Atypical Pneumonia - PowerPoint PPT Presentation


Title: Atypical Pneumonia


1
AtypicalPneumonia
  • BY
  • Annerie Hattingh
  • 26/08/09

2
Introduction
  • Pneumonia caused by atypical pathogens
  • Typical pathogens usually includes
  • - Strep. pneumonia
  • - Haemophilus pneumonia
  • - Klebsiella pneumonia
  • Does not respond to the usual antibiotics
  • Causes a milder form of pneumonia (hence the term
    walking pneumonia)
  • Characterized by a more drawn out coarse of
    symptoms

3
Introduction
  • Legionella SARS are exceptions to the above
  • both can be very severe infections
  • Typical pneumonia can come on more quickly with
    more severe early sx
  • The arbitrary classification of typical vs.
    atypical pneumonia is of limited clinical value
  • Literature now shows that a primary pathogen may
    co-exist with a secondary one, further blurring
    this distinction

4
Introduction
  • Causes
  • Classical atypical pneumonias
  • 1.) Mycoplasma pneumonia
  • 2.) Chlamydia pneumonia
  • 3.) Legionella pneumonia

5
Introduction
  • Causes
  • Other micro-organisms that cause similar patterns
  • of presentation
  • 1.) Chlamydia psittaci (exposure to birds)
  • 2.) Coxiella burnetti (presenting as Q fever)
  • 3.) Viral pneumonias - Influenza A
  • - SARS
  • - RSV
  • -
    Adenoviridae
  • - Varicella
    pneumonitis

6
Epidemiology
  • It is thought that the 3 main atypical pathogens
    might be implicated in up to 40 of CAP
  • The precise incidence is not known
  • Often not identified in clinical practice due to
    lack of readily available, reliable standardized
    tests to confirm dx
  • By age 20, 50 of people in the USA have
    detectable levels of Antibodies to Chlamydia
  • pneumonia

7
Risk Factors
  • Mycoplasma Chlamydia spread by person-to-person
    contact
  • - spread most common in closed populations
    e.g.
  • schools, offices military barracks
  • Legionellae found most commonly in fresh water
    man-made H2O systems

8
Risk Factors
  • - sources of contaminated H2O includes
  • showers
  • condensers
  • whirlpools
  • cooling towers
  • respiratory equipment
  • air conditioning systems

9
Risk Factors
  • Other risk factors include
  • - young, healthy people
  • - cigarette smoking
  • - lung disease (like COPD)
  • - weakened immune system (e.g. chronic
    steroid
  • use or HIV)

10
Presentation
  • Mycoplasma pneumonia
  • Gram neg bacteria with no true cell wall
  • Frequent cause of CAP in adults children
  • Prevalence in adults with pneumonia 2 30
  • Tends to be endemic, occurring _at_ 4-7yr intervals

11
Presentation
  • Mycoplasma pneumonia
  • Clinical Features
  • Symptomatic / asymp
  • Gradual onset (over few days weeks)
  • Prodrome of flu-like symptoms

12
Presentation
  • Mycoplasma pneumonia
  • Clinical Features
  • Including - headache
  • - malaise
  • - fever
  • - non prod. Cough
  • - sore throat

13
Presentation
  • Mycoplasma pneumonia
  • Clinical Features
  • Objective AbN on physical exam are minimal in
    contrast to the pts reported symptoms
  • Present like many of common viral illnesses BUT
    persistence progression of sx help to mark it
    out

14
Presentation
  • Mycoplasma pneumonia
  • Extrapulm. Manifestations/Complications
  • Can involve CNS, Blood, Skin, CVS, Joints, GIT

15
Presentation
  • Mycoplasma pneumonia
  • Extrapulm. Manifestations/Complications
  • Neurological compl.
  • Aseptic meningitis
  • Cerebellar ataxia
  • Transverse myelitis
  • Peripheral neuropathy

16
Presentation
  • Mycoplasma pneumonia
  • Extrapulm. Manifestations/Complications
  • Neurological manifestations are infrequent
  • Usually found in kids, if seen
  • Associated with increased morbidity mortality
  • Antecedent resp. infection not always present

17
Presentation
  • Mycoplasma pneumonia
  • Extrapulm. Manifestations/Complications
  • Hematological compl.
  • Hemolytic anemia
  • IgM antibodies to erythrocyte membrane I antigen
    are present
  • Produces a cold agglutinin response that leads to
    hemolysis

18
Presentation
  • Mycoplasma pneumonia
  • Extrapulm. Manifestations/Complications
  • Dermatological compl.
  • Include rashes such as
  • Erythema multiforme
  • Erythema nodosum
  • Urticaria

19
Presentation
  • Mycoplasma pneumonia
  • Extrapulm. Manifestations/Complications
  • Cardiac involvement
  • Pericarditis
  • Myocarditis

