PNEUMONIA

Pneumonia is an inflammation of the parenchyma of the lung. - Most cases of pneunomin are caused by microorganism. - non infectious causes include aspiration of food or gastric acid foreign bodies hydrocarbons and lipoid. substances hypersensitivity reaction and drug or radiation induced pneumonitis.

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Classification . 1 : Anatomical classification.
A lobar pneumonia . The consolidalion involves all or part of lobe B Bronchopneumonia the consolidation involves scattered lobules C - Interstitial pneumonia . As in viral pneumonia where inflammatory . Infiltrate involve mainly interstitial tissue between alveli.

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2 : Etiological classfication. the cause of pneumonia in patient is often difficult to determine because direct culture of lung tissue invasive and rarely performed. - culture obtained from upper respiratory tract or sputum genenally not accurately.

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Causes of infectious pneumonia. Bacterial. Common. - streptococcus pneumoniae Group B streptococci Group A streptococci . - Mycoplasma pneumoniae - chlamydia pneumoniae - chlamydia trachomatis -Mixed anaerobes pneumonia - Gram-negative enteric.

Adolescent. infant. Aspiration

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Uncommon.
Haemphilus influenza Staphylococcus aureus Moraxella catarrhalis Neisseria meningitides Francisella tularensis Nocardia species Chlamydia psittaci Yersinia pestis Legionella species water. Unimmunized.

animal fly contact Immunosuppressed person. Bird contact. Plague Exposure to contamianted

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- Viral -Common
Respiratory syncytial virus Parainflueza type 1 3 Influeza A . B Adenovirus Metapneumovirus - Un Common Rhinovirus Enterovirus Neonates Herpes simplex Neontes Cytomegalovirus Immunosuppressed person. Measles Varicella Hantavirus Sars agent.

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-Fungal. Histoplasma capsulatum Cryptococcus neoformans Aspergillus species Mucomycosis Coccidioides immitis Blastomyces dermatitides
- Rickettsial Coxiella burnetii Goat sheep cattle exposure Rickettsia rickettsiae

Bird bat contact Bird contact. Immunosuppressed. Immunosuppressed

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Mycobacterial
Nycobacterium Tuberculosis Developed countries Nycobacterium avium-inteacellulare Immunosuppressed.

Parasitic
Pneumocystis Carini Immunosuppressed. Steroid. Eosinophilic Ascaris . Loeffler syndrom

Non infectious causes

-Aspiration Of food. -Gastric acid. -foreign body. -Hydrocarbon Kerosen -Lipoid substances - Aspiration of amniotic fluid.

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Age group
Neonate <1mo 1-3 mo febrile Pneu Afebrile Pneu 3 12 mo

Frequent Pathogens
Group B straptococcus E coli streptococcus Pneumoniae H influeza. Rsv . Influenza viruses para fluenza viruses adenovirus S. pneumoniae . H . influenza Chlamydia trachomatis Mycoplasma hominis cytomegalovirus.

R.S.V

Influenza viruses para fluenza viruses adenovirus S. pneumoniae H . Influenza Chlamydia trachomatis Mycoplasma pneumoniae Group A straptococcus Influenza viruses para fluenza viruses adenovirus S. pneumoniae H . Influenza Mycoplasma pneumoniae Chlamydia pneumoniae Group A straptococcus S . Aureus. Mycoplasma pneumoniae S. pneumoniae Chlamydia pneumoniae H . Influenza Influenza viruses adenovirus Mycoplasma pneumoniae S. pneumoniae Chlamydia pneumoniae H . Influenza Influenza viruses adenovirus.

2 5 yr 5 18 yr > 18 yr

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Hospitalization of children with pneumonia
- Age < 6 month - Sickle cell anemia with acute chest syndrom. - Multiple lobe involvement. -Immunocompromised Toxic appearance . - Sever respiratory distress Requirement for supplemental oxygen.Dehydration Vomiting.No response to oral antibiotic.- Non compliant parent.

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Recurrent pneumonia
-Hereditary disorder Cystic fibrosis Sickle cell disease -Disorders of immunity Aids Bruton agammaglobulemia Selective IgG subclass deficiencies Common variable immunodeficiency syndrom Sever combined immunodeficiency syndrom -Disorders of leukocytes Chronic granulomatous disease Hyperimmunoglobulin E syndrome Leukocyte adhesion defect

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- Disorders of cilia Immotile cilia syndrom Kartagener syndrom -Anatomic disorder Sequestration Lobar emphysema Esophageal reflux Foreign body Tracheo esophageal fistula ( H type ) Gastroesophageal reflux Bronchietasis Aspiration ( oro pharyngeal in coordination )

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Pathogenesis
The lower respiratory tract is normally sterile by -Physiologic defense mechanisms including -Mucociliary clearance -ProPerties of normal secretion such as secretory immunoglobulin A IgA - Clearing of air way by coughing Immunologic defense mechanism of lung limit invasion by pathogenic organisms Includes macrophages are present in alveoli and bronchioles secretory IgA and others immunoglobulins

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Viral pneumonia
usually result from spread of infection along the air way. Accompanied by direct injury of respiratory epithelium resulting in air way obstruction from swelling abnormal secretion and cellular debris small calibar of air way in young infant makes them particularly susceptible to sever infection. Viral infection predispose to secondary bacterial infection by disturbing normal host defense mechanism altering secretion and modifying bacterial flora.

