1. Pneumonia
9/3/2006
……..
I have no concerns that this group of students are in any way
resting on their laurels. So far the feedback from the medical staff
has been excellent. There have been a number of preceptors who
have noted the substantial difference between this years 4th yrs and
last years 4th yrs. A number of their preceptors in the hospital, who
are not easily impressed, have gone out of their way to tell me how
impressed they have been with this group.
…………
Impressive….! Keep it up…..!
1

2. Pneumonia
CPC-4
 Mr. Turner is a 38 years old Vietnamese
cane farmer living near Cairns. He is married
to an indigenous woman and has 2 children
aged 10 and 12. He is sent by his GP to A&E
with high fever, shortness of breath and
cough. He feels very unwell and is flushed
and feeling breathless and faint.
2

3. Pneumonia
CPC-4
 Questions:
 Duration, course, sputum, wt loss.
 Past history, Family
 Smoking, recent contacts/visits.
 Diabetes, sexual/venereal diseases.
 Differential diagnoses:
 Cardiovascular – MI, CCF, etc..
 Respiratory – Pneumonia, Bronchiolitis,
aspiration/inhalation injury, Asthma, ARDS, Pulm.
Embolism, Empyema.
 Metabolic – Acidosis, Diabetic, Septicemia – focus of
infection? AIDS, Q fever, Legionella.
 Others: Cystic Fibrosis, Immunodeficiency.
3

4. Pneumonia
Pathogenesis of Clinical features:
 Tachypnoea, Dyspnoea, Resp Acidosis  Solid/airless lungs
– decreased oxygenation.
 Dull percussion - Consolidation – Exudation
 Rusty sputum – RBC+WBC (LRT bleed), S.pneum,
 Greenish sputum – Pseudomonas.
 Foul smelling sputum- anaerobic.
 Current jelly sputum-Klebsiella.
 Fever – Inflammatory mediators.
4

5. Pneumonia
"In the presence of greatness, pettiness
disappears. In the absence of a great
dream, pettiness prevails."
Robert Fritz
Composer, Filmmaker and Author
5

6. Pathology of
Lung Infections
Dr. Venkatesh M. Shashidhar
Assoc. Prof & Head of Pathology

7. Pneumonia
Normal Lung
Tr.Air Sh
Br. Mar.
7

8. Normal Lung
Type 2
Type 1-Pneumocyte

9. Pneumonia
Respiratory system: Introduction
 5000 sq meters of area….! (olympic track)
 Filters >10,000 L of air / day…!
 Normal lungs are sterile.
 Delicate, thin resp. mem – gas exch.
 Filter, humidify, sterilize, highly sensitive.
 RTI – commonest in medical practice.
 Pathology:
 Injury, Infections & Neoplasia. Acute / Chronic.
 Disorders of Airway – Bronchitis, COPD, Asthma, tumors.
 Disorders of Lung tissue –Pneumonia, Pneumoconiosis.
9

10. Pneumonia
Patterns of Lung disorders:
 Airway
 Bronchitis, Bronchiectasis, Bronchiolitis.
 Tumors / Cancer
Parenchyma

 Pneumonia. *
Infections
 Lung abscess, TB
 Hyaline membrane dis (HMD & ARDS)
 Pneumoconiosis
 Tumors / Cancer
 Pleura:
 Pleural effusion (TB)
 Tumors / Cancer
10

11. Pneumonia
Pneumonia: Definition & Etiology
 Inflammation of Lung tissue (not Bronchi)
 LRT/Distal airways – Alveoli & Terminal bronchioles
 Decreased defense / Strong Pathogen
 Immunodeficiency, damaged lung (COPD),
 Virulent infection - Lobar pneumonia
 Defective Clearing mechanism
 Cough/gag Reflex – Coma, paralysis, sick.
 Mucosal Injury – smoking, toxins, aspiration.
 Low Alveolar defense - Immunodeficiency
 Pulmonary edema – Cardiac failure, embol.
 Obstructions – foreign body, tumors, cystic fibrosis. 11

12. Pneumonia
Pneumonia Types:
Etiologic Types: Morphologic types:
 Lobar
 Infective
 Broncho
 Viral
 Interstitial
 Bacterial
 Fungal Duration:
 Acute
 Tuberculosis
 Chronic
 Non Infective
Clinical:
 Toxins
 Primary / secondary.
 chemical
 Typical / Atypical
 Aspiration
 Community a / hospital a
12