20
Presentation
  • Mycoplasma pneumonia
  • Extrapulm. Manifestations/Complications
  • Joint involvent (occationately described)
  • Arthralgia
  • Arthritis

21
Presentation
  • Mycoplasma pneumonia
  • Extrapulm. Manifestations/Complications
  • GIT symptoms
  • N V
  • Diarrhea
  • Pancreatitis (rarely)

22
Presentation
  • Chlamydia
  • Genus Chlamydia includes 3 species that infect
    humans - C. psittaci
  • - C. trachomatis
  • - C. pneumonia
  • Small, coccoid, Gram neg bacteria that resemble
    rickettsiae

23
Presentation
  • Chlamydia
  • Chlamydia trachomatis - seen in newborn infants

  • during delivery
  • - has
    been ass. with

  • pneumonia in adults

24
Presentation
  • Chlamydia
  • Chlamydia psittaci
  • Ornithosis is a systemic infection often acc. by
    pneumonia
  • Common in birds some domestic animals
  • Pet shop employees poultry workers _at_ risk
  • Other systems involved CNS (meningoencephalitis)
    CVS (cult. neg. endocarditis)

25
Presentation
  • Chlamydia pneumonia
  • Prevalence varies by yr geographic setting
  • Causes 5-15 of all CAP
  • Repeat infection is common
  • Gradual onset which may show improvement before
    worsening again
  • Incubation 3-4 weeks
  • Initial non-specific URTI Sx lead to bronchitic/
  • pneumonic features

26
Presentation
  • Chlamydia pneumonia
  • Most infected remains quite well asymptomatic
  • Can cause prolonged, acute bronchitis with
  • prod. cough
  • Hoarseness headache are common features
  • Fever relatively uncommon
  • Sx may drag on for weeks/months despite course of
    appropriate antibiotics

27
Presentation
  • Chlamydia pneumonia
  • Clinical severity usually caused by a secondary
    pathogen or co-existing illness e.g. diabetes
  • Complications
  • Sinusitis, otitis media
  • New onset asthma after acute infection
  • Endocarditis, myocarditis

28
Presentation
  • Legionella pneumonia
  • Aerobic, motile, non-encapsulated, Gram neg
    bacilli
  • Tends to be the most severe of the atypical
    pneumonias
  • Focal outbreaks centered around poorly maintained
    air conditioning / humidification systems
  • Incubation 2-10 days
  • Initial mild headache, myalgia leading to fever,
    chills rigors

29
Presentation
  • Legionella pneumonia
  • Minimally prod. cough
  • Dyspnoea, pleuritic pain hemoptysis are not
    uncommon
  • Extra pulmonary legionellosis is rare but can be
    severe
  • CVS most common extrapulm. site causing
    myocarditis, pericarditis endocarditis
  • Also pancreatitis, peritonitis,
    glomerulonephritis focal neurological deficit

30
Diagnosis
  • CXR findings are usually non-specific and
    difficult to distinguish from other pneumonias
  • Chest signs on examination minimal
  • Rx of suspected atypical pneumonias should be
    empirical
  • Cultures serologic tests are not routinely
    available in laboratories

31
Diagnosis
  • A 53yr old patient with severe
  • Legionella pneumonia.
  • CXR shows dense consolidation in both lower
    lobes.

32
Diagnosis
  • A 40yr old patient with Chlamydia pneumonia.
  • CXR shows multifocal, patchy consolidation in the
    right upper, middle and lower lobes.

33
Diagnosis
  • A 38yr old patient with Mycoplasma pneumonia.
  • CXR shows a vague, ill defined opacity in the
    left lower lobe.

34
(No Transcript)
35
Management
  • Severe cases should be admitted
  • Atypical pneumonias usually Rx as for other
  • CAP, at least initially
  • No evidence that routinely giving antibiotics
    active against atypical organisms leads to better
    outcomes in non-severe CAP

36
Management
  • Macrolides, such as Erythromycin, Clarithromycin
    Azithromycin have been shown to be effective in
    the Rx of all 3 organisms
  • Erythromycin tends to be less well tolerated
    only few trails demonstrates its efficacy in the
    Rx of Legionella
  • Severe Legionella infections may require
    rifampicin a macrolide
  • Tetracycline, Doxycycline Fluoroquinolones are
    also effective
  • Recommened duration of therapy usually 2-3 weeks

37
THE END QUESTIONS??
38
References
  • Shakeel Amanullah Atypical Bacterial Pneumonia
    eMed. March 2008.
  • www.patient.co.uk Atypical Pneumonias Jan.
    2007.
  • www.thirdage.com Encyclopedia Atypical
    Pneumonia (Mycoplasma and Viral) (Walking
    Pneumonia) May 2008.
  • Rosens Emergency Medicine Online Community
    Acquired Pneumonia
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Atypical Pneumonia

