1. John Mathew D.O.

2.  Impairment/Breech of body barriers
 Neutropenia
 Cell-mediated immunity defect
 Humeral immunity defect
 Obstruction

5.  HIV
 ALCOHOLICS
 NURSING HOME
 ELDERLY
 TRANSPLANT
 DIABETICS

6.  Etiology:
 Cancer Chemotherapy
 Meds: Azathioprine, cyclophosphamide
 Leukemia
 Acquired immunodeficiency's
 Microbes
 Gram neg bacteria
 Fungal infections

7.  Etiology
 AIDS
 Lymphoma
 Organ transplantation and immunosuppressive
meds
 Microbes
 Intracellular bacteria e.g. Listeria
 Mycobacterium
 Fungal e.g. Cryptococcus, Pneumocystisjiroveci
 Viral e.g. EBV, CMV
 Protozoa eg Toxoplasmosis

8.  Etiology
 Congenital
 Acquired egmyeloma
 Microbes
 Encapsulated bacteria eg Haemophilus,
Pneumococcus

9.  Inflammatory condition of the alveoli or
gas exchanging portion of the lung
 Spread is commonly airborne or aspiration,
but also include, direct penetration,
hematogenous spread
 Etiologydepends on
 Community vs. Nosocomial
 Age
 Comorbidities
 Immunosuppression

11.  Bacterial
 Mycobacterial
 Fungal
 Protozoal
 Viral

12.  Bacterial
 Strep pneumoniae
 Haemophilus influenzae, Chlamydia, Mycoplasma
 Klebsiella
 Pseudomonas
 Staph aureus
 Legionella pneumophila
 Gram negative bacilli
 Nocardia

13.  Gram + cocci in chains or
pairs
 Lobar pneumonia
 Presentation
 Sudden onset
 Rigors, bloody sputum, high
fever, chest pain ( classic)
 At risk population
 Chronic diseases
 Neutropenic, Cell mediated, and
Humeral deficient patients
 Asplenia, sickle cell
 HIV/AIDS
 Elderly

14.  Gram negative non-
motile organism
 More common in
alcoholic, COPD, sm
okers, elderly
 Presentation with
fever, rigors, chest
pain
 Commonly
presenting with
lobar infiltrate

15.  Gram + cocci in
clusters
 Pts with chronic
lung disease,
laryngeal cancer,
immunosupressed
pt, aspiration risk
 Insidious onset, low
grade fever.
Sputum, and
dyspnea

16.  Gram – rod
 Seen in pt’s on prolonged
hospitalizations, broad-
spectrum antibiotic’s ,
high dose steroid
therapy, nursing home
residents, structural lung
disease, burn victims,
central venous catheters
 Severe pneumonia, with
cyanosis, confusion, and
other systemic symptoms

17.  Gram neg encapsulated
organism
 Elderly, chronic lung
disease, neutropenic
pt’s, sickle cell pt’s,
alcoholics, and diabetics
 Can present both
indolently and similar
to strep pneumo

19.  Mycoplasma, Legionella
, Chlamydia
 Unusual presentation
 Extrapulmonary
features
 CXR often normal early
in infection
 WCC normal
 Diagnosis-
serology, urine
 Treatment-
macrolides, newer
quinolones

20.  Etiology: Mycobacterium tuberculosis
 Subacute infection/Latent
 Chronic cough +/- hemoptysis
 Fever
 Weight loss
 Night sweats
 Extrapulmonary and atypical
pulmonary presentations more
common in IC host
 Miliarytb- symptoms, include fever,
chills, hepatospenomegaly, multi
system illness
 Risk 100-fold higher in HIV/AIDS

21.  Sputum x 3 for
AFB and TB
culture
 +/- Bronchoscopy
 Other fluid if
involved eg
pleural, CSF etc
 Mantouxtest

22.  Focal infiltrates
 Cavitationespupp lobes
 Hilaradenopathy
 Pleural effusion
 Non-specific infiltrates in HIV+

23.  Induration>5mm
 Close contact
 Strong suspicion
 IC host
 Induration>10mm
 Chronic med conditions
 Induration>15mm
 No risk factors
 Prophylaxis: Isoniazid

24.  Isolation
 Diagnosis confirmed
 Patient smear negative
 Combination therapy
 Isoniazid+rifampicin+pyrazinamide
 Add ethambutol is drug resistance is suspected
 Duration of therapy dependent on site of infection-
normal 6months, 9 months, in HIV, pregnant
females

25.  Endemic fungi
 Histoplasmosis
 Blastomycosis
 Coccidioidomycosis
 Aspergillus
 Cryptococcus
 Candida

26.  Coccidioidomycosis
 Coccidioides immitus
 San Joaquin Valley, South West US
 Blastomycosis
 Blastomyces dermatitidis
 Endemic regions Midwest and South Central US
 Acute illness more mimics bacterial pneumonia
 Characteristic skin lesion irregular borders, and crusted
surface
 Histoplasmosis
 H capsulatum
 Endemic regions include Midwest, South Central US
 Progressive disseminated histoplamosis can occur in pt’s
with HIV, or other cell mediated deficiency's

