To definite the pathogen of the pneumonia

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Diagnosis

• History and physical examination(5W)
• X-ray examination
• Pathogen identification

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Differentiation

• Pulmonary tuberculosis
• Lung cancer
• Acute lung abecess
• Pulmonary embolism
• Noninfectious pulmonary infiltration

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Pathogen identification

• Sputum More than 25 white blood cells (WBCs) and
  less than 10 epithelial cells.
• Nasotracheal suctioning
• BAL, ETA, PSB, LA
• Blood culture or pleural effusion culture
• Serologic testing (immunological testing)
• Molecular Techniques

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The principal of therapy

• Select antibiotics
• According to guideline

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Therapy

• The therapy should always follow confirmation of
  the diagnosis of pneumonia and should always be
  accompanied by a diligent effort to identify an
  etiologic agent.
• Empiric therapy,(4-8h)
• Combined empiric therapy to target therapy

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It is important to evaluate the severity degree
of pneumonia

• The critical management decision is whether the
  patient will require hospital admission. It is
  based on patient characteristics, comorbid
  illness, physical examinations, and basic
  laboratory findings.

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The diagnostic standard of sever pneumonia

• Altered mental status
• Pa02lt60mmHg. PaO2/FiO2lt300, needing MV
• Respiratory rategt30/min
• Blood pressurelt90/60mmHg
• Chest X-ray shows that bilateral infiltration,
  multilobar infiltration and the infiltrations
  enlarge more than 50 within 48h.
• Renal function Ult20ml/h, and lt80ml/4h

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CAP (???????)

• CAP refers to pneumonia acquired outside of
  hospitals or extended-care facilities .
• Streptococcus pneumoniae remains the most
  commonly identified pathogen.
• Other pathogens include Haemophilus influenzae,
  mycoplasma pneumoniae, Chlamydophilia pneumoniae,
  Moraxella catarrhalis and ects.
• Drug resistance streptococcus pneumoniae(DRSP)

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Clinical manifestation

• The onset is accute
• Respiratory symptoms
• Extrapulmonary symptoms

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signs

• Consolidation signs
• Moist rales
• Respiratory rate or heart rate

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Laboratory examination

• WBC
• X-ray features

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Diagnosis

• Clinical diagnosis
• Pathogen diagnosis
• Evaluate the severity degree of pneumonia

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Therapy

• Antiinfectious therapy(Combined empiric therapy
  to target therapy)
• Supportive therapy

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Empiric therapy (1)

• Outpatientlt60 years old and no comorbid diseases
• Common pathogens S pneumoniaes, M
  pneumoniae, C pneumoniae, H
  influenzae and viruses

• A new generation macrolide
• A beta-lactam the first generation cephlosporin
• A fluoroquinolone

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Empiric therapy (2)

• Outpatientgt65 years old or having comorbid
  diseases or antibiotic therapy within last 3
  months
• Common pathogens S pneumoniae(drug-resistant), M
  pneumoniae, C pneumoniae, H pneumoniae, H
  influenzae, Viruses, Gram-negative bacilli and S
  aureus

• A fluoroquinolone
• A beta-lactam / beta-lactamase inhibitor
• The second generation cephalosporin
• or combination of a macrolide

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Empiric therapy (3)

• Inpatient Not severely ill.
• Common pathogenS pneumoniae, H influenzae,
  polymicrobial, Anaerobes, S aureus, C pneumoniae,
  Gram-negative bacilli.

• The second or third generation cephalosporin plus
  A macrolide
• A beta-lactam/betalactamase inhibitor.
• A newer fluoroquinolone

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Empiric therapy (4)

• Inpatient severely ill
• Common pathogensS pneumoniae, Gram-negative
  bacilli, M pneumoniae, S aureus and viruses

• The second or third generation cephalosporin plus
  A macrolide
• A beta-lactam/betalactamase inhibitor.
• A newer fluoroquinolone
• Vancomycin

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Empiric therapy (5)

• Patients in ICU without Pneudomonas aeruginosa
  infection

• The second or third generation cephalosporin plus
  A macrolide
• A beta-lactam/betalactamase inhibitor.
• A newer fluoroquinolone
• Vancomycin

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Empiric therapy (6)

• Patients in ICU with Pneudomonas aeruginosa
  infection

• A antipneudomonas aeruginosa beta-lactam/betalacta
  mase inhibitor plus fluoroquinolone

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HAP(???????)

