CP2 4.13 path of pneumonia

There are two types of pneumonia.

What is alveolar pneumonia?

intraalveolar inflammation, either as a Bronchopneumonia or Lobar pneumonia.

There are two types of pneumonia.

What is interstitial pneumonia?

inflammation fo the alveolar septae, which includes viral pneumonia

To what structures are focal alveolar pneumonia limited?
alveolus and terminal bronchiole

what is the cause of alveolar pneumonia?
bacterial infection, mostly normal flora. commonly follows pulmonary edema or chronic heart failure. this accounts for 75% of cases.

which populations are predisposed to alveolar pneumonia?
elderly, or debilitated patients that are confined to a bed.

to what structures is bronchopneumonia limited to?
segmental bronchi and surrounding parenchyma

image lobar vs bronchopneumonia. both are alveolar pneumonia.
image lobar vs bronchopneumonia. both are alveolar pneumonia.

What is characteristic about Interstitial Pneumonias?
usually diffuse and often bilateral, caused by viruses.

what are the bacteria most commonly responsible for pneumonia?
Streptococcus, Staphylococcus and Hemophilus influenza.

Since the upper air ways do not harbor gram negative or anaerobes, where do hese bacteria come from?
enteric flora and can cause pneumonia by contamination of the blood to the lungs.

What are some exogenous species of bacteria that can cause pneumonia if inhaled?
Legionella or T.B., as well as various fungi and viruses

how is legionella usually acquired?
inhalation of bacteria from humidifiers or air-conditioning systems.

what are some endogenous viruses that can cause penumonia?
reactivation of herpes and CMV can cause pneumonia. exogenous viruses must be inhaled for infection.

what are the four ways that infection can reach the lungs?
1) inhalation of particles- viruses and TB
2) aspiration of infected secretions from the upper respiratory tract- Strep and Staph
3) aspiration of gastric contents- anaerobic bacteria, common in the unconscious, who have neurologic deficits, or are alcoholics and have lost control of their gag reflex.
4)Hematogenous Spread- common in sepsis and may develop after UTI’s or GI tract infections

What is the pathology in Bronchopneumonia?
bacterial invasion, followed by exudation of PMN’s into the lumen of the airways, spreads from the bronchi into the adjacent alveoli. can be focal or diffuse.

What is consolidation?
As the intra-alveolar exudate accumulates, it replaces the air, and the lung parenchyma becomes consolidated.

what is hepatization?
after consolidation, the lungs resemble the liver, and this process is called Hepatization.

Pneumonia is recognized on X-ray studies as infiltrates or consolidations

What is the pathology of Interstitial Pneumonias?
usually diffuse and bilateral and the inflammation primarily affects the alveolar septae and does not result in exudation of PMN’s into the alveolar lumen (like alveolar pneumonias).

what is the etiology of interstitial pneumonias?
caused by viruses that invade the septae and cause cell necrosis along with a mononuclear cell infiltration

What are the characteristic X-ray findings of interstitial pneumonia?
reticular patterns with no major consolidations seen on X-rays

what are there complications with this type?
cause only minor alveolar damage and resolve without consequences, although some may progress to a chronic stage characterized by interstitial fibrosis as a late complication.

what are the complications with Bacterial Pneumonias?
pleuritis, abcesses

what is pleuritis?
Extension of the inflammation to the pleural surface that commonly leads to a pleural effusion.

what is a Pyothorax?
infection that results in pus filling the entire pleural cavity.

what is empyema?
what is empyema?
infection encapsulated by fibrous tissue into pockets.

what is Suppurative pleuritis?
what is Suppurative pleuritis?
heals slowly and usually results in pleural fibrosis encasing the entire lung and obliterating the pleural cavity, restricting inspiration.

what are the causes and end results of abcess formation?
usually associated with virulent organisms, such as Staphylococcus, and causes destruction of the lung parenchyma and suppuration.

what is Bronchiectasis?
pus inside the bronchi causes destruction of their walls and permanent dilatation.

what is Chronic Lung Disease?
complication caused by an unresponsiveness to treatment. Destruction of the lung parenchyma with concomitant fibrosis transform the lung into a honeycomb-like structure.

What age groups are most affected by pneumonia?
<5yoa or >70yao

what is Primary or Community-Acquired pneumonia?
infection of a previously healthy individual

what is secondary pneumonia?
which are hospital-acquired (Nosocomial) or which arise in persons with preexisting illnesses

What are some risk factors for secondary pneumonia?
smoking, alcoholism, and immunosuppression.

What are the clinical signs and symptoms of pneumonia?
high fever, chills, and prostration (extreme fatigue) along with local signs related to bronchial inflammation such as coughing and expectoration, along with SOB, dyspnea, and tachypnea.

