Pneumonia: Symptoms, Diagnosis And Treatment (public Health In The 21st Century)

Pneumonia, an inflammatory condition of the lung, is one of the most common serious infections, causing two million deaths annually among young and old alike. This new book studies the symptoms, diagnoses and treatment of pneumonia. Topics discussed include the modes of supportive treatment in patients with pneumonia; pneumocystis jirovecii in AIDS patients; nosocomial pneumonia surveillance and prevention in PICU and NICU; ventilator-associated pneumonia; community acquired staphylococcal pneumonia associated with influenza and radiological patterns of pulmonary infections. Copyright © Contents Preface vii Chapter I Pneumocystis jirovecii Pneumonia 1 Chapter II Supportive Treatment to Improve Outcome of Pneumonia 37 Chapter III Quality Improvement in the Nosocomial Pneumonia Surveillanceand Prevention in PICU and NICU Chapter IV Ventilator-Associated Pneumonia 93 Chapter V Community Acquired Staphylococcal PneumoniaComplicating Influenza Chapter VI Radiological Manifestations of Pneumonia in Common Practice: AnEtiological Approach according to the Host  ALVEOLAR PATTERN.  INTERSTITIAL PATTERN.  BRONCHOPNEUMONIA PATTERN. Figure 3. 24 year old male with probable pulmonary sepsis. In a previous study (3A and 3B), a multicysticlesion on posterior left segments was observed(asterisk). This was not easy to recognise on the PAprojection, when the patient was asymptomatic. Superinfection of these densities as see fromthe air-fluidlevel (asterisk) indicated a cystic adenomatoid malformation (MAQ) or sequestration as predisposing factorto infection in the CRX (3C and 3D) and CT with lung parenchyma window(3E). The existence of the MAQwas confirmed during surgery. Figure 4. (A: Posteroanterior, B: Lateral). 64 year old male with central lung cancer andpostobstructivepneumonitis (with atelectatic component, white arrow) in right upper lobe. Taken together,this sign is known as the 'Golden S' (asterisk), and consists of a concave upward lateral edge, resulting fromthe collapse, and a concave medial border towards the hilium, resulting from conglomerate mass-centrallymph node (black arrow). 1) HEALTHY PATIENTS Figure 5. A: 20 year old woman with alveolar pattern in the right lung base with a tendency to coalesce(arrow), suggestive of CAP. From 2-3 days before her visit in the Emergency services, she presented a stuffynose, cough and dark expectoration, to which 40oC fever was added on the last day. Pneumococcalantigenuria was positive. Note the well-defined consolidation limits in relation to the cisural surface (dashedarrow) against the poor definition for the rest of the lesion. B: In other cases, pneumococcal pneumonia, canbe associated with a major effusion, as seen in this 5 year old girl covering the left hemithorax (asterisk). Figure 6. 4 month old baby with basal left lung consolidation (asterisk), corresponding to a RSVlunginfection. Note the air bronchogram sign or radiolucency on aerated bronchi, which are distinguished withinthe radiodensealveolar space occupation. Clinically the baby had breathing difficulty. Symptoms are selflimitingwithin a few days. Figure 7. 56 year old woman who complained of fever, left rib pain and malaise of 48 hoursduration.Analysis found leukocytosis and increased acute phase reactants. The left paracardial hyperdensity,affecting the whole lung base on that side allows the identification of vascular structures, where a 'groundglass pattern' (arrows) can be seen. A similar picture is visible in the anterior segment of right upper lobe(dashed arrow). The patient also had a thymoma (asterisk). This chest radiography pattern, the presence offlu-like symptoms and multifocality indicates viral pneumonia. Serology confirmed the diagnosis ofInfluenza N1H1. Figure 8. 42 year old male who presented fever, cough, dyspnea, and vesicular rash. A nodular pattern(asterisks) in immunocompetent patients can orient the diagnosis towards atypical or viral pneumonia, as inthis case where the responsible germ was the Chickenpox virus. Figure 9. 27 year old male aluminum worker, whose infection begen with fever, dyspnea and nonproductivecough. The patient's occupational history signalled the possibility of atypical pathogens. In this caseLegionella pneumoniae was isolated. Studies show multiple bilateral alveolar infiltrates (arrow). 2) INMUNOCOMPETENT PATIENTS WITH CERTAIN DISEASES Figure 10. 58 year old male with cardiac transplant, presenting 40oC fever, hypotension and acute renalfailure. There is a right basal pulmonary infiltrate (arrows). The rapidly progressive nature of the diseaseindicated aggressive pneumonia. K. pneumoniae bacteremia sensitive to amoxi-clavulanic was obtained andisolated in the peripheral catheter tip. Figure 11. 75 year old male with uncontrolled diabetes, presenting dyspnea, anterior chest wall pain and rustysputum. The consolidation of the anterior segment of the upper left lobe (arrow) in close contact with thechest wall. The CT confirmed the rib involvement (arrow). Mucor was isolated on the biopsy as the germcausing the inflammation. 