• HAP refers to pneumonia acquired in the hospital
  setting.
• Enteric Gram-negative organisms, S. aureus,
  Pneudomonas aeruginosa, ects.

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The pathogen of HAP

• Gram-negative bacteria (GNB) account for 55 to
  85 of HAP infections
• gram-positive cocci account for 20 to 30 and
  some other pathogens.

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EPIDEMIOLOGY

• General risk factors for developing HAP include
  age more than 70 years, serious comorbidities,
  malnutrition, impaired consciousness, prolonged
  hospitalization, and chronic obstructive
  pulmonary diseases.

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EPIDEMIOLOGY

• HAP is the most common infection occurring in
  patients requiring care in an intensive care
  unit (ICU), with incidence rates ranging from 6
  up to
• 52, much higher than the 0.5 to 2
  incidence reported for hospitalized patients as a
  whole.
• This increased incidence is due to the fact
  that patients located in an ICU often require
  mechanical ventilation, and mechanically
  ventilated patients are 6 to 21 times more likely
  to develop HAP than are nonventilated patients.
  Mechanical ventilation is associated

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PATHOGENESIS

• Aspiration Microaspiration of contaminated
  oropharyngeal secretions seems to be the most
  important of these factors, as it is the most
  common cause of HAP.
• Inhalation
• Contamination

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Clinical manifestations

• The onset is acute or insidious
• Respiratory symptoms
• Physical signs

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Laboratory examinations

• Chest X-ray

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diagnosis

• Clinical diagnosis
• Pathogen diagnosis
• Evaluate the severity degree of pneumonia

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Treatment (1)

• Antibiotic therapy antimicrobial therapy begin
  promptly because delays in administration of
  antibiotics have been associated with worse
  outcomes.
• The initial selection of an antimicrobial agent
  is almost always made on an empiric basis and is
  based on factors such as severity of infection,
  patient-specific risk factors, and total number
  of days in hospital before onset.

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Treatment (2)

• All empiric treatment regimens should include
  coverage for a group of core organisms that
  includes aerobic gram negative bacilli
  (Enterobacter spp, Escherichia coli, Klebsiella
  spp, Proteus spp, Serratia marcescens, and
  Hemophilus influenzae) and gram-positive
  organisms such as Streptococcus pneumoniae and
  Staphylococcus aureus.

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Treatment (3)

• In patients with mild or moderate infections and
  no specific risk factors for resistant or
  unusual pathogens, monotherapy with a
  second-generation cephalosporin such as
  cefuroxime a nonpseudomonal third-generation
  cephalosporin such as ceftriaxone or a
  beta-lactam/beta-lactamase inhibitor such as
  ampicillin/sulbactam, ticarcillin/clavulanate, or
  piperacillin/tazobactam may be appropriate.
• For patients in this low-risk category who have
  an allergy to penicillin, it is appropriate to
  initially use a fluoroquinolone

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Treatment (4)

• Patients with severe infections with specific
  risk factors should have broadened empiric
  coverage.
• Combination therapy should be employed in these
  cases because of the high rate of acquired
  resistance among these organisms.
• Appropriate combinations for this group of
  patients include an aminoglycoside or
  ciprofloxacin in addition to a beta-lactam with
  antipseudomonal coverage.
• Additionally, vancomycin should be considered if
  the patient has risk factors that suggest
  methicillin-resistant Staphylococcus aureus could
  be a pathogen.

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Prevention

• Release aspiration
• Washing hands
• vaccination

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ICHP (????????)

