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Primary
bronchus
Secon
bronchus
Tertia
Alveoli enlarged
Termin al
Chi

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Pneumonia   is inflamed or swollen lung tissue due to infection with a germ

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Symptoms & signs:  fever, malaise, cough, dyspnea and grunting……Tachypnea, retractions & X-ray chest abnormalities.

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1- Community-acquired pneumonia (CAP):  pneumonia in a previously healthy person who acquired the infection outside a hospital (or a  longterm  care facility).  2- Hospital-acquired pneumonia (HAP):  patients live in long-term care facilities or have recently visited a hospital.

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Disease may be “typical” or “atypical.”    “Typical” pneumonia:  is characterized by shaking chills, purulent sputum, and x-ray abnormalities that are proportional to the physical signs.   “Atypical” pneumonia  is characterized by insidious onset, scant sputum and x-ray abnormalities greater than predicted by physical signs.

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"Typical" versus "Atypical" pneumonia
Typical Pneumonia: (virulent bacteria)
• Sudden onset.
• Productive cough with purulent sputum.
• Pleuritic chest pain.
• leukocytosis (high no. of WBC) or leukopenia (low no.
of WBC).
Atypical Pneumonia:
(viral, M. pneumoniae, others)
• Gradual onset.
• Nonproductive cough.
• Substernal chest pain.
• White blood count normal.

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Typical vs. Atypical Pneumonia
Historical Classification
Typical Pneumonia
S pneumoniae. H innuenzae,
Detectable on gram stain.
grows on standard media
Abrupt onset
Fever. pleuritic chest pain.
cough producbve Of purulent.
sometimes blocd•tinged
sputum
Often lobar inntrate
• Elevated Count
Atypical Pneumonia
Chlamydia.
viral
Not detectable on gram stain
or cultivatable on standard
bacteriomc media
May begin as mild URI
followed later by ryostly dry
cough and dyspnea
Infiltrates to
patchy than bhar
exception)
Categ«ies to presentation but is rot

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Strept   pneumoniae Morphology:  Gram positive  cocci  Ovoid or lancet shape, arranged in pairs ( diplococci ), Capsulated.

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Cultural characters:  They grow on blood agar producing  α - haemolysis  or greenish  discolouration  similar to  viridans  streptococci from which they are differentiated by the following tests:

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Pneumocoeci          Viridaris  Streptococci  Solubility in bile                       Soluble                         Not soluble Fermentation of inulin             Fermented                     Not fermented Sensitivity to  optochin             Sensitive                        Not sensitive Pathogenicity to mice             Pathogenic                     Not pathogenic Quellung  test                          Positive                           Negative

Streptococcus
mitis
not lysed by bile
Negative
Streptococcus
pneumoniae
lysed by bile
Positive
Bile solubilitytest

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Antigenic structure and virulence factors:  1-Capsule:   There are at least 91 serotypes of pneumococci based on the chemical specificity of the capsular polysaccharide.  Types 1-8 are responsible for 75% of cases of pneumococcal pneumonia in adults and for more than half of the fatalities in pneumococcal  bacteraemia  in children. 2- IgA1 Protease. 3- Peptidoglycan and  teichoic  acid. 4- Autolysin,  pneumolysin  and  pilli .

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Diseases caused by  pneumococci. It is exclusively a human pathogen that spreads by droplet. Pneumococci cause  pneumonia, meningitis, otitis media, sinusitis, conjunctivitis, endocarditis and other pyogenic infections.

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Diagnosis of pneumonia: 1-Film : Direct microscopic examination of gram stained sputum smears will show the prevalent organism to be pneumococci among pus cells. 2-Culture : Sputum is cultured on blood agar in 5-10% . Alpha  haemolytic  colonies should be differentiated from   viridans  streptococci by (see table)

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3-Quellung reaction:  Fresh emulsified sputum (or CSF deposit in meningitis) mixed with polyvalent anti-pneumococcal serum and methylene blue and examined under the microscope, reveals swollen capsules i.e. a positive ‘ quellung  reaction”. This can be done for rapid identification. 4-Intraperitoneal injection of sputum into mice.   Animals die in 24-48 hrs.  the organism can be seen in tissue smears, and pure culture can be obtained from heart blood . 5-Blood cultures  are positive in 15-25% of pneumococcal infections.