13. Pneumonia
Broncho – Pneumonia - Lobar
 Extremes of age.  Middle age – 20-50
 Secondary, in sick.  Primary in a healthy adult.
 Both genders.  males common.
 Staph, Strep, H.infl.  95% pneumococcus (Klebs.)
 Patchy consolidation  Entire lobe consolidation
 Around Small Bronchi  Diffuse
 Not limited by anatomic  Limited by anatomic
boundaries. boundaries.
 Usually bilateral.  Usually unilateral
13

14. Pneumonia
Etiologic
agents in
Pneumonia:
14

15. Pneumonia
Common Pathogens:
 Community-Acquired Acute Pneumonia:
 Strep, H.influenzae, Staph aureus, Klebsiella.
 Community-Acquired Atypical Pneumonia:
 Mycoplasma, Chlamydia, SARS*
 Nosocomial Pneumonia:
 Klebsiella spp., Serratia, E coli.
 Aspiration Pneumonia:
 Anaerobic oral flora (Bacteroides)
 Chronic Pneumonia:
 Nocardia, Actinomyces, TB, Atyp. Mycob. Fungal
 Necrotizing Pneumonia and Lung Abscess:
 Anaerobic bacteria (foreign body, tumor)
 Pneumonia in the Immunocompromised:
 CMV, Pneumocystis, Atyp. Mycob. Fungal. (candida, aspergillus).
15

16. Pneumonia
Agar? Morphology? diagnosis? Further tests?
16

17. Pneumonia
Pathogenesis of infective Pneumonia:
Step 1: Entry
 Aspiration
 Inhalation
 Inoculation
 Colonization
 Hematogenous
 Direct spread
17

18. Grey Hepatization
Resolution
Pathogenesis
of Pneumonia
Congestion
Red Hepatisation

19. Pneumonia
Lobar Pneumonia:
 whole lobe, exudation - consolidation
 95% - Strep pneum.(Klebsiella in
aged, DM, alcoholics)
 High fever, rusty sputum, Pleuritic chest pain.
 Four stages: (*also in bronchopneumonia)
 Congestion – 1d – vasodilatation congestion.
 Red Hepatization 2d Exudation+RBC
 Gray Hepatizaiton 4d neutro & Macrophages.
 Resolution – 8d few macrophages, normal.
19

20. Pneumonia
Lobar
Pneumonia:
20

21. Pneumonia
Lobar
Pneumonia: Red
Hepatization
21

22. Pneumonia
Lobar
Pneumonia:
Grey Hepatization
22

23. Pneumonia
Lobar
Pneumonia:
Grey Hepatization
23

24. Pneumonia
Lobar
Pneumonia:
24

25. Pneumonia
Left lower Lobar
Pneumonia:
25

26. Pneumonia
Lobar
Pneumonia:
26

27. Pneumonia
Left lower Lobar
Pneumonia:
Methylene blue stain:
27

28. Pneumonia
Lobar Pneumonia – Gray hep…
28

29. Pneumonia
Lobar Pneumonia – Acute Fibrinous pleurisy
29

30. Pneumonia
Lobar Pneumonia:
30

31. Pneumonia
Lobar Pneumonia: Microscopy:
Congestion  red hepatization
31

32. Pneumonia
Lobar Pneumonia: Red hepatization.
• Acute inflammatory
cells & RBC Filling
alveolar spaces
Uniformly.
• Congested capillaries
in the alveolar septa
32

33. Pneumonia
Lobar Pneumonia: Red hepatization.
• Acute inflammatory
cells. Filling alveolar
spaces Uniformly.
• Congested capillaries
in the alveolar septa
33

34. Pneumonia
Lobar Pneumonia: Red  Grey
hepatization.
34

35. Pneumonia
Lobar Pneumonia: Grey hepat.
35

36. Pneumonia
Lobar Pneumonia:
36

37. Pneumonia
Lobar Pneumonia:
37

38. Pneumonia
Lobar Pneumonia: Which lobe?
38

39. Pneumonia
Broncho-
pneumonia
39

40. Pneumonia
Broncho-
pneumonia
40

41. Pneumonia
Broncho-
pneumonia
41

42. Pneumonia
Bronchopneumonia (patchy)
 Extremes of age. (infancy and old age)
 Secondary to Risk factors.
 Staph, Strep, Pneumo & H. influenza
 Patchy consolidation – not limited to lobes.
 Suppurative inflammation
 Usually bilateral
 More in Lower lobes
42