3) IMMUNOCOMPROMISED NON-AIDS PATIENTS Figure 12. 61 year old woman with a history of IgG lambda multiple myeloma, presenting two days of feverwith nonproductive cough and dyspnea with mobilization. The interstitial pattern of both lungs (arrows) inthis nosocomial pneumonia raised the possibility of atypical germ vs viral infection, because of the extensiveinvolvement of both lungs. Serology confirmed the existence of Influenza A, and the clinical course includeda very torpid evolution in the context of her immunosuppression. Figure 13.68 year old male with liver transplant, was admitted to ICU for acute renal insufficiency. Theclinical symptoms were accompanied with leukocytosis and crackles at auscultation, which started two weeksbefore admission with irritative dry cough and sore throat with fever up to 39oC. The history of iatrogenicimmunosuppression for trasplant, was a crucial guide to the viral etiology of this case. The pattern of bilateralbronchopneumonia and bilateral nodular lesions (arrows) between the 15 days separating the two figures,gave way to a basic interstitial pattern that was attributed to interstitial lung disease from takingimmunosuppressant drugs. Figure 14. 24 year old male, in treatment for a hematologic malignancy who begins to develop fever. TheCXR shows the existence of a cavity with thin and circumscribed borders (arrows, compare with Figure 1C)in the anterior segment of right upper lobe occupied by material in the decline area acquiring the typicalappearance of the “intracavitary fungus ball”. The patient was treated with antifungals which resolved theoccupation image, while cavitation persisted. Figure 15. 62 year old women treated with chemotherapy for cervical carcinoma who was admitted withcough and expectoration. The CXR showed a cavitated image in the anterior/apical segment of the upper leftlobe (dashed arrow) and alveolar infiltrate in the upper right lobe that cavitated during its evolution (asteriskand arrow). Sputum culture showed Serratia marcensens, and the radiographic pattern was cavitarypneumonia with fungal invasion (aspergilloma) in the lesion of the upper right lobe. Figure 16. 27 year old male, immunodepressed by bone marrow transplantation presented with fever andrespiratory symptoms. The CXR showed an alevolar lesion in the anterior segment of the upper right lobesurrounded by a 'ground glass' halo (arrows) that suggested in this clinical setting the existence of aninvasive type of aspergillosis. The peripheral halo corresponds to perilesional hemorrhage due to fungalvascular invasion. Figure 17.The pulmonary infections spectrum in AIDS patients. The coordinate axis represents the number ofCD4 + / UL. The line represents the range where the infection may be and the drawer the levels where it ismost common. Adapted from Reference 1. 4) IMMUNOCOMPROMISED AIDS PATIENTS Figure 18. 43 year old male, HIV positive CD4 + 58c/UL and granulomatous tuberculosis sequel, whopresented clinical symptoms of cough with mucopurulent expectoration, and occasionally hemoptysis of 7days duration, an alveolar occupation (arrow) with discrete right lung volume expansion related to bacterialCAP. Figure 19. 47 year old male, HIV positive, with fever and pneumonia symptoms. On the conventional cheststudy a lung mass was discovered (arrow). The CT showed air bronchogram within the lesion (dashed arrow).The final diagnosis was a Rodoccocus motivated abscess. Figure 20. 45 year old male HIV positive and Hodgkin's lymphoma in chemotherapy treatment. Initial torpidevolution with development of acute respiratory failure and focusing of respiratory symptoms (nonproductivecough.) The ground glass pattern (arrow) in this clinical context guided the radiological management. Afterinitiation of empiric treatment for Pneumocystis with cotrimoxazole and steroids, the patient began to evolvefavorably with marked improvement. On leaving hospital he was eupneic, afebrile and asymptomatic. Figure 21. 35 year old man with alveolar pattern mass in middle lobe (solid arrows), CT data addedoccupation of small airways (discontinuous arrows), suggesting a tuberculous etiology which was laterconfirmed. Index 147 Pneumocystis jirovecii pneumonia / Enrique J. Calderón ... [et. al.] Supportive treatment to improve outcome of pneumonia / Michael Eisenhut, Tomasz Rajkowski Quality improvement in the nosocomial pneumonia surveillance and prevention in PICU and NICU / P.A. Fuster-Jorge ... [et. al.] Ventilator-associated pneumonia / Noyal Mariya Joseph, Joshy Maducolil Easow Community acquired staphylococcal pneumonia complicating influenza / Yoav Keynan, Ethan Rubinstein Radiological manifestations of pneumonia in common practice : an etiological approach according to the host / Angel Daniel Dominguez-Perez ... [et. al.] Pneumonia : symptoms, diagnoses and treatments / Krishna M. Sundar Airbag-related pneumonia : a new clinical study.