• Pneumonia in an immunocompromised host describes
  a lung infection that occurs in
• a person whose ability to fight infection is
  greatly impaired.
• (Non-HIV-ICH)

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Causes, incidence, and risk factors

• Immunosuppression can be caused by HIV infection,
  leukemia, organ transplantation, bone marrow
  transplant, and medications to treat cancer.
• Microorganisms include all kinds of bacteria and
  virus(CMV), candida(???) and aspergilosis(??).
• pneumocystis carinii(PCP,??????)

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Symptoms

• The onset is incidous , but clinical Symptoms are
  severe.
• Fever
• Nonproductive (dry) cough or cough with
  mucus-like, greenish, or pus-like sputum
• PCP
• Fungal infection

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Diagnosis

• Earlier finding and diagnosis
• Pathogen diagnosis
• Chest x-ray
• Sputum gram stain, other special stains, and
  culture
• Arterial blood gases
• Bronchoscopy
• Chest CT scan,
• Tissue diagnosis

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Treatment

• Antimicroorganism therapy
• The goal of treatment is to get rid of the
  infection with antibiotics or antifungal agents.
  The specific drug used will depend on what kind
  of organism
• is causing the problem. One drug may kill one
  type of organism, but not another.
• Respiratory treatments (to remove fluid and
  mucus) and oxygen therapy are often needed.

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Pneumococcal pneumonia
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Abstraction

• Pneumococcal pneumonia is produced by
• streptococcal pneumoniae
• It is the most commonly occurring bacterial
  
• pneumonia

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Etiology

• Streptococcus pneumonia are encapsulated,
• gram-positive cocci that occur in chains
  or
• pairs
• The capsule which is a complex
  polysaccharide
• has specific antigenicity
• Type 3 is the most virulent, usually
  causing
• severe pneumonia in adults, but type
  6,14,19
• and 23 are virulents is children

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Bacteria are introduced into the lungs by the
four routes

• Source Route Response
  Outcome
• colonization aspiration
• Air inhalation
• Non-pulmonary blood lung
  pneu.
• infection stream defenses
• Contiguous direct
• infection extention

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pathogenesis

• Pneumococci usually reach the lungs by inhalation
  or aspiration. They lodge in the bronchioles,
  proliferation and initiate an inflammatory
  process.

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Pathology

• Congestion
• red hepatization
• grey hepatization
• resolution)

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Pathology
Red hepatilization
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• ? All of the four main stages of the
  inflammatory
• reaction described above may be present at
  the
• same time
• ? In most cases, recovery is complete with
• restoration of normal pulmonary anatomy

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Clinical manifestations

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Clinical manifestations (1)

• Many patients have had an upper respiratory
  
• infection for several days before the onset
  of
• pneumonia
• Onset usually is sudden, half cases with
  a
• shaking chill
• The temperature rises during the first few
• hours to 39-40?

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Clinical manifestations (2)

• Typically, patients have the symptoms of high
  fever , shaking chill, sharp chest pain, cough,
  dyspnea and blood-flecked sputum.
• But in some cases, especially those at age
  extremes symptoms may be more insidious.

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Clinical manifestations (3)

• The pulse accelerates
• Sharp pain in the involved hemi thorax
• The cough is initially dry with pinkish or
• blood-flecked sputum
• Gastrointestinal symptoms such as,
• anorexia, nausea, vomiting abdominal
• pain, diarrhea may be mistaken as acute
• abdominal inflammation

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Signs 1

• The acutely ill patient is tachypneic, and
• may be observed to use accessory muscles
• for respiration, and even to exhibit nasal
• flaring
• Fever and tachycardia are present, frank
• shock is unusual, except in the later stages
• of infection or DIC

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Signs 2

• Auscultation of the chest reveals
• bronchovesicular or tubular breath
• sounds and wet rales over the
• involved lung
• A consolidation occurs, vocal and
• tactile fremitus are increased

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Laboratory examinations

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Laboratory examinations (1)

