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Pneumonia 100906122529-phpapp02
PNEUMONIA
• Pneumonia is an inflammation of the parenchyma of
  the lung.

  - Most cases of pneunomin are
  caused by microorganism.
  - non infectious causes include
  aspiration of food or
  gastric acid foreign bodies
  hydrocarbons and lipoid.
  substances hypersensitivity
   reaction and drug or radiation
   induced pneumonitis.
PNEUMONIA
• Classification .
1 : Anatomical classification.
A – lobar pneumonia .
   The consolidalion involves all or part of lobe
B – Bronchopneumonia
   the consolidation involves scattered lobules
C - Interstitial pneumonia .
   As in viral pneumonia where inflammatory .
Infiltrate involve mainly interstitial tissue between alveli.
PNEUMONIA

2 : Etiological classfication.
the cause of pneumonia in patient is often difficult to
   determine because direct culture of lung tissue
   invasive and rarely performed.
   - culture obtained from upper respiratory tract or
   sputum genenally not accurately.
PNEUMONIA
• Causes of infectious pneumonia.
  Bacterial.
  Common.
  - streptococcus pneumoniae
  Group B streptococci
  Group A streptococci .
  - Mycoplasma pneumoniae
  - chlamydia pneumoniae              Adolescent.
  - chlamydia trachomatis          infant.
  -Mixed anaerobes                  Aspiration pneumonia
  - Gram-negative enteric.
PNEUMONIA
Uncommon.
- Haemphilus influenza       Unimmunized.
- Staphylococcus aureus
- Moraxella catarrhalis
- Neisseria meningitides
- Francisella tularensis     animal fly contact
- Nocardia species            Immunosuppressed person.
- Chlamydia psittaci         Bird contact.
- Yersinia pestis            Plague
- Legionella species         Exposure to contamianted water.
PNEUMONIA
   Viral -
-Common
Respiratory syncytial virus
Parainflueza type 1 – 3
Influeza A . B
Adenovirus
Metapneumovirus
 Un Common -
 Rhinovirus
 Enterovirus             Neonates
 Herpes simplex           Neontes
  Cytomegalovirus          Immunosuppressed person.
 Measles
 Varicella
 Hantavirus
         .Sars agent
PNEUMONIA
-Fungal.
  Histoplasma capsulatum        Bird bat contact
  Cryptococcus neoformans  Bird contact.
  Aspergillus species       Immunosuppressed.
  Mucomycosis               Immunosuppressed
  Coccidioides immitis
  Blastomyces dermatitides
 Rickettsial -

    Coxiella burnetii    Goat sheep cattle exposure
 Rickettsia rickettsiae
PNEUMONIA
• Mycobacterial

Nycobacterium Tuberculosis  Developed countries
Nycobacterium avium-inteacellulare  Immunosuppressed.
•Parasitic
Pneumocystis Carini  Immunosuppressed. Steroid.
Eosinophilic  Ascaris .
Loeffler syndrom
•Non infectious causes
-Aspiration Of food.
-Gastric acid.
-foreign body.
-Hydrocarbon  Kerosen
-Lipoid substances
- Aspiration of amniotic fluid.
PNEUMONIA
Age group       Frequent Pathogens
Neonate <1mo    Group B straptococcus – E coli
                streptococcus Pneumoniae – H influeza.
1-3 mo          Rsv . Influenza viruses para fluenza viruses – adenovirus
febrile Pneu    S. pneumoniae . H . influenza
Afebrile Pneu   Chlamydia trachomatis Mycoplasma hominis cytomegalovirus.