27.  Usually found in pigeon or other bird dropping
 Very rarely a pulmonary infection, and seldom
more than granulomatous inflammatory
reaction
 Most significant complication is in Cell
mediated immunity defects
 Cryptococcal Meningitis

28.  10-20% leukemia
 5-25% heart or
lungtransplant
 Advanced Aids
 Chronic high dose
steroid users
 34% respond to
current therapy

31.  Bronchoscopy
 Antifungal agent
 Amphotericin
 Imidazoles
 Caspifungins
 Granulocyte colony stimulating factor
 Supportive measures

32.  The most common life threatening infection in
AIDS patients in developed countries
 AIDS defining illness in 60%
 Occurs in 80% of AIDS patients in absence of
antibiotic prophylaxis

33.  Unicellular eukaryote-Fungus
 Ubiquitous geographic distribution
 Caused infection in patients with underlying T-
lymphocyte disorders
 AIDS
 Lymphoproliferative disorders
 CLL
 Post stem cell transplantation
 Prolonged corticosteroid therapy and Cushing's
disease

34.  SYMPTOMS  SIGNS
 Gradual onset over  Cyanosis
weeks  Increased resp rate
 Non-productive  Often normal lung
cough examination
 Dyspnoea  Other OI eg oral
 Fever thrush

35.  Bilateral perihilar
infiltrate
 Normal heart size
 Pneumothorax
occasionally

37.  LABORATORY  HISTOLOGY
 ABG : hypoxemia  Induced sputum
 Elevated LDH  Bronchoscopy and
 CD4 <200 BAL
 Lung biopsy
 Autopsy

38. PCP
 Normal alveoli

39.  Trimethoprim/
sulfamethoxazole
 Dapsone/clindamycin
 Pentamidine iv
 Steroids

40.  INDICATIONS  TMP/SMX daily
 CD4 count < 200  Dapsone daily
 Prior episode of PCP  Pentamidine
 Oral candidiasis aerosolised monthly

42.  Influenza
 Cytomegalovirus (CMV)
 Herpes simplex virus (HSV)

43.  Orthomyxovirus
 ssRNA virus
 Influenza A,B,C
 Subtypes based on
(HA) and
neuramindase (NA)
 Yearly vaccine
developed on H/N
type

44.  Clinical presentation  Diagnosis
 Acute onset fever  Virus isolation
 Apathy, headache  Antigen detection
 Anorexia, myalgia  Serology (HA
 Dyspnoea antigen)
 Cough-later
 Duration 5-7d
 Complications
 Bacterial
pneumonia
 encephalitis

45.  Vaccination  Amantidine
/Ramantidine
 Adequate immune
 Targets envelope
response takes 2
protein
weeks
 Used in prev. and Rx
 Immunity weans in
 NA inhibitors
few months
 Oseltamivir or
 Contraindication with ranamivir
egg allergy and
 Use at onset of Sx-
allergy to other uto 48 hours
vaccine components
 Reduce Sx by 1 day

46.  CMV pneumonitis is the
most serious infection of
the spectrum of disease
from CMV
 Median onset CMV- 50
days- in transplant patients
 It should always be in the
differential of Transplant
pt
 Sustained fever, non
productive cough, and
dyspnea. Marked hypoxia
is an indicator of if
threatening infection

47.  Alcoholics:
 Aspiration risk
 Higher rate of
colonization with
gram neg
 Alcoholism
depresses depresses
granulocyte and
lymphocyte counts

48.  Diabetes
 Independent risk
factor for
pneumonia
 Diabetes in age of
25-64 are 4x more
likely to have
pneumonia
 Impaired
chemotaxis

49.  Elderly
 Most common infection
pneumonia
 Many comorbid
conditions
 Most common atypical
agent is Legionella
 Most common viral
illness is influenza
 Poor prognostic
indicators include:
hypothermia, fever
>100.9, low wbc count,
gram neg bacteria, staph
infection, b/l infiltrates

50.  Nursing Home
 Similar risk factors as the
elderly
 8 independent factors
that predict pneumonia
in this population: >
pulse rate, RR > 30, Temp
> 100.4, decreased LOC,
acute confusion, lung
crackles, absence of
wheezes, > leukocyte
count
 Most common infections:
Strep, gram neg, H flu,
and influenza

51.  HIV/AIDS
 Strep most common
infection
 >800 cd4 bacterial
infections
 250-500 –
TB, Cryptococcus
, Histoplasmosis
 < 200 –PJP
 < 50 MAI