Finding only suggest diagnosis. Imaging and labs are necessary.

describe the appearance of the sputum in pneumonia?
Inflammatory exudates cause tissue destruction and bleeding giving rise to mucopurulent, blood-tinged, “rust-colored sputum”

what are the finding on auscultation?
rales, rhonchi, and other signs of pulmonary consolidation.

why is CXR necessary for diagnosis?
localizing the pulmonary infiltrates and for assessing the extent of pulmonary consolidation.

why are Bacteriologic Studies of the Sputum necessary for diagnosis?
very reliable and yield conclusive proof of infection. Bacteriologic data also provide the best guidance for treatment.

why are Peripheral Blood Smears necessary for diagnosis?
bacterial pneumonias are accompanied by Leukocytosis (Neutrophilia), viral pneumonias are not, al-though it may be associated with a Lymphocytosis in the blood.

why is Blood Gas Analysis necessary for diagnosis?
May detect hypoxia and even respiratory acidosis.

What are the treatments for pneumonias?
bacterial- antibiotics.
viral- supportive, prevent bacterial.

what is the most common kind of pneumonia?
pneumococcal pneumonia account for over 50% of cases.

What is the first of four pathologic sequential phases of pneumococcal pneumonia?
Engorgement: the first 4-12 hours. Serous exudate pours into the alveoli from dilated, leaky blood vessels.

What is the second of four pathologic sequential phases of pneumococcal pneumonia?
Red Hepatization: The next 48 hours. The lungs assume a red liver-like appearance, as RBC’s, fibrin, and PMN’s fill the alveoli.

What is the third of four pathologic sequential phases of pneumococcal penumonia?
Gray Hepatization: By 3-8 days, the lungs become grayish as the WBC’s and fibrin consolidate in the alveoli.

what is the fourth of four pathologic sequential phases of pneumococcal penumonia?
Resolution: By 7-11 days, the exudate is lysed and resorbed by macrophages, restoring the tissue to the original structure.

What are clinical features of Pneumococcus?
sudden onset with chills, fever, pleuritic chest pain, cough and rust-colored sputum.

Who is the vaccine best used for?
80-90% effective against most serotypes and is usually given to high-risk patients, i.e., sickle cell, multiple myeloma, diabetes, cancer, alcoholics, splenectomy patients as well as the elderly.

What is characteristic about Staph aureus Pneumonia?
multiple abscesses, Common in debilitated hospitalized patients. The mortality rate is over 50%.

What is characteristic about Pseudomonas pneumonias?
most common hospital-acquired, vascular lesions that cause infarcts and necrosis of the lung parenchyma, and are the most common causes of lung infections in Cystic Fibrosis pt’s. A common source is contaminated ventilatory equiptment, and the mortality rate is over 70%.

What is characteristic about Klebsiella pneumonias?
occurs in middle-aged, alcoholic males. A thick current-red jelly sputum is characteristic.

What are features of Atypical Pneumonia?
diffuse pneumonia caused by Mycoplasma pneumoniae, a bacterial-like organism that causes an interstitial pneumonia.

the typical pneumonia symptoms are less pronounced, with no signs of septicemia, leukocytosis, or abscesses

what disease does Legionella pneumophila cause?
Causes Legionnaires Disease, both in the community and in hospitalized immuno-compromised patients

What is characteristic about Legionella pneumophila?
aerobic, gram-negative rod that stains faintly with the gram stain, and is famous for causing an outbreak of pneumonia at an American Legion convention in Philadelphia in 1976.

where is legionella found?
ubiquitous in natural and man-made water environments, air-conditioning systems, cooling towers, and whirlpools. Outbreaks have even been found associated with growth in shower heads. No person to person transmission has been identified.

how does legionella cause disease?
facultative intracellular organism that settles in the lower respiratory tract and is engulfed by macrophages, inhibits phagocytosis, survives and replicates inside the macrophage,

which populations are predisposed to legionella infection?
older men, smokers, alcoholics, AIDS, cancer, and renal transplants are also predisposed to infection.

how do patients with legionaire’s disease present clinically?
severe pneumonia and high fevers, along with mental confusion, proteinuria, and microscopic hematuria, cough, sputum is scanty and nonpurulent. Atypical Pneumonia seen is similar to Mycoplasma.

Should be suspected in patients who smoke, over 50 and if the sputum gram stains reveals neutrophils and very few organisms.

How can Legionaire's dz be diagnosed pathologically?
How can Legionaire’s dz be diagnosed pathologically?
Legionella antigens by using fluorescent antibody staining on lung biopsy

how does legionaire’s dz resolve?
resolve spontaneously in 7-10 days, but in older or immunocompromised patients the infection can be fatal,

what is the drug o choice for legionaire’s tx?