3 – 12 mo       R.S.V Influenza viruses para fluenza viruses adenovirus
                S. pneumoniae H . Influenza Chlamydia trachomatis Mycoplasma
                pneumoniae Group A straptococcus
2 – 5 yr        Influenza viruses para fluenza viruses adenovirus S. pneumoniae
                 H . Influenza Mycoplasma pneumoniae Chlamydia pneumoniae
                Group A straptococcus S . Aureus.
5 – 18 yr       Mycoplasma pneumoniae S. pneumoniae Chlamydia pneumoniae
                H . Influenza Influenza viruses adenovirus
> 18 yr         Mycoplasma pneumoniae S. pneumoniae Chlamydia pneumoniae
                H . Influenza Influenza viruses adenovirus.
Pneumonia 100906122529-phpapp02
PNEUMONIA
• Hospitalization of children with pneumonia
Age > 6 month -
- Sickle cell anemia with acute chest syndrom.
.- Multiple lobe involvement
Immunocompromised-
 . Toxic appearance-
Sever respiratory distress -
.Requirement for supplemental oxygen-
 Dehydration-
.Vomiting-
.No response to oral antibiotic-
.Non compliant parent -
PNEUMONIA
• Recurrent pneumonia
-Hereditary disorder
Cystic fibrosis
Sickle cell disease
-Disorders of immunity
Aids
Bruton agammaglobulemia
Selective IgG subclass deficiencies
Common variable immunodeficiency syndrom
Sever combined immunodeficiency syndrom
-Disorders of leukocytes
Chronic granulomatous diseaseٍ
Hyperimmunoglobulin E syndrome
 Leukocyte adhesion defect
PNEUMONIA
- Disorders of cilia
Immotile cilia syndrom
Kartagener syndrom


-Anatomic disorder
Sequestration
Lobar emphysema
Esophageal reflux
Foreign body
Tracheo esophageal fistula ( H type )
Gastroesophageal reflux
Bronchietasis
Aspiration ( oro pharyngeal in coordination )
PNEUMONIA
 • Pathogenesis
 The lower respiratory tract is normally sterile by
 -Physiologic defense mechanisms including
 -Mucociliary clearance
 -ProPerties of normal secretion such as secretory immunoglobulin A  IgA
 - Clearing of air way by coughing
 Immunologic defense mechanism of lung limit invasion by pathogenic
 organisms
 Includes macrophages are present in alveoli and bronchioles secretory IgA
 and others immunoglobulins
PNEUMONIA
PNEUMONIA
•Viral pneumonia
usually result from spread of infection along the air way. Accompanied by
 direct injury of respiratory epithelium resulting in air way obstruction from
swelling abnormal secretion and cellular debris small calibar of air way in
 young infant makes them particularly susceptible to sever infection.
Viral infection predispose to secondary bacterial infection by disturbing
 normal host defense mechanism altering secretion and modifying bacterial flora.
PNEUMONIA
 •Bacterial infection
 In bacterial infection pathologic process varies according
  to the invading organism
 M . Pneumoniae attaches to
 the respiratory epithelium inhibit ciliary action and
 Lead to cellular destruction and an inflammatory response in the submucosa
 as the infection progresses sloughed cellular debris inflammatory cell and mucus
 Cause airway obstruction with spread of infection occuriang along the bronchial
 Tree as in viral pneumoia.



- S . Pneumoniae
Produce local edema that aids in the proliferation of organism and their spread
Into adjacent portion of lung often resulting in the characteristic focal lobar
Involvement
PNEUMONIA
-Grop A . Streptococcus
pathology Includes necrosis of tracheobronchial mucosa formation
-of large
 amount of exudate edema and local hemorrhage with extension into the
Interalveolar septa and involvement of lymphatic vessel and pleura.

-S – aureus pneumonia
produces Toxin and enzymes as hemolysin coagulase and
staphylo kinase-
It causes broncho pneumonia often unilateral characterized by
prensence of
 Hemorrhagic necrosis and irregular areas of cavitation of
lung parenchyma
Resulting in pneumatoceles empyema or broncho pulmonary fistula
.Pyopneumothorax
PNEUMONIA
 Following changes stages:
 1- congestion alveoli are failed with edema fluid and organism.
 2- red hepatization alveoli contain polymorph RBCs fibrin edema and organism.
 3-grey hepatization deposition of fibrin over the pleural surface phagocytosis
 starts inside the alveoli which are now filled with polymorph and fibrin.
 4-resolution: neutrophil degenerate fibrin thread and remaining bacteria and
  digested and removed by phagocyte