43. Pneumonia
Broncho
Pneumonia
43

44. Pneumonia
Bronchopneumonia:
44

45. Pneumonia
Bronchopneumonia - CT
45

46. Pneumonia
Bronchopneumonia
46

47. Broncho – Pneumonia - Lobar

48. Pneumonia
Interstitial / atypical Pneumonia
 Primary atypical pneumonia in the
immunocompetant host (Mycoplasma or
Chlamydia)
 Interstitial pneumonitis
 immunocompromised host : Pneumocystic carinii; CMV
 Immunocompetant host: Influenza A
 Gross features:
 Lungs are heavy but not firmly consolidated
 Microscopic features:
 Septal mononuclear infiltrate
 Alveolar air spaces either ‘empty’ or filled with
proteinaceous fluid with few or no inflammatory cells
48

49. Pneumonia
Interstitial Pneumonia:
Lymphocyte
Infiltrate in
alveloar wall
49

50. Pneumonia
Acute viral Pneumonia:
Fibrin
Lymphocytes
B.V
50

51. Pneumonia
Chronic Pneumonia
 Chronic, lymphoid infiltrate,
 No classic stages.
 Lung destruction – cavity, abscess etc.
 Organisms
 Mycobacterium tuberculosis
 Histoplasma capsulatum
 Aspergillosis
 Actinomyces
51

52. Pneumonia
Complications of Pneumonia
 Abscesses
 Localized suppurative necrosis, Right side
often in aspiration.
 Staphylococcus; Klebsiella; Pneudomonas
 Pleuritis / Pleural effusion.
 Inflammation of the pleura ( Streptococcus
pneumoniae)
 Blood rich exudate (esp. rickettsial diseases)
 Empyema
 Pus in the pleural space.
 Septicemia
52

53. Pneumonia
Abscess formation
53

54. Pneumonia
Lung Abscess:
54

55. Pneumonia
Lung Abscess:
55

56. Pneumonia
Lung Abscess:
56

57. Pneumonia
Abscess formation
57

58. Pneumonia
Lung Abscess:
58

59. Pneumonia
Lung Fungal Abscess: Candida
59

60. First step to make your dreams
come true is to…...
wake up!
— Paul Valery

61. Pneumonia
CPC-1.5 – Pneum
 Pathology - Core Learning Issues:
 Pathology of pneumonia and the course of pathological changes.
 Different diagnostic modalities in the diagnosis of pneumonia
(chest x-ray, blood gases, sputum culture, bronchial washings,
serology)
 Histopathology of pneumonia – Lobar, Broncho.
 Complications of pneumonia, ARDS, effusions, empyema etc.,.
 Basic science - Core Learning Issues:
 Anatomy of the lobes of the lung. Why does aspiration occur on
right side?
 Spread of infectious disease - mechanisms
 Physiology of Respiration, Blood gases and Pulse Oxymetry.
 Metabolic and respiratory acidosis.
 Importance of oxygenation and oxygen delivery
 Common respiratory pathogens
61

62. Pneumonia
34y, M, H.Fever - Lung. ? Diagnosis
1. Lobar pneumonia
2. Broncho pneumonia
3. Interstitial pneumonia
4. Fungal pneumonia
5. Carcinomatous pneumonia
0% 0% 0% 0% 0%
1 2 3 4 5
62

63. Pneumonia
34y, M, H. Fever - Lung. ? Diagnosis
1. Lobar pneumonia
2. Broncho pneumonia
3. Interstitial pneumonia
4. Fungal pneumonia
5. Carcinomatous pneumonia
0% 0% 0% 0% 0%
1 2 3 4 5
63

64. Pneumonia
54y, M, H. dyspnoea- Lung. ? Diagnosis
1. Lobar pneumonia
2. Broncho pneumonia
3. Interstitial pneumonia
4. Fungal pneumonia
5. Carcinomatous pneumonia
0% 0% 0% 0% 0%
1 2 3 4 5
64

65. Pneumonia
74y, Ca prostate, Lung - lobar pneumonia.
? Which Lobe
1. Left lower
2. Left middle
3. Right middle
4. Left apical
5. Right lower
0% 0% 0% 0% 0%
1 2 3 4 5
65

66. Pneumonia
74y, Ca prostate, Lung - ? diagnosis
1. Lobar Pneum+Broncho Pneum.
2. Lobar Pneum+metastasis
3. Lobar pneum + Abscess
4. Smokers lung + Lobar pneum
5. COPD+Lung Abscess
0% 0% 0% 0% 0%
1 2 3 4 5
66