• The peripheral white blood cell (WBC)
  count
• Before using antibiotic, the culture of
  blood and
• of expectorated purulent sputum between
  24-48
• hours can be used to identify
  pneumococci
• Colony counts of bacteria from
  bronchoalveolar
• lavage washings obtained during
  endoscopy are
• seldom available early in the course of
  illness
• Use of the PCR may amplify pneumococcal
• DNA and improve potential for detection

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X-ray examination

• Chest radiographs is more sensitive than
• physical examination
• PA and lateral chest radiographs are
• invaluable to detect pneumonia

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X-ray examination

• Usually lobar or segmental consolidation
• suggests a bacterial cause for pneumonia
• If blunting of the costophrenic angle is
  noted, pleural effusion may be exist.

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The features of CT
Air-bronchogram sign
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Complications

• In 5 to 10 of patients, infection may
  extend into the pleural space and result
  in an empyema (??)
• In 15 to 20 of patients, bacteria may
  enter
• the blood stream (bacteremia) via the
  lymphatics
• and thoracic dust.
• Invasion of the blood stream by pneumococci
  
• may lead to serious metastatic disease at a
  
• number of extra pulmonary sites
  (meningitis,
• arthritis, pericarditis, endocarditis,
  peritonitis,
• ostitis media etc).

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Complications

• sepsis (?????)
• lung abscess(???) or empyema
• pleural effusion(????)
• pleuritis
• ARDS(?????????)
• ARF(??????)
• pneumothorax(??)
• Extrapulmonary infections

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Diagnosis

• According to history, the clinical signs ,
  physical examinations, laboratory examinations
  and radiographic features
• it is not difficult to make the diagnosis

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Differential diagnosis

• pulmonary tuberculosis
• Other microbial pneumonias
• klebsiella pneumonia,
• staphylococal pneumonia,
• pneumonias due to G (-)
  bacilli,
• viral and mycoplasmal
• Acute lung abscess
• Bronchogenic carcinoma
• Pulmomary infarction

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Treatments

• Antibiotics
• Support therapy
• Therapy of complications

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Antibiotic therapy (1)

• All patients with suspected pneumococcal
  
• pneumonia should be treated as promptly as
  
• possible with penicillin G
• The dose and route of delivery may have
  to
• be on the basis of patients status adverse
  rea-
• ction or complication that occur

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Antibiotic therapy (2)

• For patients who are believed to be
  allergic to penicillin, one may select the first
  or second generation cephalosporin or advanced
  macrolide ß -lactam or respiratory
  fluoroquinolone alone.
• For patients with PRSP, one may select the second
  and third generation cephalosporin or advanced
  macrolide ß -lactam or respiratory
  fluoroquinolone alone.
• In some cases, vancomycin may be used.

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Antibiotic therapy

• Treatment with any effective agent should
  be given for at least 5 to 7 day or after the
  patients have been afebrile for 2-3 days

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• Supportive measure
• Supportive measure are generally used in
• the initial management of acute pneumo-
• coccal pneumonia, such measures include
• Bed rest
• Monitoring vital signs and urine output
• Administering an occasional analgesic to
• relieve pleuritic pain
• Replacing fluids, if the patient is
  dehydrated
• Correcting electrolytes
• Oxygen therapy

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• Treatment of complications
• Empyema develops in appoximately 5 of
  patients
• with pneumococcal pneumonia, although
  pleural
• effusion commonly develop in 10- 20
  patients
• Chest X-ray with lateral decubitus films
  are often
• useful in the early recognition of
  pleural effusion,
• pleural fluid that is removed should be
  subjected to
• routing examination
• If pneumococcal bacteremia occurs, extra
  pulmonary
• complications such as arthritis,
  endocarditis must be
• excluded, because the therapy requires higher
  dosages
• Treatment of infections shock

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Prognosis
Prognosis is much better Any of the following
factors makes the prognosis less favorable and
convalescence more prolonged elderly
involvement of 2 or more lobes underlying
chronic diseases (heart lung kidney)
normal temperature and WBC count lt5000
immunodeficiency with severe complication
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Prevention