 Clinical Manifestation
 Viral & bacterial pneumonia are often preceded by several day of symptoms
 of URTI typically rhinitis and cough.
 In viral pneumonia:
 fever is usually present lower than in bacteria.
 Tachypnea increased work of breathing accompanied by intercostal, subcostal
 and suprasternal retraction nasal flaring and use of accessory muscle.
 Severe infection accompanied by cyanosis and respiratory fatigue in infant.
 Auscultation of chest wheezing and crackle
PNEUMONIA
 In bacterial pneumonia:
 Sudden shaking chill followed high fever, cough, grunting, chest pain,
  drowsiness, rapid respiration, dry cough, anxiety circumoaral cyanosis.

 Physical finding:
 Depends on the stage of pneumonia diminished breath sound scattered crackels
 and rhonchi over affected lung.
 Increasing consolidation or complication.
 As effusion empyema or pyopneumothorax dullness on percussion and breath
 Sound.
 Diminished abdominal distension because of gastric dilation from swallowed
  air or ileus. Abdominal pain in lower lobe pneumonia
 Liver may seem enlarged because downward of diaphragm secondary to hyper
 inflation of lung
 Neck rigidity without meningitis in right upper lobe.
PNEUMONIA
Diagnosis:
Chest X-ray diagnosis of pneumonia may indicate complication pleural
 effusion or empyema.
Viral pneumonia X-ray  hyper inflation with bilateral interstitial infiltrate
 pneumococcal pneumonia lobar consolifation
repeat chest x-ray are not required for proof of cure for ratient with
 uncomplicated pneumonia.
- WBC can differentiating viral from bacterial in virtual WBC normal or
elevated but usually not highert han 20,000/mm3 with lymphocyte predominance
Bacterial 15,000- 40,000 predominance granulocyte.
-Pleural effusion – lobar consolidation and high fever at onset of illness suggestive
of bacterial.
-Atypical pneumonia due to C.pneumoniae or M.pneumoniae is difficult to
distinguish from pneumococal pneumonia by X-ray and other lab.
-pneumococcal pneumonia higher in WBC count ESR-CRP.
- Isolation of organism from blood-pleural fluid or lung culture of sputum blood culture.
positive PCR in viruses
Pneumonia 100906122529-phpapp02
PNEUMONIA
 Treatment:
 Treatment based on cause and clinical appearance of child.
 Children do not require hospitalization.
 -Amoxicillin ( 80-90mg/kg/24 hrs )
 - cefuroxime = Zinnat or Amoxicillinclavulante = ogmin.
 - For school age children with M-pneumonia.
 -C.pneumonia (atypical pneumonia)
 mcrolide antibiotic such as azilhromjcin
 Bacterial pneumonia in hostpitalized child
 cefuroxime (150 mg/kg/24 hrs) = Zinnat
 cefotaxime = claforan
 cefftriaxone = Rocephin
 - If staphylococcal pneumatotocele empyema
 Vancomycin or clindamycin
 Viral pneumonia
  no respiratory distress with hold antibiotic therapy
 - Up to 30% of patient wih known viral infection may have coexisting
  bacterial pathogen.
PNEUMONIA
 Deterioration in clinical status antibiotic therapy should be initiated
 Response to treatment:
 Patient with uncomplicated bacterial pneumonia respond to therapy with improvement
 in clinical symptom (fever, cough, tachypnea, chest pain) within 48-96 hrs.
 Slowly resolving pneumonia
 1- complication as empyema.
 2- bacterial resistance.
 3- non bacterial etiology as viruses and aspiration of foreign bodies or food.
 4- bronchial obstruction from endobronchial lesion foreign body or mucus plug.
 5- pre-existing diseases such as immunodeficiencies- ciliary dyskinesia- cysticfibrosis
    pulmonary sequestration cystic adenomatoid malformation.
 6- non infectious causes:
    - bronchoilitis obliterans.
    - hypersensitivity pneumonitis
    - eosinophils pneumonia
    - aspiration
    - wegener granulomatosis
PNEUMONIA
 Complication:
 Usually result of direct spread of bacterial infection within thoracic cavity.
 (pleural effusion- empyema- pericarditis)
 or bacteremia and hematologic spread meningitis suppurative arthritis osteomyelitis
X-RAYS




