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Pneumonia

Question 1

An HIV+ patient with a CD-4+ count of 802 is found to be hypoxic on room air. Chest X-ray shows multi-lobular consolidation. What is the most likely causative organism? A. Moraxella catarrhalis B. Klebsiella pneumoniae C. Staphylococcus aureus D. Streptococcus pneumoniae E. Mycobacterium tuberculosis Pre-Test

Question 2

A 47 year old homeless alcoholic male presents to your clinic complaining of insidious onset dry cough. He describes his sputum as “red jelly.” Chest x-ray shows a bulging fissure. What is the most likely diagnosis? A. Aspiration Pneumonia B. Acute Bronchitis C. Ventilator Associated Pneumonia D. Hospital Acquired Pneumonia E. Adult Respiratory Distress Syndrome Pre-Test

Question 2

A 47 year old homeless alcoholic male presents to your clinic complaining of insidious onset dry cough. He describes his sputum as “red jelly.” Chest x-ray shows a bulging fissure. What is the most likely diagnosis? A. Aspiration Pneumonia B. Acute Bronchitis C. Ventilator Associated Pneumonia D. Hospital Acquired Pneumonia E. Adult Respiratory Distress Syndrome Pre-Test

Question 3

A 62 year old male presents with a non-productive cough of 2 weeks duration. Physical exam reveals wheezing, rhonchi, crackles. The patient has a normal pulse in but a high fever. What type of pneumonia is most likely? A. Typical Community Acquired Pneumonia B. Hospital Acquired Pneumonia C. Atypical Community Acquired Pneumonia D. Ventilator Associated Pneumonia Pre-Test

Question 4

An HIV+ patient who has a CD-4+ count of 52 presents with acute onset cough and fever. He does not take antiretroviral meds or TMP- SMX, is hypoxic on room air, and has a diffuse bilateral infiltrate on chest film. What is the most likely causative organism? A. Streptococcus pneumoniae B. Pneumocystis carinii C. Aspergillis fumigatus D. Coccidiodes E. Mucormycosis Pre-Test

Question 5

An elderly man presents w/ pneumonia, GI disturbance, bradycardia, and hyponatremia. What is the most likely causative organism? A. Streptococcus pneumoniae B. Staphlococcus aureus C. Legionella pneumophilia D. Coxiella burnetti Pre-Test

Question 5

An elderly man presents w/ pneumonia, GI disturbance, bradycardia, and hyponatremia. What is the most likely causative organism? A. Streptococcus pneumoniae B. Staphlococcus aureus C. Legionella pneumophilia D. Coxiella burnetti Pre-Test

Pneumonia

• Lower respiratory tract infection : Inflammatory condition of the lung which primarily affects alveoli. It is usually caused by infection
• Typical symptoms include a cough, chest pain, fever, and difficulty breathing
• D/dx: URI, Acute Bronchitis, Lung Abscess
• Epidemiology :
  • Among the first 10 leading causes of death in the U.S.
  • Affects ~450 million people globally per year (seven percent of the world population)
  • Results in ~4 million deaths worldwide, mostly in third-world countries Introduction

Classification

• Community Acquired Pneumonia (CAP)
  • Occurs in the community or within the first 72 hours of hospitalization; Can be typical or atypical
  • Most common bacterial pathogen is S. Pneumoniae (60%)
• Hospital Acquired Pneumonia (HAP)
  • Occurs during hospitalization after first 72 hours
  • Gram-negative bacilli (Pseudomonas, Klebsiella, E. coli, Enterobacter, Serratia, Acinetobacter, & S. aureus, including MRSA)
  • Acid suppression (PPI use) may increase risk
  • Ventilator Associated Pneumonia
• Aspiration Pneumonia
  • Chemical pneumonitis due to aspiration of gastric contents
  • Bacterial pneumonia ≥24–72 h later, due to aspiration of oropharyngeal microbes - Outpatients : typical oral flora (Strep, S. aureus, anaerobes) - Inpatients or chronically ill : GNR and S. aureus Introduction

Clinical Symptoms

• “Typical” CAP
  • Acute onset of fever, productive cough w/ purulent sputum, dyspnea, pleuritic pain
• “Atypical” CAP: originally described as culture (-)
  • Insidious onset of dry (nonproductive) cough
  • Extrapulmonary sx: Nausea, Vomiting, diarrhea, headache, myalgias, sore throat)
• Ventilator Associated Pneumonia
  • Fever, Hypoxia
  • Increasing secretions Work-Up

Clinical Signs

• “Typical” CAP
  • Tachycardia, tachypnea
  • Late inspiratory crackles, bronchial breath sounds, increased tactile and vocal fremitus, dullness on percussion
  • Pleural friction rub: associated with pleural effusion
• “Atypical” CAP
  • Pulse–temperature dissociation: normal pulse in the setting of high fever is suggestive of atypical CAP.
  • Wheezing, rhonchi, crackles Work-Up

Imaging

• Typical CAP – Lobar Consolidation on CXR
• Atypical CAP - Patchy interstitial pattern on CXR Work-Up (From Erkonen WE, Smith WL. Radiology 101: The Basics and Fundamentals of Imaging. Philadelphia, PA: Lippincott Williams & Wilkins, 1998:110, Figure 6-54A and B.)

Chest Radiology In Pneumonia

Left Lobar Pneumonia with pleural effusion Right Middle Lobar Pneumonia Right Upper Lobar Pneumonia Right Upper Lobe Pneumonia with air bronchograms