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Title: Atypical Pneumonia


1
AtypicalPneumonia
  • BY
  • Annerie Hattingh
  • 26/08/09

2
Introduction
  • Pneumonia caused by atypical pathogens
  • Typical pathogens usually includes
  • - Strep. pneumonia
  • - Haemophilus pneumonia
  • - Klebsiella pneumonia
  • Does not respond to the usual antibiotics
  • Causes a milder form of pneumonia (hence the term
    walking pneumonia)
  • Characterized by a more drawn out coarse of
    symptoms

3
Introduction
  • Legionella SARS are exceptions to the above
  • both can be very severe infections
  • Typical pneumonia can come on more quickly with
    more severe early sx
  • The arbitrary classification of typical vs.
    atypical pneumonia is of limited clinical value
  • Literature now shows that a primary pathogen may
    co-exist with a secondary one, further blurring
    this distinction

4
Introduction
  • Causes
  • Classical atypical pneumonias
  • 1.) Mycoplasma pneumonia
  • 2.) Chlamydia pneumonia
  • 3.) Legionella pneumonia

5
Introduction
  • Causes
  • Other micro-organisms that cause similar patterns
  • of presentation
  • 1.) Chlamydia psittaci (exposure to birds)
  • 2.) Coxiella burnetti (presenting as Q fever)
  • 3.) Viral pneumonias - Influenza A
  • - SARS
  • - RSV
  • -
    Adenoviridae
  • - Varicella
    pneumonitis

6
Epidemiology
  • It is thought that the 3 main atypical pathogens
    might be implicated in up to 40 of CAP
  • The precise incidence is not known
  • Often not identified in clinical practice due to
    lack of readily available, reliable standardized
    tests to confirm dx
  • By age 20, 50 of people in the USA have
    detectable levels of Antibodies to Chlamydia
  • pneumonia

7
Risk Factors
  • Mycoplasma Chlamydia spread by person-to-person
    contact
  • - spread most common in closed populations
    e.g.
  • schools, offices military barracks
  • Legionellae found most commonly in fresh water
    man-made H2O systems

8
Risk Factors
  • - sources of contaminated H2O includes
  • showers
  • condensers
  • whirlpools
  • cooling towers
  • respiratory equipment
  • air conditioning systems

9
Risk Factors
  • Other risk factors include
  • - young, healthy people
  • - cigarette smoking
  • - lung disease (like COPD)
  • - weakened immune system (e.g. chronic
    steroid
  • use or HIV)

10
Presentation
  • Mycoplasma pneumonia
  • Gram neg bacteria with no true cell wall
  • Frequent cause of CAP in adults children
  • Prevalence in adults with pneumonia 2 30
  • Tends to be endemic, occurring _at_ 4-7yr intervals

11
Presentation
  • Mycoplasma pneumonia
  • Clinical Features
  • Symptomatic / asymp
  • Gradual onset (over few days weeks)
  • Prodrome of flu-like symptoms

12
Presentation
  • Mycoplasma pneumonia
  • Clinical Features
  • Including - headache
  • - malaise
  • - fever
  • - non prod. Cough
  • - sore throat

13
Presentation
  • Mycoplasma pneumonia
  • Clinical Features
  • Objective AbN on physical exam are minimal in
    contrast to the pts reported symptoms
  • Present like many of common viral illnesses BUT
    persistence progression of sx help to mark it
    out

14
Presentation
  • Mycoplasma pneumonia
  • Extrapulm. Manifestations/Complications
  • Can involve CNS, Blood, Skin, CVS, Joints, GIT

15
Presentation
  • Mycoplasma pneumonia
  • Extrapulm. Manifestations/Complications
  • Neurological compl.
  • Aseptic meningitis
  • Cerebellar ataxia
  • Transverse myelitis
  • Peripheral neuropathy

16
Presentation
  • Mycoplasma pneumonia
  • Extrapulm. Manifestations/Complications
  • Neurological manifestations are infrequent
  • Usually found in kids, if seen
  • Associated with increased morbidity mortality
  • Antecedent resp. infection not always present

17
Presentation
  • Mycoplasma pneumonia
  • Extrapulm. Manifestations/Complications
  • Hematological compl.
  • Hemolytic anemia
  • IgM antibodies to erythrocyte membrane I antigen
    are present
  • Produces a cold agglutinin response that leads to
    hemolysis

18
Presentation
  • Mycoplasma pneumonia
  • Extrapulm. Manifestations/Complications
  • Dermatological compl.
  • Include rashes such as
  • Erythema multiforme
  • Erythema nodosum
  • Urticaria

19
Presentation
  • Mycoplasma pneumonia
  • Extrapulm. Manifestations/Complications
  • Cardiac involvement
  • Pericarditis
  • Myocarditis