67. Pneumonia
39y, M chronic smoker, High fever, Lung
? What type of pneumonia
1. Lobar pneumonia
2. Interstitial pneumonia
3. Broncho pneumonia
4. Fungal pneumonia
5. Carcinomatous pneumonia
0% 0% 0% 0% 0%
1 2 3 4 5
67

68. Enter question text...
1. Enter answer
text...

69. Pneumonia
Peter is 58 years old and is a non-smoker and he suffers aspiration of
gastric contents during cardiac resuscitation. Over the next 10 days he
develops a non-productive cough & fever. A chest radiograph reveals a 4
cm diameter mass with an air-fluid level in the right lung. A sputum gram
stain reveals mixed flora.
Of the following conditions which is he most likely to have?
1. Lobar pneumonia
2. Broncho pneumonia
3. Interstitial pneumonia
4. Fungal pneumonia
5. Lung abscess
0% 0% 0% 0% 0%
1 2 3 4 5
69

70. Pneumonia
59y F, Recurrent fever, cough, dyspnoea,
Lung biopsy. ? Diagnosis
A. Lobar pneumonia
B. Broncho pneumonia
C. Interstitial pneumonia
D. Fungal pneumonia
E. Lung abscess
0% 0% 0% 0% 0%
1 2 3 4 5
70

71. Pneumonia
CPC 1.5 – Pneu - KFP Questions:
 Pneumonia – types (clin, path, Broncho, lobar)
 Gross stages – congestion, red, grey, resol.
 Microscopy of pneumonia (stages)
 Complications of pneumonia – acute, chronic.
 Pathogenesis of clinical features:
 Fever, dyspnoea, tachypnoea, dull percussion, bronchial
breathing, increase/decreased tactile and vocal
fremitus, fine rales etc.
 Investigations:
 Clinical:
 Pathology: Blood gas, sputum mircroscopy,
microbiological C&S,
71

72. Pneumonia
29y M, High fever, cough, dyspnoea,
Sputum gram stain ? Possible type of pneumonia
1. Lobar pneumonia
2. Broncho pneumonia
3. Interstitial pneumonia
4. Fungal pneumonia
5. Lung abscess
0% 0% 0% 0% 0%
1 2 3 4 5
72

73. Pneumonia
29y M, High fever, cough, dyspnoea,
Sputum culture-blood agar, optochin disc. Shows ?
1. Alpha hemolysis
2. Beta hemolysis
3. Optochin resitance
4. Optochin sensitivity
5. No hemolysis
Note: Multiple correct answers
0% 0% 0% 0% 0%
1 2 3 4 5
73

74. Pneumonia
29y M, High fever, cough, dyspnoea,
Sputum – quad ID plate. ? diagnosis
1. Streptococcus pneumoniae
2. Staphyloccous aureus
3. Hemophilus influenza
4. Escherichia coli
5. Pseudomonas aeruginosa
0% 0% 0% 0% 0%
74
1 2 3 4 5

75. Pneumonia
29y M, High fever, cough, dyspnoea,
Chest Radiograph ? Likely Etiologic Agent
1. Streptococcus pneumoniae
2. Staphyloccous aureus
3. Hemophilus influenza
4. Escherichia coli
5. Pseudomonas aeruginosa
0% 0% 0% 0% 0%
75
1 2 3 4 5

76. Pneumonia
“Big Jobs usually go to the men who prove
their ability to outgrow small ones.”
–Ralph Waldo Emerson
76

77. Pneumonia
List
Gross features:
77

78. Pneumonia
Aspergillus pneumonia in a HIV Patient:
78

79. Pneumonia
Tuberculosis:
79

80. Pneumonia
Non-infective pneumonias
 Bronchiolitis obliterans/organising
pneumonia (BOOP):
 Reactive – irritants. TypeII cell hyperplasia.
 Aspiration pneumonia
 Lower lobe, sec infection, abscess.
 Lipid pneumonia
 Airway obstruction, atelectasis.
 Eosinophilic pneumonia
 Asthma, Löffler's syndrome.
80

81. The only place where
success comes before work is in a
dictionary…!
Vidal Sassoon

82. Case Study:

83. Pneumonia
History
 49-year-old white male with a
productive cough (green–yellow
sputum) for the past
3 days presents to his General
Practitioner (GP) with progressive
dyspnoea, which is severe upon
minimal exertion
83