• The most important preventive tool available
• is using a poly valent pneumococcal vaccine
• in those with chronic lung diseases,
  chronic
• liver diseases, splenectomy, diabetes
  mellitus
• and aged

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Staphylococcus pneumonia

• Staphylococcal pneumonia is usually
  caused by
• staphylococcus aureus
• It is often a complication of
  influenza, but may be
• primary, particularly in infants and
  the aged

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• It occurs in immunocompromissed patients such as
• diabetes mellitus
• hematologic disease ( leukemia,
  lymphoma, leukopenia )
• AIDS, liver disease, malnutrition,
  alcoholism
• Staphylococcal bacteremia complicating
  infections at
• other sites (furuncles, carbuncles) may
  cause
• hematogenous pulmonary involvement (due
  to blood
• spread)

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• Some or all of the symptoms of
  pneumococcal
• pneumonia (high fever, shaking chill,
  pleural pain,
• productive cough) may be present, sputum
  may be
• copious and salmon-colored
• Prostration is often marked
• According the symptoms, signs of
  pneumonia,
• leukocytosis and a positive sputum
  or blood
• culture, the diagnosis can be made

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• Gram stain of the sputum provides
  earliest
• diagnostic clue
• Chest X-ray early in the disease
  shows
• many small round areas of densities
  that
• enlarge and coalesce to from abscess,
  and
• leave evidence of multiple cavities

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• Until the sensitivity results are know, a
  
• penicillinaseresistant penicillin or
  a
• cephalosporin should be given
• Therapy is continued for 2 weeks after
• the patient has become afebrile and the
• lungs have shown signs of clearing
• Vancomycin is the drug of choice for
• patients allergic to penicillin and
  cepha-
• losporin and for those not responding to
• other antistaphylococcal drugs, mainly
  used in MRSA.

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Pneumonia caused by klebsiella

• Klebsiella pneumonia ( also named Friedlander
• pneumonia) is an acute lung infection, caused by
• Klebsiella pneumoniae 1, it occurs much more in
• aged, malnutrition, chronic alcoholism, and
  in
• whom with bronchial pulmonary disease

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• This pneumonia is most likely to be found
  in
• man with middle age, onset usually is
  sudden,
• with high fever, cough, pleuritic pain,
  abundant
• sputum, cyanosis, tachycardia my be
  present,
• half cases with a shaking chill
• Shock appears in early stage

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• Clinical manifestations are similar
  to sever
• pneumococcal pneumonia
• The sputum is viscid and ropy, and
  may be
• brick red in color
• Chest X-ray shows a downward curve of
  the
• horizontal interlobar fissure,
  if the right
• upper lobe is involved
• Areas of increased radiance whithin
  dense
• consolidation suggest cavitation
• It constitutes 2 of bacterial
  pneumonia,
• but mortality may be as high as
  30

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• When an elderly patient suffered from acute
• pneumonia with sever toxic symptom, viscid
• and brick red, sputum must consider
  this
• disease
• The diagnosis is determined by
  bacterial
• examination of sputum
• Early using antimicrobial therapy is
  im-
• portant for patients with
  survivable ill-
• illnesses, aminoglycoside (Kanamycin,
  Amikacin,
• Gentamycin ) and the third generation
  cephalosporin are often used.

