Professor Of Pediatrics,

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Pneumonia

• By
• Professor Of Pediatrics,
• Head of Allergy Clinical Immunology Unit -
  Mansoura University
• Egypt

Magdy Zedan.
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Out Line

• (1) Definition and Pathophysiolgoy of
  pneumomnia
• (2) Does the patient have a pneumonia?
• (3) What is the microbial etiology?
• (4) Where you treat?
• (5) How to treat?

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Definition

• Its an infection in alveolar spaces
• (pulmonary parenchyma) leading to their
• Consolidation.
• Consolidation means the alveoli are
• filled with exudates and inflammatory
• cells with loss of their gaseous content.

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Pathophysiology

• A- Development of Pneumonia
• Virulent organism.
• Immune compromised host Local
• 
  Systemic
• B- Pulmonary host defenses
• (1)Mechanical and structural
• Cough.
• Mucocilliary clearance
• Airway branching (configuration)
• continue

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Pathophysiology

• Pulmonary host defenses
• (2) Cellular defenses
• Resident alveolar macrophages
• Recruited Neutrophils occures when alveolar
  macrophages are over whelmed in lower respiratory
  tract infections.
• continue

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Pathophysiology

• (3)Humoral defenses
• IgA in upper airway
• IgG in lower airway
• (4) Inflammatory and molecular defenses
• Airway epithelium through secretion of peptides
  called defensins, and chemokines.
• Cytokines as IL-10,GM- CSF.
• continue

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Pathophysiology

• Bacteria or virus gain access to respiratory
  tract from
• Inhalation of contaminated air
• Microaspiration
• Hematogenous seeding of the lung.
• Whether Pneumonia is the result of such
  bacterial entry depends on interaction between
  the bacterium (load, Virulence) and pulmonary
  defense mechanism.
• continue

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Pathophysiology

• The usual out come is ingestion of bacteria or
  virus by alveolar macrophages, an alternative but
  less common is complement mediated bacterial
  lyses
• When these mechanisms dont destroy alveolar
  bacteria,polymorph nuclear leukocytes with their
  phagocytic capability are required with the
  result inflammatory response results
  in Pneumonia passing in 3 stages.

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Pathology of Pneumonia

• 1- Stage of congestion (red hepatization)
• Due to antigen antibody reaction no
• radiological findings.
• 2- Stage of gray hepatiztion
• Respiratory distress and homogenous
• opacity in chest rdiography.
• 3- Stage of resolution
• When immune system takes upper
• hand, resolution and convalescence.

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Pathology
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Classification of Pneumonia

• Two types typical And atypical.
• (1) Typical pneumonia
• (2) Atypical pneumonia
• Another Classification
• (1) Community- acquired pneumonia ( CAP)
• (2) hospital acquired pneumonia (
  nosocomial
• pneumonia)

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Out Line

• (1) Definition and Pathophysiolgoy of pneumomnia
• (2) Does the patient have a pneumonia?
• (3) What is the microbial etiology?
• (4) Where you treat?
• (5) How to treat?

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Clinical and Radiological Diagnosis of Pneumonia

• (1) Respiratory distress
• (2) Bronchial breathing or fine
• consonating creptation by
• auscultation
• (3) Homogenous opacity is a cardinal
• radiological sign

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Clinical and Radiological Diagnosis of Pneumonia

• To differentiate between Bacterial and viral
  etiology
• Look for
• - preceding symptoms
• - Fever
• - Para pneumonic effusion
• - Wheezes
• - Distribution size of homogenous
• opacity

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Radiology
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Radiology
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Out Line

• (1) Definition and Pathophysiolgoy of pneumomnia
• (2) Does the patient have a pneumonia?
• (3) What is the microbial etiology?
• (4) Where you treat?
• (5) How to treat?

