Pneumonia & Pulmonary Infections

I: Bacterial Infections
1. Lobar Bacterial Pneumonia (Alveolar spaces filled, septa normal thickness): Uniform, 1 lobe
a. Stages: Congestion red hepatization grey hepatization resolution or organization
b. Gross: Lungs firm, w/ red or grey appearance depending on stage
c. Microscopic: Alveolar spaces filled with RBCs, WBCs, fibrin, edematous fluid depending on
stage
d. Strep pneumoniae
e. Organization collagen deposition via BM damage & repair rxn use trichrome to highlight
2. Bacterial Bronchopneumonia: Lobular, patchy/nonuniform
a. Gram +/- bacteria
b. S. aureus & P. aeruginosa likely to organize abscesses/permanent lung damage &
vasculitis/necrosis respectively
c. Gross: Tiny pneumonia patches, esp. near major airways
d. Microscopic: Similar to lobar pneumonia, also includes alveolar M & is less extensive
3. Aspiration pneumonia: Due to aspiration of food, respiratory secretions, etc. (acute or chronic)
a. Caused by enteric & anaerobic organisms
b. Gross: RML & RLL necrosis right main stem bronchus is more vertical
c. Microscopic: Foreign material w/ foreign body giant cells, PMNs interstitial/septal thickening
4. Atypical Bacteria: Produce interstitial pneumonia similar to viral pneumonia
a. Mycoplasma pneumoniae, Chlamydia trachomatis, C. pneumoniae
5. Tuberculosis: Still around due to Dx like HIV/AIDS
a. Mycobacterium tuberculosis
b. Incidence = 8M cases/year, mortality rate = 3M cases/year
II. Viral Pneumonia
1. Bronchiolitis
a. Peribronchiolar collection of lymphocytes, epithelial damage/sloughing, squamous metaplasia,
mucous plug in bronchiole, hyperinflation (can lung collapse)
b. RSV, influenza A/B, parainfluenza, adenovirus
c. Can bronchiolitis obliterans (uncommon)
2. Interstitial pneumonia: Negative image of bacterial pneumonia
a. Alveolar septa thickened lymphocytes & plasma cells in septa & maj. airways, occ. hyaline
b. RSV & influenza
3. Viral inclusions: Often intranuclear but can be elsewhere in the cell as well
a. CMV: Large inclusions (intranuclear & intracytoplasmic) w/ Owls eye appearance
b. Adenovirus: Intranuclear inclusions smudge cells
c. Measles: Intranuclear inclusions in Warthin-Finkeldey Giant Cells
d. Herpes: Multinucleated cells w/ ground glass n., nuclear molding & chromatin margination
i. Examine w/ bronchoalveolar lavage (cytology)
III: Fungal Pneumonia
1. Histoplasma capsulatum
a. Inhaling airborne microspores from chicken houses, pigeon coops, bat habitats
b. MI & OH R. basins
c. Acute: Spores reach bronchioles & alveoli yeast forms

i. Yeast taken up by M but cannot be digested M migrate to LN, liver, spleen

infiltrate development
ii. 2-3wk: Cellular immunity activated tissue & caseation necrosis
iii. Healing via fibrosis/calcification but trapped yeast cells can persist for a while
d. Disseminated: Immunocompromised patients
e. Chronic pulmonary Infection: Emphysema patients, usu. involves apex
f. Excessive (mediastinal) fibrosis
g. Produce interstitial pneumonia similar to viral pneumonia
2. Blastomyces dermatitidis
a. Inhaling spores from moist, wooded areas
b. MI R. basin
c. Mixed inflammation: PMNs, noncaseating granulomas (may not find if immunocompromised)
d. Microscopic: Thick walled yeast cells, broad-based bud (not pinched)
e. Stain w/ PAS
3. Coccidioides immitis: One of the most virulent fungal pathogens
a. Inhaling arthroconidia e.g. from workplace exposure to soil dust
b. Southwestern US (arid)
c. PMNs & granulomas w/ large spherules
4. Cryptococcus neoformans
a. Inhaling aerosolized organisms, 50% of pts have predisposing condition
i. Steroids, Hodgkins Dx, sarcoidosis, HIV i.e. immunosuppressed
b. Saprobe, associated w/ pigeon excreta
c. Absent chronic inflammation (including giant cells), spherical\oval budding yeast cells of
varying size
d. Yeast cells stain + w/ mucicarmine their capsules are thick
5. Aspergillus
a. Inhaling spores
b. Saprobe, associated with A. fumigatus & A. flavus
c. Allergic
d. Colonizing: Aspergilloma/fungus ball
e. Invasive: Septate hyphae @ 45 invade blood vessels infarction, hemorrhage, PMN infiltrate
i. See branching in Ag stain
6. Zygomycetes
a. Inhaling spores, esp. if diabetic and/or ketoacidotic
b. Saprobe
c. Aseptate, ribbon-like hyphae w/ 90 branching invade vessels
7. Pneumocystic jirovecii
a. Colonizes immunocompetent patients, causes Dx in immunocompromised (AIDS) patients
b. Alveoli fill w/ eosinophilic foam, interstitial infiltrate of plasma cells & lymphocytes
c. Stain replicating form (trophozoites) w/ Giemsa stain
d. Stain cysts w/ Ag stain