84. Pneumonia
Comm – Pneumonia - Nosoc
 In healthy adults  In *sick patients.
 Gram positive.  gram-negative bacilli
 Streptococcus  Pseudomonas
pneumoniae (90%) aeruginosa, Escherichia
 Strep. coli, Enterobacter, Proteu
Pyogenes, Staph, H. s, and Klebsiella.
influenzae and
Klebsiella in elderly
or with COPD.
84

85. Pneumonia
History
 Patient’s past medical history includes:
 arterial hypertension for 5 years
 urinary tract infection 1 month previously, which
was treated with ciprofloxacin 200 mg three-times
daily for 5 days
 Patient has smoked 20 cigarettes/day for
35 years, although obstructive lung disease
is not evident
 Current medication:
 metoprolol tartrate 100 mg/day
85

86. Pneumonia
Examination
 Clinical findings:
 awake
 deteriorated clinical state
 dyspnoea during rest (32 breaths/min)
 rales (abnormal respiratory sound) over the
left lung
 prolonged exhalation
 no pathological findings in other organs
 arterial blood pressure 100/50 mmHg
 pulse rate 108/min
 temperature 39.0°C
86

87. Pneumonia
Laboratory findings
Leukocytes 19.0 x 109/L (19 000/µL)
Haemoglobin 7.1 mmol/L (11.5 g/dL)
Haematocrit 0.35 (35 mL/dL)
Platelets 195 x 109/L (195 000 /µL)
C-reactive protein 279.4 mg/dL [<5]
Blood urea nitrogen 6.6 nmol/L (9.0 mg/dL)
Creatinine 95 µmol/L (1.1 mg/dL)
Sodium 135 mmol/L (135 mEq/L)
Potassium 4.56 mmol/L (4.56 mEq/L)
Glucose 6.8 mmol/L (121.4 mg/dL)
PaO2 62.1 mmHg
PaCO2 33.8 mmHg
sat O2 91.2%
pH 7.41
87

88. Pneumonia
Additional investigations
 Chest X-ray is requested by the GP
 X-ray shows a large infiltration in the
left upper and lower lobe of the lung,
suggestive of pneumonia
88

89. Chest X-ray: findings?

90. Pneumonia
Treatment decision
 Patient is admitted to hospital on the
basis of his clinical and X-ray
findings, together with his smoking
history
90

91. Pneumonia
lnvestigations
lnvestigations
 Diagnostic tests performed include:
 bronchoscopy with lavage of the left upper
lobe for microbiological investigation
 blood cultures (three pairs)
 urine screening for Legionella spp. antigen
91

92. Pneumonia
Initial empiric treatment
 The patient receives oral azithromycin
500 mg once daily
92

93. Pneumonia
Hospital Day 3 examination
 Clinical findings:
 clinical state has not improved. Patient is
slightly disorientated
 respiratory rate 35 breaths/min
 blood pressure 100/65 mmHg
 pulse rate 136/min
 temperature 38.9–39.9°C
93

94. Pneumonia
Hospital Day 3 laboratory findings
Leukocytes 22.4 x 109/L (22 400/µL)
Haemoglobin 6.1 mmol/L (9.8 g/dL)
Haematocrit 0.30 (35 mL/dL)
Platelets 395 x 109/L (39 500/µL)
C-reactive protein 394.2 mg/dL [<5]
Blood urea nitrogen 16.6 nmol/L(22.7 mg/dL)
Creatinine 145 µmol/L (1.7 mg/dL)
Sodium 138 mmol/L (138 mEq/L)
Potassium 3.88 mmol/L (3.88 mEq/L)
Glucose 8.2 mmol/L (146.4 mg/dL)
PaO2 55.2 mmHg
PaCO2 30.1 mmHg
sat O2 86.9%
pH 7.46
94

95. Pneumonia
Hospital Day 3 investigations
 Chest X-ray is repeated:
 shows enlarged infiltration in the left upper
and lower lobes of the lung, with possible
pleural effusion (left)
 Microbiological tests show:
 all cultures negative (tracheal secretion, blood
culture)
 Legionella spp. antigen negative
 What would you do now?
95

96. Pneumonia
Chest X-ray: hospital Day 3
96

97. Pneumonia
Hospital Day 3 diagnostic and therapeutic procedures
 Bronchoscopy with bronchoalveolar lavage
(BAL) is performed
 differential cell count: 48% granulocytes,
10% lymphocytes, 42% macrophages
 S. pneumoniae antigen is positive in the
urine
 Patient is switched to levofloxacin 500 mg
IV three-times daily and is transferred to
the intensive care unit (ICU)
97