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
Cause of pneumonia Mycoplasma pneumoniae Legionella pneumophila Chlamydophila (Chlamydia) pneumoniae
Blood tests May be raised WCC or rarely evidence of haemolytic anaemia. ESR may be elevated. Serology titres and complement fixation tests/ELISA can help to confirm the diagnosis. FBC may show left shift. Severe cases may have DIC evident on FBC/INR. Hyponatraemia may occur due to syndrome of inappropriate ADH secretion. Urea/creatinine can be raised if complicated by renal failure or dehydration. LFTs often non-specifically deranged. CK may be elevated in rhabdomyolysis. Serological tests on blood or urine may be used to confirm diagnosis. Usually non-specific and unhelpful. Serology titres or polymerase chain reaction tests may be used to confirm the diagnosis.
CXR Usually single lower-lobe bronchopneumonia pattern with lobar consolidation rare. Other possible patterns include atelectasis, nodular infiltration akin to TB/sarcoidosis, hilar adenopathy and rarely pleural effusion. 50 have pleural effusion. Patchy alveolar infiltrates may be seen. CXR can take up to 4 months to return to normal and may initially progress despite therapy. Usually lower-lobe single subsegmental infiltrate. Pleural effusion found in up to a quarter of cases. Can progress to ARDS. CXR changes may take up to 3 months to resolve.
ABGs may be checked to assess respiratory function in acute, severe cases of community-acquired pneumonia. Similarly, blood cultures should be taken to aid subsequent microbiological diagnosis. In cases of atypical pneumonia where there is evidence of focal or global cerebral impairment, an LP should be considered. ABGs may be checked to assess respiratory function in acute, severe cases of community-acquired pneumonia. Similarly, blood cultures should be taken to aid subsequent microbiological diagnosis. In cases of atypical pneumonia where there is evidence of focal or global cerebral impairment, an LP should be considered. ABGs may be checked to assess respiratory function in acute, severe cases of community-acquired pneumonia. Similarly, blood cultures should be taken to aid subsequent microbiological diagnosis. In cases of atypical pneumonia where there is evidence of focal or global cerebral impairment, an LP should be considered. ABGs may be checked to assess respiratory function in acute, severe cases of community-acquired pneumonia. Similarly, blood cultures should be taken to aid subsequent microbiological diagnosis. In cases of atypical pneumonia where there is evidence of focal or global cerebral impairment, an LP should be considered.
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
  1. Shakeel Amanullah Atypical Bacterial Pneumonia
    eMed. March 2008.
  2. www.patient.co.uk Atypical Pneumonias Jan.
    2007.
  3. www.thirdage.com Encyclopedia Atypical
    Pneumonia (Mycoplasma and Viral) (Walking
    Pneumonia) May 2008.
  4. Rosens Emergency Medicine Online Community
    Acquired Pneumonia
View by Category
About This Presentation
Title:

Atypical Pneumonia

Description:

Does not respond to the usual antibiotics. Causes a milder form of pneumonia (hence ... possible patterns include atelectasis, nodular infiltration akin to TB ... – PowerPoint PPT presentation

Number of Views:2306
Avg rating:3.0/5.0
Slides: 39
Provided by: annerieh
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

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
Cause of pneumonia Mycoplasma pneumoniae Legionella pneumophila Chlamydophila (Chlamydia) pneumoniae
Blood tests May be raised WCC or rarely evidence of haemolytic anaemia. ESR may be elevated. Serology titres and complement fixation tests/ELISA can help to confirm the diagnosis. FBC may show left shift. Severe cases may have DIC evident on FBC/INR. Hyponatraemia may occur due to syndrome of inappropriate ADH secretion. Urea/creatinine can be raised if complicated by renal failure or dehydration. LFTs often non-specifically deranged. CK may be elevated in rhabdomyolysis. Serological tests on blood or urine may be used to confirm diagnosis. Usually non-specific and unhelpful. Serology titres or polymerase chain reaction tests may be used to confirm the diagnosis.
CXR Usually single lower-lobe bronchopneumonia pattern with lobar consolidation rare. Other possible patterns include atelectasis, nodular infiltration akin to TB/sarcoidosis, hilar adenopathy and rarely pleural effusion. 50 have pleural effusion. Patchy alveolar infiltrates may be seen. CXR can take up to 4 months to return to normal and may initially progress despite therapy. Usually lower-lobe single subsegmental infiltrate. Pleural effusion found in up to a quarter of cases. Can progress to ARDS. CXR changes may take up to 3 months to resolve.
ABGs may be checked to assess respiratory function in acute, severe cases of community-acquired pneumonia. Similarly, blood cultures should be taken to aid subsequent microbiological diagnosis. In cases of atypical pneumonia where there is evidence of focal or global cerebral impairment, an LP should be considered. ABGs may be checked to assess respiratory function in acute, severe cases of community-acquired pneumonia. Similarly, blood cultures should be taken to aid subsequent microbiological diagnosis. In cases of atypical pneumonia where there is evidence of focal or global cerebral impairment, an LP should be considered. ABGs may be checked to assess respiratory function in acute, severe cases of community-acquired pneumonia. Similarly, blood cultures should be taken to aid subsequent microbiological diagnosis. In cases of atypical pneumonia where there is evidence of focal or global cerebral impairment, an LP should be considered. ABGs may be checked to assess respiratory function in acute, severe cases of community-acquired pneumonia. Similarly, blood cultures should be taken to aid subsequent microbiological diagnosis. In cases of atypical pneumonia where there is evidence of focal or global cerebral impairment, an LP should be considered.
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
  1. Shakeel Amanullah Atypical Bacterial Pneumonia
    eMed. March 2008.
  2. www.patient.co.uk Atypical Pneumonias Jan.
    2007.
  3. www.thirdage.com Encyclopedia Atypical
    Pneumonia (Mycoplasma and Viral) (Walking
    Pneumonia) May 2008.
  4. Rosens Emergency Medicine Online Community
    Acquired Pneumonia
About PowerShow.com