         Viral pneumonia x-ray
X-RAYS




         (Lobar pneumonia x-ray (RUL
X-RAYS




         bronchopneumonia x-ray
X-RAYS




         Staph pneumonia x-ray
THANKS ALOT

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Pneumonia 100906122529-phpapp02

  • 2. PNEUMONIA • Pneumonia is an inflammation of the parenchyma of the lung. - Most cases of pneunomin are caused by microorganism. - non infectious causes include aspiration of food or gastric acid foreign bodies hydrocarbons and lipoid. substances hypersensitivity reaction and drug or radiation induced pneumonitis.
  • 3. PNEUMONIA • Classification . 1 : Anatomical classification. A – lobar pneumonia . The consolidalion involves all or part of lobe B – Bronchopneumonia the consolidation involves scattered lobules C - Interstitial pneumonia . As in viral pneumonia where inflammatory . Infiltrate involve mainly interstitial tissue between alveli.
  • 4. PNEUMONIA 2 : Etiological classfication. the cause of pneumonia in patient is often difficult to determine because direct culture of lung tissue invasive and rarely performed. - culture obtained from upper respiratory tract or sputum genenally not accurately.
  • 5. PNEUMONIA • Causes of infectious pneumonia. Bacterial. Common. - streptococcus pneumoniae Group B streptococci Group A streptococci . - Mycoplasma pneumoniae - chlamydia pneumoniae  Adolescent. - chlamydia trachomatis  infant. -Mixed anaerobes  Aspiration pneumonia - Gram-negative enteric.
  • 6. PNEUMONIA Uncommon. - Haemphilus influenza  Unimmunized. - Staphylococcus aureus - Moraxella catarrhalis - Neisseria meningitides - Francisella tularensis  animal fly contact - Nocardia species  Immunosuppressed person. - Chlamydia psittaci  Bird contact. - Yersinia pestis  Plague - Legionella species  Exposure to contamianted water.
  • 7. PNEUMONIA Viral - -Common Respiratory syncytial virus Parainflueza type 1 – 3 Influeza A . B Adenovirus Metapneumovirus Un Common - Rhinovirus Enterovirus Neonates Herpes simplex Neontes Cytomegalovirus Immunosuppressed person. Measles Varicella Hantavirus .Sars agent
  • 8. PNEUMONIA -Fungal. Histoplasma capsulatum  Bird bat contact Cryptococcus neoformans  Bird contact. Aspergillus species  Immunosuppressed. Mucomycosis  Immunosuppressed Coccidioides immitis Blastomyces dermatitides Rickettsial - Coxiella burnetii Goat sheep cattle exposure Rickettsia rickettsiae
  • 9. PNEUMONIA • Mycobacterial Nycobacterium Tuberculosis  Developed countries Nycobacterium avium-inteacellulare  Immunosuppressed. •Parasitic Pneumocystis Carini  Immunosuppressed. Steroid. Eosinophilic  Ascaris . Loeffler syndrom •Non infectious causes -Aspiration Of food. -Gastric acid. -foreign body. -Hydrocarbon  Kerosen -Lipoid substances - Aspiration of amniotic fluid.
  • 10. PNEUMONIA Age group Frequent Pathogens Neonate <1mo Group B straptococcus – E coli streptococcus Pneumoniae – H influeza. 1-3 mo Rsv . Influenza viruses para fluenza viruses – adenovirus febrile Pneu S. pneumoniae . H . influenza Afebrile Pneu Chlamydia trachomatis Mycoplasma hominis cytomegalovirus. 3 – 12 mo R.S.V Influenza viruses para fluenza viruses adenovirus S. pneumoniae H . Influenza Chlamydia trachomatis Mycoplasma pneumoniae Group A straptococcus 2 – 5 yr Influenza viruses para fluenza viruses adenovirus S. pneumoniae H . Influenza Mycoplasma pneumoniae Chlamydia pneumoniae Group A straptococcus S . Aureus. 5 – 18 yr Mycoplasma pneumoniae S. pneumoniae Chlamydia pneumoniae H . Influenza Influenza viruses adenovirus > 18 yr Mycoplasma pneumoniae S. pneumoniae Chlamydia pneumoniae H . Influenza Influenza viruses adenovirus.