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Treatment:  Most pneumococci are sensitive to  penicillin . Erythromycin or azithromycin  are used for penicillin allergic patients.  Ceftriaxone and  Vancomycin   is used for treatment of penicillin resistant pneumococci.

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Prophylaxis: 1-A polyvalent (23 types) Polysaccharide vaccine (PPV-23).  It is safe, fairly effective and provides long lasting (at least 5 years) protection.  It is recommended for susceptible immunosuppressed individuals e.g. the elderly, debilitated,  asplenic  patients, HIV patients or those under immunosuppressive therapy. 2-A pneumococcal conjugate vaccine(PCV 13).  containing the capsular Polysaccharide of the 13 most common pneumococcal serotypes coupled to a carrier protein. This vaccine is recommended for all children at 2, 4 and 6 months and at 12-15 months.

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With atypical pneumonia → the infection is caused by different bacteria other than the more common ones that cause pneumonia. This causative agent cannot be isolated on ordinary  laboratory media and cannot stained by Gram stain.  Also the clinical picture  of atypical pneumonia does not resemble that of typical pneumonia.

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It presents with → History of upper respiratory tract infection. Gradual onset. Dry cough with scanty sputum. Low grade fever. Sub sternal chest pain. Extra pulmonary manifestations. White blood count normal.

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1- Mycoplasma  pneumoniae 2- Legionella  pneumophilia 3- C.  pneumoniae   4- C.  psittaci 5-  Coxiella   burnetii 6- Viral pneumonia 7- Fungal pneumonia

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Three specific infectious bacteria cause the majority of atypical pneumonia cases: Mycoplasma  pneumoniae   usually infects people under 40 with mild pneumonia symptoms. It commonly causes earaches, headaches, and a sore throat, as well. Chlamydophila   pneumoniae   is common in school-aged children and young adults. Legionella  pneumophila   is more severe, generally, and seen most often in older adults, people who smoke, and those with weakened immune systems. It is also called Legionnaires' disease.

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1-  M.pneumoniae   causes atypical pneumonia. 2-  Ureaplasima   urealyticum   is urease positive. It causes 20% of non- gonococcal  urethritis and neonatal sepsis in premature infants. 3- M  hominis   is associated with postpartum fever and pelvic inflammatory disease e.g.  salpingitis . 4- M.  genitalium   is associated with non- gonococcal  urethritis. - All may be the cause of septic arthritis in  immunocompromised  persons

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Morphology and cultural characters of M.  pneumoniae

Mycoplasma are the  smallest free living  organisms.  They lack cell wall →   وعشان كده they are  pleomorphic ,  stain poorly with gram  but can be stained by  Geimsa  stain.  They are the only bacteria that  contain cholesterol in their cell membrane. They  require special enriched media  for growth

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1- Direct detection in sputum or nasopharyngeal aspirates of: a-Antigens  by  immunofluoiescence  using specific antisera. b-Specific nucleotide sequence  using DNA probes  orPCR .