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Bacterial infection In bacterial infection pathologic process varies according to the invading organism M . Pneumoniae attaches to the respiratory epithelium inhibit ciliary action and Lead to cellular destruction and an inflammatory response in the submucosa as the infection progresses sloughed cellular debris inflammatory cell and mucus Cause airway obstruction with spread of infection occuriang along the bronchial Tree as in viral pneumoia.

- S . Pneumoniae Produce local edema that aids in the proliferation of organism and their spread Into adjacent portion of lung often resulting in the characteristic focal lobar Involvement

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-Grop A . Streptococcus
pathology Includes necrosis of tracheobronchial mucosa formation -of large amount of exudate edema and local hemorrhage with extension into the Interalveolar septa and involvement of lymphatic vessel and pleura.

-S aureus pneumonia
produces Toxin and enzymes as hemolysin coagulase and staphylo kinaseIt causes broncho pneumonia often unilateral characterized by prensence of Hemorrhagic necrosis and irregular areas of cavitation of lung parenchyma Resulting in pneumatoceles empyema or broncho pulmonary fistula Pyopneumothorax.

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Following changes stages:
1- congestion alveoli are failed with edema fluid and organism. 2- red hepatization alveoli contain polymorph RBCs fibrin edema and organism. 3-grey hepatization deposition of fibrin over the pleural surface phagocytosis starts inside the alveoli which are now filled with polymorph and fibrin. 4-resolution: neutrophil degenerate fibrin thread and remaining bacteria and digested and removed by phagocyte

Clinical Manifestation
Viral & bacterial pneumonia are often preceded by several day of symptoms of URTI typically rhinitis and cough. In viral pneumonia: fever is usually present lower than in bacteria. Tachypnea increased work of breathing accompanied by intercostal, subcostal and suprasternal retraction nasal flaring and use of accessory muscle. Severe infection accompanied by cyanosis and respiratory fatigue in infant. Auscultation of chest wheezing and crackle

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In bacterial pneumonia: Sudden shaking chill followed high fever, cough, grunting, chest pain, drowsiness, rapid respiration, dry cough, anxiety circumoaral cyanosis.

Physical finding:
Depends on the stage of pneumonia diminished breath sound scattered crackels and rhonchi over affected lung. Increasing consolidation or complication. As effusion empyema or pyopneumothorax dullness on percussion and breath Sound. Diminished abdominal distension because of gastric dilation from swallowed air or ileus. Abdominal pain in lower lobe pneumonia Liver may seem enlarged because downward of diaphragm secondary to hyper inflation of lung Neck rigidity without meningitis in right upper lobe.

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Diagnosis:
Chest X-ray diagnosis of pneumonia may indicate complication pleural effusion or empyema. Viral pneumonia X-ray hyper inflation with bilateral interstitial infiltrate pneumococcal pneumonia lobar consolifation repeat chest x-ray are not required for proof of cure for ratient with uncomplicated pneumonia. - WBC can differentiating viral from bacterial in virtual WBC normal or elevated but usually not highert han 20,000/mm3 with lymphocyte predominance Bacterial 15,000- 40,000 predominance granulocyte. -Pleural effusion lobar consolidation and high fever at onset of illness suggestive of bacterial. -Atypical pneumonia due to C.pneumoniae or M.pneumoniae is difficult to
distinguish from pneumococal pneumonia by X-ray and other lab. -pneumococcal pneumonia higher in WBC count ESR-CRP. - Isolation of organism from blood-pleural fluid or lung culture of sputum blood culture. positive PCR in viruses

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Treatment:
Treatment based on cause and clinical appearance of child. Children do not require hospitalization. -Amoxicillin ( 80-90mg/kg/24 hrs )
- cefuroxime = Zinnat or Amoxicillinclavulante = ogmin. - For school age children with M-pneumonia. -C.pneumonia (atypical pneumonia) mcrolide antibiotic such as azilhromjcin

Bacterial pneumonia in hostpitalized child cefuroxime (150 mg/kg/24 hrs) = Zinnat cefotaxime = claforan cefftriaxone = Rocephin - If staphylococcal pneumatotocele empyema Vancomycin or clindamycin Viral pneumonia
no respiratory distress with hold antibiotic therapy - Up to 30% of patient wih known viral infection may have coexisting bacterial pathogen.

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Deterioration in clinical status antibiotic therapy should be initiated

Response to treatment:
Patient with uncomplicated bacterial pneumonia respond to therapy with improvement in clinical symptom (fever, cough, tachypnea, chest pain) within 48-96 hrs.

Slowly resolving pneumonia

1- complication as empyema. 2- bacterial resistance. 3- non bacterial etiology as viruses and aspiration of foreign bodies or food. 4- bronchial obstruction from endobronchial lesion foreign body or mucus plug. 5- pre-existing diseases such as immunodeficiencies- ciliary dyskinesia- cysticfibrosis pulmonary sequestration cystic adenomatoid malformation. 6- non infectious causes: - bronchoilitis obliterans. - hypersensitivity pneumonitis - eosinophils pneumonia - aspiration - wegener granulomatosis

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Complication:
Usually result of direct spread of bacterial infection within thoracic cavity. (pleural effusion- empyema- pericarditis) or bacteremia and hematologic spread meningitis suppurative arthritis osteomyelitis

X-RAYS

Viral pneumonia x-ray

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Lobar pneumonia x-ray (RUL)

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bronchopneumonia x-ray

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Staph pneumonia x-ray

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