20
Presentation
  • Mycoplasma pneumonia
  • Extrapulm. Manifestations/Complications
  • Joint involvent (occationately described)
  • Arthralgia
  • Arthritis

21
Presentation
  • Mycoplasma pneumonia
  • Extrapulm. Manifestations/Complications
  • GIT symptoms
  • N V
  • Diarrhea
  • Pancreatitis (rarely)

22
Presentation
  • Chlamydia
  • Genus Chlamydia includes 3 species that infect
    humans - C. psittaci
  • - C. trachomatis
  • - C. pneumonia
  • Small, coccoid, Gram neg bacteria that resemble
    rickettsiae

23
Presentation
  • Chlamydia
  • Chlamydia trachomatis - seen in newborn infants

  • during delivery
  • - has
    been ass. with

  • pneumonia in adults

24
Presentation
  • Chlamydia
  • Chlamydia psittaci
  • Ornithosis is a systemic infection often acc. by
    pneumonia
  • Common in birds some domestic animals
  • Pet shop employees poultry workers _at_ risk
  • Other systems involved CNS (meningoencephalitis)
    CVS (cult. neg. endocarditis)

25
Presentation
  • Chlamydia pneumonia
  • Prevalence varies by yr geographic setting
  • Causes 5-15 of all CAP
  • Repeat infection is common
  • Gradual onset which may show improvement before
    worsening again
  • Incubation 3-4 weeks
  • Initial non-specific URTI Sx lead to bronchitic/
  • pneumonic features

26
Presentation
  • Chlamydia pneumonia
  • Most infected remains quite well asymptomatic
  • Can cause prolonged, acute bronchitis with
  • prod. cough
  • Hoarseness headache are common features
  • Fever relatively uncommon
  • Sx may drag on for weeks/months despite course of
    appropriate antibiotics

27
Presentation
  • Chlamydia pneumonia
  • Clinical severity usually caused by a secondary
    pathogen or co-existing illness e.g. diabetes
  • Complications
  • Sinusitis, otitis media
  • New onset asthma after acute infection
  • Endocarditis, myocarditis

28
Presentation
  • Legionella pneumonia
  • Aerobic, motile, non-encapsulated, Gram neg
    bacilli
  • Tends to be the most severe of the atypical
    pneumonias
  • Focal outbreaks centered around poorly maintained
    air conditioning / humidification systems
  • Incubation 2-10 days
  • Initial mild headache, myalgia leading to fever,
    chills rigors

29
Presentation
  • Legionella pneumonia
  • Minimally prod. cough
  • Dyspnoea, pleuritic pain hemoptysis are not
    uncommon
  • Extra pulmonary legionellosis is rare but can be
    severe
  • CVS most common extrapulm. site causing
    myocarditis, pericarditis endocarditis
  • Also pancreatitis, peritonitis,
    glomerulonephritis focal neurological deficit

30
Diagnosis
  • CXR findings are usually non-specific and
    difficult to distinguish from other pneumonias
  • Chest signs on examination minimal
  • Rx of suspected atypical pneumonias should be
    empirical
  • Cultures serologic tests are not routinely
    available in laboratories

31
Diagnosis
  • A 53yr old patient with severe
  • Legionella pneumonia.
  • CXR shows dense consolidation in both lower
    lobes.

32
Diagnosis
  • A 40yr old patient with Chlamydia pneumonia.
  • CXR shows multifocal, patchy consolidation in the
    right upper, middle and lower lobes.

33
Diagnosis
  • A 38yr old patient with Mycoplasma pneumonia.
  • CXR shows a vague, ill defined opacity in the
    left lower lobe.

34
(No Transcript)
35
Management
  • Severe cases should be admitted
  • Atypical pneumonias usually Rx as for other
  • CAP, at least initially
  • No evidence that routinely giving antibiotics
    active against atypical organisms leads to better
    outcomes in non-severe CAP

36
Management
  • Macrolides, such as Erythromycin, Clarithromycin
    Azithromycin have been shown to be effective in
    the Rx of all 3 organisms
  • Erythromycin tends to be less well tolerated
    only few trails demonstrates its efficacy in the
    Rx of Legionella
  • Severe Legionella infections may require
    rifampicin a macrolide
  • Tetracycline, Doxycycline Fluoroquinolones are
    also effective
  • Recommened duration of therapy usually 2-3 weeks

37
THE END QUESTIONS??
38
References
  • Shakeel Amanullah Atypical Bacterial Pneumonia
    eMed. March 2008.
  • www.patient.co.uk Atypical Pneumonias Jan.
    2007.
  • www.thirdage.com Encyclopedia Atypical
    Pneumonia (Mycoplasma and Viral) (Walking
    Pneumonia) May 2008.
  • Rosens Emergency Medicine Online Community
    Acquired Pneumonia
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