  • 12. PNEUMONIA • Hospitalization of children with pneumonia Age > 6 month - - Sickle cell anemia with acute chest syndrom. .- Multiple lobe involvement Immunocompromised- . Toxic appearance- Sever respiratory distress - .Requirement for supplemental oxygen- Dehydration- .Vomiting- .No response to oral antibiotic- .Non compliant parent -
  • 13. PNEUMONIA • Recurrent pneumonia -Hereditary disorder Cystic fibrosis Sickle cell disease -Disorders of immunity Aids Bruton agammaglobulemia Selective IgG subclass deficiencies Common variable immunodeficiency syndrom Sever combined immunodeficiency syndrom -Disorders of leukocytes Chronic granulomatous diseaseٍ Hyperimmunoglobulin E syndrome Leukocyte adhesion defect
  • 14. PNEUMONIA - Disorders of cilia Immotile cilia syndrom Kartagener syndrom -Anatomic disorder Sequestration Lobar emphysema Esophageal reflux Foreign body Tracheo esophageal fistula ( H type ) Gastroesophageal reflux Bronchietasis Aspiration ( oro pharyngeal in coordination )
  • 15. PNEUMONIA • Pathogenesis The lower respiratory tract is normally sterile by -Physiologic defense mechanisms including -Mucociliary clearance -ProPerties of normal secretion such as secretory immunoglobulin A  IgA - Clearing of air way by coughing Immunologic defense mechanism of lung limit invasion by pathogenic organisms Includes macrophages are present in alveoli and bronchioles secretory IgA and others immunoglobulins
  • 17. PNEUMONIA •Viral pneumonia usually result from spread of infection along the air way. Accompanied by direct injury of respiratory epithelium resulting in air way obstruction from swelling abnormal secretion and cellular debris small calibar of air way in young infant makes them particularly susceptible to sever infection. Viral infection predispose to secondary bacterial infection by disturbing normal host defense mechanism altering secretion and modifying bacterial flora.
  • 18. PNEUMONIA •Bacterial infection In bacterial infection pathologic process varies according to the invading organism M . Pneumoniae attaches to the respiratory epithelium inhibit ciliary action and Lead to cellular destruction and an inflammatory response in the submucosa as the infection progresses sloughed cellular debris inflammatory cell and mucus Cause airway obstruction with spread of infection occuriang along the bronchial Tree as in viral pneumoia. - S . Pneumoniae Produce local edema that aids in the proliferation of organism and their spread Into adjacent portion of lung often resulting in the characteristic focal lobar Involvement
  • 19. PNEUMONIA -Grop A . Streptococcus pathology Includes necrosis of tracheobronchial mucosa formation -of large amount of exudate edema and local hemorrhage with extension into the Interalveolar septa and involvement of lymphatic vessel and pleura. -S – aureus pneumonia produces Toxin and enzymes as hemolysin coagulase and staphylo kinase- It causes broncho pneumonia often unilateral characterized by prensence of Hemorrhagic necrosis and irregular areas of cavitation of lung parenchyma Resulting in pneumatoceles empyema or broncho pulmonary fistula .Pyopneumothorax
  • 20. PNEUMONIA Following changes stages: 1- congestion alveoli are failed with edema fluid and organism. 2- red hepatization alveoli contain polymorph RBCs fibrin edema and organism. 3-grey hepatization deposition of fibrin over the pleural surface phagocytosis starts inside the alveoli which are now filled with polymorph and fibrin. 4-resolution: neutrophil degenerate fibrin thread and remaining bacteria and digested and removed by phagocyte Clinical Manifestation Viral & bacterial pneumonia are often preceded by several day of symptoms of URTI typically rhinitis and cough. In viral pneumonia: fever is usually present lower than in bacteria. Tachypnea increased work of breathing accompanied by intercostal, subcostal and suprasternal retraction nasal flaring and use of accessory muscle. Severe infection accompanied by cyanosis and respiratory fatigue in infant. Auscultation of chest wheezing and crackle
