Atypical Pneumonias and Fungal Pneumonias

Discuss atypical pneumonia epidemiology:
Although Step Pneumo is the leading cause of pneumonia, the 3 atypical pathogens together cause more cases than Strep pneumo

Discuss the presentation of Atypical Pneumonia:
Fever, dry cough, interstitial pattern fibronodular or patchy infiltrates by x-ray. It is less severe than typical pneumonia.
If sputem is present, it is scanty, thin, or white as opposed to that of typical pneumonia which is yellow, green, or rusty.
The X-Ray often surprises physician by showing infiltrates in mildly ill outpatient “Walking Pneumonia”
Atypical is less likely than typical to have pleuritic pain or pleural effusion.

Discuss the characteristics of Mycoplasma pneumoniae:
The organism is not visible on Gram-stain of sputum. It isn’t culturable by routine methods. Specific IgM antibody is the best diagnostic method and cold agglutinins.
It is a short rod, lacks a cell wall and has a long doubling time of about 6 hr.
Disease has an incubation period of 2-3 weeks, gradual onset of fever, malaise, dry cough
Spread by respiratory droplets.

What are the x-ray and histological findings of Mycoplasma pneumoniae?
What are the x-ray and histological findings of Mycoplasma pneumoniae?
X-Ray shows interstitial pattern with linear markings, streaky, patchy, or fibronodular
Interstitial shows thickened septae and clear alveolar spaces.
Normal is on the right. Normally, the alveolis aren’t clear.

Discuss the characteristics of Legionelle:
The bacteria requires L-cysteine and protein rather than carbohydrate.
The bacterial are small Gram- bacillus but stains poorly, but better with Silver Stains. It is Aerobic.
It grows at high temperature and well in nature inside free-living amebae. In patients it is mostly intracellular especially in macrophages.
The virulence factors are related to LPS endotoxin, and flagellin. It is slow growing on charcoal years (3-5 days)
Sources are water sources

Outline the epidemiology of Legionelle:
It is acquired from aerosols from environment usually created by water coolors, faucets, or showers.
It is NOT contagious.
Smokers, COPD, elderly, immunocompromised people are especially susceptible.

What are the symptoms of Legionalla Pneumonia?
Dry cough, fever, purulent sputum in 1/2 patients. X-Ray can be suggestive of Strep pneumoniae. There s abdominal pain and diarrhea. 10% fatal

Discuss Chlamydia Pneumonia:
Small Gram- negative bacterium, its LPS is truncated and not very endotoxic. It is an obligate intracellular organism.

Outline the Chlamydia reproduction cycle:
The Elementary body is a contagious, orgaism ridden droplet aeorol that is picked up by the host cell.
Once inside, the elementary particle reorganizes into a larger noninfectious reticulate body which is osmotically fragile.
The Reticulate body is what reproduces continuously by binary fission.
After 48 hours, these stop multiplying and condense back into elementary bodies that will eventually burst out of the cell

Discuss the Epidemiology of Chlamydophila:
Person to person via aerosol droplets. Incubation of 21 days and can be asymptomatic. It is not seasonal or winter related.
Most adults have the antibodies against it, children rarely have the antibodies. Adolescense shows a rapid rise of them.

What are the symptoms of Chlamydophila?
Dry cough, malaise, sometimes no fever, can last weeks or months.
XRay shows nonspecific infiltrate. WBC is normal.

Discuss the characteristics of Psittacosis:
Caused by C. psittaci. This is contracted from fecal aerosol of sick birds (parrots usually).
Causes atypical pneumonia and febrile illness like mono or influenza

What causes Whooping Cough?
Bordetella Petussis, a Gram – coccobacillus that is aerobic. It is a delicate bacteria that dies to cold and drying (even a cotton swab).

What must Pertussis grow on in culture?
Nicotinamide on a “Bordet-Gengou agar”.

What are the virulence factors of Perussis?
Adherence by: Fimbriae, FIlamentous hemagglutinin, and Pertactin.
The toxins are Pertussis toxin which elevate ICF cAMP which will activate Adenyl Cyclase. It also has adenylate cyclase toxin and tracheal cytotoxin.

Outline the Pathogenesis of Pertusis:
Tracheitis and Brochitis occur with the accumulation of mucus, inflammatory cells, bacteria, and dead epithelial cells.
There is intense coughing against closed vocal cords causing Valsalva-like maneuvers. This can cause hemorrhages in conjunctiva and the brain.
There is mainly Leukocytosis in which there is a predominance of lymphocytes.
Infection rarely extends to lung to cause pneumonia and the ear to cause otitis media.

What are the 4 stages of Pertussis?
Incubation (1 week)
Catarrhal (basic flu-like 1-2weeks)
Paroxysmal (2-4 weeks) Whooping Cough
Convalescent (3-4 weeks or longer) Secondary Complications

What is “The Whoop?”
Series of short expiratory coughing bursts working to expel mucus.
There is an inspiratory gasp with whoop as air passes turbulently through mucus.
Coughing may induce vomiting and cyanosis as well as cause mucus plugs.

Discuss the unique epidemiology of Whooping Cough
It is HIGHLY contagious (50-100% transmission)
In pre-vaccine times, mother’s antibody protected baby for 1 year. Most cases were 1-5 years old.
Vaccine is effective for 12 years, adults not protected.
Seizures in 3% of adults with long term, death in 1%.