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Etiological Diagnosis

• It is difficult to determine the causative
  organism of Pneumonia. So the treatment usually
  empirical based on Predicting factors for the
  causative organism as the following.
• a) Age of the patient.
• b) Immune status,
• c) Extra pulmonary manifestations.
• It can be confirmed by
• Culture Specific tests.
• continue

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Etiological Diagnosis

• Age as a predictor for eteological diagnosis
• A- In CAP
• Neonates
• Common- Group B B- hemolytic streptococci
• Gram negative enteric bacilli
  such as Escherichia coli and Klepsella pneumoniae
  
• Less frequent
• Staph-auras
• P.aeruginosa
• continue

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• Etiological Diagnosis
• Children Past neonatal period
• 1- 5 month age Chlamydia trachomatis
• gt 5 years Atypical (intracellular)
  micro-organisms as mycoplasma pneumoniae,
  legonella, chlamydia SPP are the commonest
  etiological agents.
• All ages
• Frequent S. pneumoniae
• Infrequent causes as
• - H. influenza (vaccine)
• - S, aureus but it needs
  special consideration for
• rapid progression of the
  disease.
• - Group A B hemolytic
  streptococci are uncommon
• cause of pneumonia
• continue

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Etiological Diagnosis

• In hospital acquired pneumonia
• Common
• Gram negative organism such as
• K. pneumonia, Pseudomonas aurugnosia and serrata
  spaces
• Gram positive organisms such as
• S. Aureus most frequent leogionella pneumoniae is
  rare

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Investigation of Pneumonia

• Routine Investigation
• X ray
• CBC with differential
• SaO2,
• Blood culture
• Specific Investigation
• Bronchoscopy and C.T for unresolved pneumonia
• Serology ( IgM, IgE, IgG)
• Sputum and pleural evaluation

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Out Line

• (1) Definition and Pathophysiolgoy of pneumomnia
• (2) Does the patient have a pneumonia?
• (3) What is the microbial etiology?
• (4) Where you treat?
• (5) How to treat?

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Indication for Hospitalization in Pneumonia

• 1) Patients with tacchypnea, toxic
• appearance, poor feeding , dehyration
• 2) Infant lt 2 months of age
• 3) Massive para pneumonic affusion
• 4) Associated co-morbidty
• 5) Immundeficiency.

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Staphylococcal Pneumonia

• It is an infrequent cause of pneumonia
• Age under one year , it occurs either community
  acquired following influenza or at nosocomial
  setting
• Characters-
• 1) At the onset, chest radiographs may be
  normal
• However. S. aureus pneumonia is more
• commonly bronchopneumonia with a patchy
• central infiltrate. Usually unilateral
• Continue
• continue

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Staphylococcal Pneumonia

• 2) Rapid progression of the disease from
• Patchy cansolidation to cavity, pneumatocele
  or
• tension pneumothorax should raise the
  possibility of S. aureus pneumonia, when it
  occurs
• 3) Effusion or empyema
• Develops in about 90 of patients
• Spontaneous pneumothorax or pyopneumothorax
• Occur in about 25-50 of cases
• Pneumatocele
• Occur in gt 50 of cases and may change
  hourly in number or size in acute phase.
• continue

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Staphylococcal Pneumonia

• This previous radiographic picture of S. aureus
  pneumonia is not pathognomonic as it occurs with
• Pneumonia caused by
• Klebsiella species, other gram negative
  bacteria group A streptococci and occasionally
  pneumococci
• OR it may mimic congenital diaphragmatic hernia.
• 4) Staphylococcal pneumenia
• It should be suspected in hospitalized
  infants (particularly those in ICU) who develop
  parenchymal unexplained opaque shadows.
• continue

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Staphylococcal Pneumonia

• 5) Species of staphylococci
• A) S. aureus
  coagulase positive
• B) S. albus
• C) Staphylococcus epidermidis ?
  coagulase
• negative
• Morphologically all staphylococci are gram
  positive
• Coagulase does not reflect virulence
• Virulence of S. aureus related to secretion of
  different toxins as hemolysins and leukocidin
  that kills neutrophils.