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2- Serology is most useful in diagnosis : a-Detection of M.  pneurnoniae   IgM ( rising  titre  of  IgG  by ELISA or complement fixation. b-Detection of cold agglutinin  at a  titre  of 1∕128 or higher indicates recent infection.  These are autoantibodies against type O red cells that agglutinate these cells at 4°C but not at 37°C.  It is positive in 50% of cases. It is non-specific and may be positive in other diseases including viral infections, malaria and acquired  haemolytic   anaemia . 3- Isolation from sputum is difficult and time consuming

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They are treated by  tetracyclines , erythromycin or azithromycin

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There are about  40 species  of Legionella found in soil and water.  L.  pneumophila   is the major cause of disease in man.  It causes outbreaks of  Atypical pneumonia  “ Legionnaire’s disease ”.  It also causes  Pontiac fever  characterized by fever, malaise, headache, muscle pains and cough (flulike condition)

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Motile weakly gram negative rods.  They are fastidious and require for growth media containing L-cysteine, iron, and  α - ketoglutarate  as in buffered charcoal yeast extract (BCYE) agar.  They are catalase and oxidase positive

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Infection occurs by  inhalation  of water aerosols contaminated by these organisms. It can be community-acquired or nosocomial. Risk groups include alcoholics, diabetics, AIDS, cancer and transplant patients

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L.  pneumophila  can survive  intracellularly  in alveolar macrophages, as they inhibit  phagosomal   lysosomal  granules fusion.  They produce proteases that cause patchy infiltrations in the lungs.  Bacteraemia  may occur in severe cases. accompanied by damage to the vascular endothelium in organs like the brain and kidney. Cell mediated immunity is the most important defense mechanism, because of the intracellular growth of the organism

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Erythromycin  alone or in combination with  rifampicin  is the treatment of choice

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Characters:    - Similar to bacteria in:  1. cell wall→ typical of Gram-negative bacteria.  2. cytoplasm →both RNA , DNA , ribosome  3.  Multiplication→by  simple binary fission.  4.Morphology→pleomorphic  coccobacilli   5. treated by antibiotics  - Similar to viruses in:  1. Obligate intracellular (cannot cultivated on inanimate media as it is unable to synthetize ATP)  2. Culture→ cell culture,  embryonated  eggs, susceptible animals.

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3 species:   1- C. trachomatis 2- C.  psittaci  &  3- C  pneumoniae

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Developmental cycle of chlamydia  2 forms :  1. Elementary body (EB):  infectious non replicating form, 0.25 - 0.3  μm  in diameter released from ruptured infected cells and  can be transmitted from one individual to another.  2. Reticulate body (RB):  intracytoplasmic  replicating form, 0.5 - 0.6  μm  in diameter.  EB enters the cell by endocytosis and develops into RB within a cytoplasmic vacuole with no cell wall & divides by binary fission to form particles which after synthesis of the outer cell wall, develop into new infectious EB & released from the cell to infect other cells.

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Chlamydiae  that infect humans are divided into three species

1-Chlamydia trachomatis →  causes ocular. genital and respiratory infections. 2-Chlamydia  psittaci → causes psittacosis in birds that may be transmitted to man. 3-Chlamydia  pneumoniae →   causes atypical pneumonia

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1- Sample → sputum  2. Direct smear → Inclusion bodies in scraped tissue cells detected by staining with  Giemsa  or with fluorescent monoclonal antibodies  3. Culture:  on  - McCoy cells. - yolk sac of  embryonated  egg:  4. Serological tests: - Antigen detection  → directly in specimens by using specific  immunofluorescent  antibodies  - Antibodies detection  →in sera from infected humans by the complement fixation or immunofluorescence tests.  5. Molecular techniques  DNA probes & PCR.

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Treatment → Tetracycline & erythromycin  &  Penicillin is not effective.  Control   No vaccine

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Q fever  – caused by  Coxiella   burnetii .   The infection is acquired by inhalation of infectious material.   After an incubation of 14-26 days there is a sudden onset of fever, chills, and headache, but no rash.   The disease is characteristically an atypical pneumonia lasting 5-14 days with a low mortality rate. Hepatitis is frequent enough that the combination of pneumonia and hepatitis should suggest Q fever. Treatment:  Doxycycline with ciprofloxacin or rifampicin. Prevention:  A formalin-killed whole cell vaccine is available for those occupationally at risk.  Proper pasteurization of milk

Pneumonia

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