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Mycoplasmal pneumonia

• Mycoplasmal pneumonia is caused by
  Mycoplasmal
• pneumoniae
• Mycoplasmal pneumoniae is one of the
  smallest
• organisms 125-150 µm capable of
  replication in
• cell-free media
• Infection is spread form person to
  person by
• respiratory secretions expelled during
  bouts of
• coughing, causing epidemic or sporadic
  occurance

98

• It commonly occurs in children, adolescent,
  mainly
• in fall and winter
• It constitutes more than 1/3 of non
  bacterial
• pneumonias, or 10 of pneumonias from all
  cause
• Cellular infiltrate around bronchioles,
  and in
• alveolar interstitium, consists mostly
  of mono-
• nuclear elements

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Clinical findings

• The illness begins insidiously with
  constitutional
• symptomatology
• malaise, sore throat, cough, fever,
  myalgia
• Half of cases have no symptom

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Chest X-ray

• Chest X-ray findings are manifold
• Most patients have unilateral lower
  lobe
• segmental abnormalities
• The earliest signs are an interstitial
  accentuation
• of marking with subsequent patch air
  space
• consolidation and thickened bronchial
  shadows

101

• The pneumonia may persist for 3-4
  weeks
• a slight leukocytosis is seen,
  with a normal
• differential count
• The diagnosis is generally proved by a
  single
• antibody titer of 132 or greater,
  a titer of
• cold agglutinins of 132 or greater
  a single
• Ig M determination
• The most promising in terms of
  speed,
• sensitivity and specificity is PCR
  although
• cost and lack of general availability
  limit its
• routine use

102
Therapy

• A definite clinical response
• is seen to erythromycin and
  some other newer macrolide

103
Legionnaies Pneumonia

• Legionella can be an opportunistic pathogen.
• Patients with immunosuppression are at
  increased risk for infection. But sometimes
  outbreaks do occur in previously healthy
  individuals.

104

• Legionellae are small, gram-negative, obligately
  aerobic baclli.
• .

105

• Legionnaires disease is acquried by inhaling
  aerosolized water containing Legionella organisms
  or possibly by pulmonary aspiration of
  contaminated water.
• The contaminated water are derived from
  humidifiers, shower heads, respiratory therapy
  equipment, industrail cooling water.
• Because of the frequently use of air conditioner,
  Legionnaies pneumonia is also seen in CAP

106
Clinical manifestations

• The onset of L.pneumonia is sometimes severe.
• High fever, rigors, and significant hypoxemia are
  usually seen in patients with L.pneumonia.
• Failure to rapidly appropriate therapy in these
  cases is likely to result in a poor outcome.

107

• Common signs include cough, dyspnea, pleuritic
  chest pain, gastrointestinal symptoms, especially
  diarrhea or localized abdominal pain, nausea,
  vomitting are a prominent finding in 20 to 40
  of patients with L.pneumonia.

108
Physical examination

• Physical finding are often similar to other
  pneumonias.
• Rales are usually present over involved areas
• Pulse rate is not coincide to the body temperate.

109
Chest X-ray

• No diagnostic features on the chest X-ray
  distinguish it from other pneumonia
• Infiltrates can be unilateral, bilateral, patchy,
  or dense, and can spread very quickly to involve
  the entire lung, pleural effusion, usually small
  in volume occurs
• Routine laboratory tests also are nonspecific.

110
Laboratory examination

• Serologic testing is the most often used for
  establishing a diagnosis.
• A fourfold or greater rise in antibody is
  considered definitively exist for Legionella.

111
Diagnosis

• According to history, clinical signs, X-ray
  features and serologic testing, we can diagnose
  it.

112
Therapy

• Erythromycin is considered the drug of choice.It
  should be given until clinical improvement is
  seen.It usually lasts 2-3 weeks.

113
Candidiasis

• Candidiasis is an opportunistic disease, it is
  caused by candida.

114
Clinical signs

• Respiratory signs fever,cough, sputum
  production, dyspnea.
• X-ray shows no specific.It is similar to acute
  pneumonia.

115
diagnosis

• Mainly according to sputum culture or biopsy of
  lung.

116
Therapy

• Nystatin or various azole drugs

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Aspergillosis

• Aspergillosis refers to infection with any of
  species of the genus Aspergillus

118
Clinical signs

• The disease generally occurs in immunosuppressed
  and anticancer therapy patients.
• There are four types of pulmonary aspergillosis.