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Treatment of Staphylococcal pneumonia

• The production of B- lactamase by nearly all S.
  aureus isolates rendered ineffective any drug
  bydrolysed by this enzyme.
• First line therapy is Hospital admission,
• B lactamase resistant penicillin
• such as Methicillin ? no longer in use
• its modern analogs i.e oxacillin, cloxacillin,
  Flucloxacillin, nafcillin
• MRSA ( methicillin resistant S. aureus) which
  was found to be resistant to all B lactams and
  all cephalosporin compounds.

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Treatment of Staphylococcal Pneumonia

• MRSA infections that are nosocomially acquired
  was found to be sensitive to Vancomycin
• Now MRSA infection became community acquired
• Clindamycin indicated in MRSA infection in
  patients allergic to B-lactams
• Duration of treatment 2-3 weeks, but 6 weeks
  recommended to decrease the risk of relapse
• Supportive therapy o2, maintenance of, fluid,
  electrolyte and hemoglobin levels
• continue
• continue

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Treatment of Staphylococcal Pneumonia

• The most important complication is
• Empyema and lung abscess, pneumothorax each
  
• has a special treatment

Treatment in summary B. lactamase resistant penicillins or first generation cephalosporin for 2-3 weeks MRSA ? vancomycin Clindamycin MRSA patient allergic to B lactams
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HaemophilusInfluenzaType b

• H. influenza is gram - negative bacilli
• H. influenza can lead to invasive infectious
  in pediatrics as pneumonia, meningitis,
  cellulites, epiglottites, septic arthritis,
  osteomyelitis percarditis and bacteremia
• Incidance of H. influenza pneumonia decrease
  after administration of Hib canjugate vaccine
• The virulence of serotype b is related to
  serotype b capsular polysaccharide

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Haemophilus Influenza Type b

• Radiographic findings of H. influenza pneumonia
  vary from-
• 1) Bronchiolctic type with central linear
• infiltrates and over inflation
• 2)Bronchopneumonia with patchy
• consolidation with no lobar affection

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Treatment of H. Influenza Pneumonia

• we have two clinical situations
• 1) pneumonia complicated with bacteremia,
• pleural effusion usually occur in
  children less
• than 12 months. Those group needs
  Hospital
• admission with I.V treatment for 7-10
  days
• continue

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Treatment of H. Influenza Pneumonia

• 2) Pneumonia and the patient is not appears
  severely ill those group treated at home with
  oral antimicrobial
• Oral therapy in mild H. influenza infection TMP/
  SMX or amoxicillin / clavulanate Erythromycin has
  poor activity
• Invasive infections IV treatment by
  cephalosporin (cefotaxime or ceftriaxone)
  Alternatively chloramphencol with ampicillin,

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Mycoplasma Pneumonia

• Mycoplasma pneumoniae causes
• Non classic bacterial pneumonias. They are small
  organisms that are able to live outside the host
  cell. Because they have no cell wall, they are
  not killed by cell wall- active agents such as
  penicillins and cephalosporins.
• Mycoplasma pneumonia is common cause
• of CAP that occurs gt 5 years of age

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Pathogenesis of Pulmonary Infections

• Infection with M. pneumoniae are acquired via
  respiratory route from droplet infection.
• The organism attaches to a receptor on
  respiratory epithelium and remains extra cellular
  causing cellular damage.
• Specific cell mediated immune responses increase
  with age so it tends to be milder in children
  than in adults and also severe in reinfection.

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Diagnosis of Mycoplasma Pneumonia

• The diagnostic clue Is the poor correlation
  between clinical symptoms which are severe, with
  minimal pulmonary physical and radiological
  findings. This poor correlation present all
  through the course of the disease and this is the
  hall mark of diagnosis of M.pneumonia.