What are features of Fungal Pneumonias?
develop from inhaled spores causing granuloma formation, scarring, calcification, and cavity formation.

what species are common in fungal pneumonias?
Histoplasma, Aspergillus, Cryptococcus, Coccidioidiomycosis, Candida, and Pneumocystis

What is Histoplasmosis and its cause?
Histoplasma capsulatum. Usually a self-limited mycosis, but can lead to a systemic granulomatous infection in the immunosuppressed (AIDS).

what are the characteristics of histoplasma capsulatum?
dimorphic fungus with a world-wide distribution. In the U.S., it is endemic to central and eastern states. It grows in soil heavily contaminated with bird or bat droppings (bat guano).

How does histoplasmosis cause disease?
inhaled spores, called Microconidia, are engulfed by macrophages and develop into yeast forms inside the lungs.

How do yeast cells appear?
infectious form: round and has a central basophilic body surrounded by a clear halo, best identified by silver stains.

Reproductive form: oval, budding yeasts inside the macrophages

what are the general features of cryptococcus neoformins?
opportunistic, systemic mycosis affecting the lungs and brain, world-wide distribution, and the main reservoir is pigeon droppings in the soil.

How does c. neoformins appear microscopically?
oval, budding yeast surrounded by a wide polysaccharide capsule that may be used for diagnosis- old method is to use india ink.

what populations do c. neoformins affect commonly?
organism must be inhaled causing an interparenchymal disease, establishes almost exclusively in persons with impaired cell-mediated immunity, especially AIDS, leukemia and lymphoma patients.

lung infections are often asymptomatic in patients with good immune systems, due to neutrophilic killing of the fungus

what is aspergillus fumigatus?
environmental fungi that produces lung infections, saprophytes in soil and decaying plant matter, and are small enough to reach the alveoli

how does aspergillus appear microscopically?
how does aspergillus appear microscopically?
septate hyphae that forms V-shaped branches

how is able to infect humans?
by invading abraded skin, wounds, burns, cornea, or paranasal sinuses

Who is most susceptible to the aspergillus infection?
Immunocompromised patients

what are the symptoms with aspergillus infection?
can invade the lungs and other organs, producing hemoptysis and granulomas

What is an aspergilloma?
aspergillus can grow within pulmonary cavities from TB and produce a mass with can be seen on X-Ray, along with cavatation

What is Coccidioidomycosis?
A chronic, necrotizing infection that resembles Tuberculosis. AKA “Valley Fever”

where is coccidioidomycosis endemic to?
arid regions of Southwestern U.S. and Latin America.

how does coccidioidomycoides appear microscopically?
hyphae with Arthrospores that are very light and can be carried by the wind to be inhaled- very highly contageous.

How does Cocciodoides cause disease in the lungs?
Arthrospores form Spherules that are large vacuoles with a thick wall that are filled with Endospores. The walls rupture, then endospores are released and differentiate to form new spherules, to spread either via the blood or by direct extension, forming caseating granulomas, similar to T.B.

What is the pathenogenesis of coccidioidomycosis?
Begins as a focal, asymptomatic pneumonitis, limited to the lungs and regional lymph nodes.

Can spread if immunocomprimised- granulomatous lesions to virtually any organ, especially the bones, skin, liver, spleen, and CNS (meningitis).

how does coccidioidomycosis present clinically?
>60% are asymptomatic, the remaining develop a flu-like syndrome with fever, malaise and cough that later resolves

What is Pneumocystis carinii?
important cause of diffuse interstitial pneumonia in immunocompromised patients, characteristics of both a fungus and a protozoan parasite, Transmission occurs by inhalation

what are the symptoms of pneumocystis carnii?
produces no disease in healthy patients, but causes pneumonia in AIDS patients. (frequently the first diagnosed opportunistic infection and the leading cause of death).

How does Pneumocystis cause disease?
cup or boat-shaped cysts in the alveoli induces an inflammatory response, resulting in a frothy, eosinophilic, edema fluid that blocks oxygen exchange

What is the clinical presentation?
Sudden onset of fever, cough, dyspnea and tachypnea. There are bilateral rales and rhonchi and the CXR reveals a diffuse interstitial pneumonia. isolated to lungs.

How is Pneumocystis diagnosed?
microscopic examination of lung tissue obtained by bronchoscopy, BAL, or open lung biopsy. The cysts can be visualized with Silver Stains. There is no serologic test.

how is pneumocystis treated?
combination to Trimethoprim and Sulfamethoxazole.

What is the prognosis of pneumocystis?
Untreated, the mortality rate is 100%, with treatment about half survive the first episode

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