  • 21. PNEUMONIA In bacterial pneumonia: Sudden shaking chill followed high fever, cough, grunting, chest pain, drowsiness, rapid respiration, dry cough, anxiety circumoaral cyanosis. Physical finding: Depends on the stage of pneumonia diminished breath sound scattered crackels and rhonchi over affected lung. Increasing consolidation or complication. As effusion empyema or pyopneumothorax dullness on percussion and breath Sound. Diminished abdominal distension because of gastric dilation from swallowed air or ileus. Abdominal pain in lower lobe pneumonia Liver may seem enlarged because downward of diaphragm secondary to hyper inflation of lung Neck rigidity without meningitis in right upper lobe.
  • 22. PNEUMONIA Diagnosis: Chest X-ray diagnosis of pneumonia may indicate complication pleural effusion or empyema. Viral pneumonia X-ray  hyper inflation with bilateral interstitial infiltrate pneumococcal pneumonia lobar consolifation repeat chest x-ray are not required for proof of cure for ratient with uncomplicated pneumonia. - WBC can differentiating viral from bacterial in virtual WBC normal or elevated but usually not highert han 20,000/mm3 with lymphocyte predominance Bacterial 15,000- 40,000 predominance granulocyte. -Pleural effusion – lobar consolidation and high fever at onset of illness suggestive of bacterial. -Atypical pneumonia due to C.pneumoniae or M.pneumoniae is difficult to distinguish from pneumococal pneumonia by X-ray and other lab. -pneumococcal pneumonia higher in WBC count ESR-CRP. - Isolation of organism from blood-pleural fluid or lung culture of sputum blood culture. positive PCR in viruses
  • 24. PNEUMONIA Treatment: Treatment based on cause and clinical appearance of child. Children do not require hospitalization. -Amoxicillin ( 80-90mg/kg/24 hrs ) - cefuroxime = Zinnat or Amoxicillinclavulante = ogmin. - For school age children with M-pneumonia. -C.pneumonia (atypical pneumonia) mcrolide antibiotic such as azilhromjcin Bacterial pneumonia in hostpitalized child cefuroxime (150 mg/kg/24 hrs) = Zinnat cefotaxime = claforan cefftriaxone = Rocephin - If staphylococcal pneumatotocele empyema Vancomycin or clindamycin Viral pneumonia no respiratory distress with hold antibiotic therapy - Up to 30% of patient wih known viral infection may have coexisting bacterial pathogen.
  • 25. PNEUMONIA Deterioration in clinical status antibiotic therapy should be initiated Response to treatment: Patient with uncomplicated bacterial pneumonia respond to therapy with improvement in clinical symptom (fever, cough, tachypnea, chest pain) within 48-96 hrs. Slowly resolving pneumonia 1- complication as empyema. 2- bacterial resistance. 3- non bacterial etiology as viruses and aspiration of foreign bodies or food. 4- bronchial obstruction from endobronchial lesion foreign body or mucus plug. 5- pre-existing diseases such as immunodeficiencies- ciliary dyskinesia- cysticfibrosis pulmonary sequestration cystic adenomatoid malformation. 6- non infectious causes: - bronchoilitis obliterans. - hypersensitivity pneumonitis - eosinophils pneumonia - aspiration - wegener granulomatosis
  • 26. PNEUMONIA Complication: Usually result of direct spread of bacterial infection within thoracic cavity. (pleural effusion- empyema- pericarditis) or bacteremia and hematologic spread meningitis suppurative arthritis osteomyelitis
  • 27. X-RAYS Viral pneumonia x-ray
  • 28. X-RAYS (Lobar pneumonia x-ray (RUL
  • 29. X-RAYS bronchopneumonia x-ray
  • 30. X-RAYS Staph pneumonia x-ray