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Clinical Picture

• Typically the patients present with gradual
  onset of malaise, headache and fever over 1 week.
  Cough dry or productive associated with symptoms
  as vomiting, diarrhea, chest pain, sore throat.
• Physical findings are relatively minimal early
  in the course of illness no finding on chest
  examination later on bronchial breathing crackles
  or wheezes can be heard.
• 3- Radiologic findings
• Usually unilateral in 87 and involves lower
  lobes
• In the early stages the pattern is reticular and
  interstitial
• Later patchy or segmental areas of consolidation
  are
• noted.
• Continue

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Clinical Picture

• 4- Extra pulmonary manifestation
• They are the second hallmark of M. pneumonia.
• Such complications commonly occur 1-21 days
  after the onset of respiratory symptoms. Most of
  the diagnosis have been based on the result of
  serology (four fold rise in complement fixation
  titres) rather than no culture confirmation.
• Neurological manifestations.
• Dermatologic manifestations.
• Cardiac manifestations.
• continue

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Clinical Picture

• 4- Extra pulmonary manifestation
• GIT manifestations.
• Hematologic manifestations.
• Musculoskeletal manifestations.
• Genitourinary manifestations.
• Immunologic manifestations.

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Diagnostic Criteria of Mycoplasma Infection

• Serologic assays are the mainstay for diagnosing
  mycoplasma infection-
• 1.Cold agglutinin identification
• Cold agglutinins usually appear by the end of
  first week and disappear by 2-3 months
• Cold agglutinin responses are non specific and
  consistent mostly IgM
• So IgM lacks specificity and sensitivity
• continue

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Diagnostic Criteria of Mycoplasma Infection

• Specific serological test-
• Complement fixation test has been used as
• standared for diagnosis with titer gt 132
• The test measures IgM antibodies
• This test has 90 sensitivity and 94
• specificity
• Polymerase chain Reaction(PCR)
• PCR diagnosis M. pneumonia in both throat
  swab and CSF.

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Treatment of M. Pneumonia

• Macrolides are the drug of choice as-
• Erythromycins, Azithromycin are specific
• treatment.
• Because M. pneumonia has no cell wall, it is
• resistant to penicillins, cephalosporins and
• other cell wall active agents.

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Pneumococcal Pneumonia

• Pneumococcus (Streptococcus Pneumoniae)
• It is the most common cause of bacterial
  pneumonia in children. The organism is gram
  positive cocci.The virulence of the pneumococci
  is related to there capsule.
• It affects all ages.
• Continue

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• Pneumococcal Pneumonia
• Diagnosis
• It is typical pneumonia with sudden onset of
  fever, cough, chest pain and dyspnea.
• Physical examination
• Pleurtic chest pain my be referred to abdomen
  with misleading suspicion of acute appendicitis.
• Symptoms and signs of meningismus may be present
  with upper lobe pneumonia.
• Continue

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Pneumococcal Pneumonia

• 2) Physical examination
• Dullness on percussion denotes empyema because
  the
• lesion usually patchy in distribution
• Fine rales difficult to be heard.

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Pneumococcal Pneumonia

• Treatment
• Penicillins are the drugs of choice in treatment
  of pneumococcal infection.
• If the patient is resistant to penicillins,
  cephalosporin is indicated.
• If the patient is allergic to penicillins
  vancomycin clindamycin or chloramphenecol are the
  drugs of choice .

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Recurrent or Unresolved Pneumonia

• I- Multiple lobe affection
• Congential heart disease with excess pulmonary
  blood flow.
• Immune deficiency either local or general.
• Specific infection as T.B and fungal infection
  (Aspergillus)
• II- Singal lobe affection
• Obstruction Intraluminal, Extraluminal.
• Structural abnormalities as pulmonary
  sequestration.

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Differential Diagnosis of Pneumonias

• 1) Between 4 common types of pneumonia
• Staph pneumonia
• Mycoplasma Pneumonia
• H. influenza pneumonia
• Pneumococcal pneumonia
• 2) From other causes of
• Respiratory distress
• Pulmonory inflitrates.

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Thank you