Discuss the Pertussis Vaccine and Treatment:
What is recommended but not a current practice?
The toxoid vaccine is an acellular (not whole bacteria) vaccine in DTaP. It also contains filamentous hemagglutinin and fimbriae. It is advised at 2, 4 ,6, 15-18 mo booster at 4-6 year old. Post-partum mothers and care-givers are advised for vaccine.
Treatment is Erythromycin

Where would you find Histoplasma?
Bird or Bat droppings on great plains along riverbeds.

Where would you find Blastomyces?
Same area for Histo PLUS the SE seaboard all the way up to Canada. This is found in decaying wood.

Where would you find Coccidoides?
Desert sand in/from SW US.

Who are those most at risk of these 3 pathogen? How are most of these spread?
They are more likely to cause serious disease in compromised patients. They are NOT contagious from person to person, everyone gets it from the environment.

Identify Histoplasma capsulatum:
Identify Histoplasma capsulatum:

Identify Blastomyces:
Identify Blastomyces:

Identify Coccidioides:
Identify Coccidioides:

Identify the important aspects of Coccidiodes immitis environmental form:
Hyphae break up into barrel shaped arthroconidia. This is found in desert sand in the SW USA.

What form is Coccidiodes immitis in tissue? Identify it:
What form is Coccidiodes immitis in tissue? Identify it:
This pathogen will be “spherules” with endospores in tissue form.

What are the symptoms of respiratory fungal pathogens?
Fever, chills, headache, arthralgia, non productive cough, chest pain, SOB, only
Lower respiratory tract, has hilar lyphadenopathy and more prominent spleen enlargement.

How does the body “rid itself” of fungal pathogens?
“Walling off” as in Tb, but they may remain viable as to reactivate decades later.

What are the disseminated external clues as to which pathogen the patient has been infected with?
Histoplasma and Coccidiodes are on mucous membranes.
Blastomyces are on cutaneous surfaces

Which groups of patients are more likely to have the pathogens disseminated?
Pregnant women in their 2nd and 3rd trimester for Coccidiodes.
For Histoplasma and Coccidioides, blacks, Fillipinos and Native Americans.

Identify Histoplasmosis Lung Inflammation
Identify Histoplasmosis Lung Inflammation

How are fungal pneumonias diagnosed via HPI?
Travel history,exposure.
Non Contagious (no one close)
No Upper Respiratory Symptoms (hoarseness)
Not responding to bacteria.

What is Sputa, BALF?
BALF is bronchiole-alveolar lavage fluids. This is a diagnostic tool used identify fungal pathogens. A KOH and gram stain are used.
Coccidiodomycosis are NOT used because it is very dangerous in the lab.

What is used to diagnose fungal dissemination?
If pulmonary Histo or disseminated fungal is suspected, fungal blood cultures and a Wright or Giemsa stain of thick blood smear are ordered.
Paired Sera is used for systemic fungal serologies.
Do not do Histoplasmin skin tests until after 2nd sera is drawn to prevent positive Histo serology.

What does Blastomycosis cause?
It causes acute chronic pulmonary disease which is disseminated and a greater tendency not to self-resolve so treatment is common.

What are the symptoms of Coccidioidomycosis?
Acute self resolving can range from asymptomatic to severe pneumonia.
This causes problem in AIDS and cancer patients.
This can cause maternal death in the 3rd trimester.

What are the Opportunistic Pulmonary Fungi?
Aspergillus, Crytococcus, Sporothrix, and Pneumocystis

What are the 4 distinctive pulmonary disease from Aspergillus?
1. Invasive pulmonary aspergillosis infection in immunocompromised.
2. Fungus balls growing free in old TB cavities
3. Allergic Bronchopulmonary Aspergillosis where the fungus grows in mucus plugs in asthmatic patients.
4. Farmer’s Lung (allergy)

Discuss the characteristics of Aspergillus fumigatus:
Discuss the characteristics of Aspergillus fumigatus:
Septate, filamentous fungus. It is a major recycler of organic material. It can be in moldy food, ceiling tiles, and compost. It is branching filaments in the body.

Where is invasive aspergillosis a problem?
Transplant patients of heart and bone. There is a huge number of spores that can land on nasal mucosa and seed into the lungs causing pneumonia. There it can grow into lung blood vessels causing pulmonary hemorrhage.

Identify Aspergilloma (Fungus Ball)
Identify Aspergilloma (Fungus Ball)

What is ABPA?
Allergic Bronchopulmonary Aspergillosis.
Found in Asthmatic patients ith alergies to Aspergillus. They develop mucous plugs and then the organism grows in the plug.
This patient has high IgE and is treated with antifungals.

Outline the important facets of Cryptococcus neoformans:
Outline the important facets of Cryptococcus neoformans:
An encapsulated yeast that is found in soil enriched with pidgeon droppings.

Discuss Pulmonary Cryptococcosis:
Usualy present where some new person has had a large exposure or in the immunocompromised.

Discuss Pulmonary Sporotrichosis:
Grows on plants (roses).
Pulmonary disease in urban homeless alcoholics. This is why it is called Alcoholic Rose Garden Sleeper’s Disease.
It looks like Tb!

Discuss Pneumocystis carinii:
Discuss Pneumocystis carinii:
Cannot grow in culture. It is an opportunistic fungus in AIDS. There is fever, dyspnea and hypoxemai.

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