119
Clinical signs of Pulmonary aspergillosis

• Presents as chronic productive cough, hemoptysis,
  dyspnea, weight loss, fatigue, chest pain, or
  fever
• Sometimes patients with pulmonary aspergillosis
  accompany with prior chronic lung disease.
• Typical picture of an aspergilloma is a fungus
  ball in a cavity in an upper lobe
• The sputum culture is positive in most patients.

120
Diagnosis

• The repeated isolation of Aspergillus from sputum
  or the demonstration of hyphae in sputum or BALF
  suggests endobronchial infection.

121
Treatment

• With intravenous amphotericin B (1.0 to 1.5 mg/kg
  daily)
• Patients with severe hemoptysis due to fungus
  ball of lung may benefit from lobectomy

122
Therapy to Infectious Shock

• Treatment in intensive care units
• cardiac rhythm, blood pressure, cardiac
  performance, oxygen delivery, and metabolic
  derangements can be monitored
• Adequate oxygenation and ventilatory support
  (sometimes mechanical ventilation)
• Effective antibiotic therapy
• Maintain blood pressure, including maintain
  circulation blood volume, use of dopamine

123
Summary

• 1.?????
• 2.?????
• 3.CAP?HAP??????????
• 4.?????????????????????????
• 5.????????????
• 6.??????????

124
Questions

• 1.What is the differences between CAP and HAP?
• 2.What is the standard of sever pneumonia?
• 3.what are the principals of antibiotic
  therapy of various of pneumonias?

125
Case report

• ??,??,32?
• ???????6?
• ??????6?????????,?????39?,????,????????,???????,?
  38?,????,???????,?????,??????,??X????????????,???
  ???6.0109 /L,N66.2,?????????????3?,????,???CT???
  ?????????????????????

126
????

• ??,???,T38?,P90?/?,R18?/?,BP110/70mmHg,?????,????
  ???????,??,??????,??????,??,???,??????,NS(-)

127
????

• ??????IgM1160
• ??
• ??CT

128
??
129
??CT
130
case2

• ??,??,50?
• ????????????
• ?????????????????????????,????,??,???,???????????
  ???????????????,????,????????,?????????????,??????
  ??,?????????,???????????CT(?CT??),?????????
• ??????????????????,?????????30mg/d,??????????,????
  ?2???????2?/d

131
?????????

• ?????????
• ??CT??

132

• How do we diagnose?

133
???

• 1.??,58 ?,????????? 15 ?,1 ?????????????,?????,??,
  ? ??????????B
• A???????
• B????????
• C???????
• D??????
• E??????

134

• 2.??,35 ?,????? 3 ?,?? 39 ?,??????????,???????????
  ?? ??????,?????? ?C
• A?????
• B???????
• C????
• D????
• E????

135

• 3.?????????????????E
• A???????
• B???????
• C??????
• D????????
• E???????

136

• 4.?,20 ?,????,??????,????,??????,??T37.8
  ?,???,??? ????,??WBC8109/L,?? 70,X
  ????????????,???????,??? ?????????????E
• A??????
• B????????
• C???????
• D???????
• E??????

137

• 5.??,25 ?,??,??,??,??,??????,????,???????,????,?
  ?? 9.6109/L,?? 86,??????????????,???????164
  ??,?? ?????????E
• A?????
• B????
• C?????
• D????????
• E????

138

• 6.????????????A
• A.???
• B.???
• C.????
• D.??????
• E.???

139

• 7.????????????? E
• A.???????
• B.???????
• C.?????????
• D. ????????
• E.????????????????????

140

• 8.??????????????B
• A ???
• B.???
• C.??????
• D.???
• E.?????

141

• 9.??,25?,???????????(39.2?)??
• ??????,???????,??X???????????????????????C
• A.?????????
• B.??????
• C.??????
• D???????????????
• E.????????

142

• 9.??????????????????????????,?????,????E
• A.??????
• B.???????
• C.???
• D.?????
• E.?????

143

• 10.???????????????A
• A.??????
• B.???
• C.??????
• D.???????
• E.???