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Lobar Pneumonia Management

Updated: Thursday, Mar 19,2009, 10:46:41 AM
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Clinical presentation
The onset is sudden with cough, rusty sputum, marked fever and rigors. There are signs of consolidation if a large area of lung is involved. Vesicles of herpes simplex occur around the lips. Chest X-ray shows consolidation in lobar distribution. Cerebral abscess is a rare complication. The pneumococcus is particularly dangerous to the splenectomised patient.

This has become less common since the advent of penicillin.
The organism most frequently cultured from sputum and blood is S. pneumoniae (pneumococcus) and this responds to i. m. crystalline penicillin (1-2 million units 6-hourly) which is the drug of first choice.
NB Lobar consolidation, particularly with loss of volume on chest X-ray, may indicate an underlying bronchial obstruction, e. g. neoplasm, foreign body.

Klebsiella pneumoniac (Fried!~nder's). This is rare and often opportunistic in patients with leukaemia, lymphomas or on steroids. The history is of sudden prostration, fever, rigors and cough with blood-stained viscous sputum. The chest X-ray 'shows patchy areas of consolidation, often involving the upper lobe. The mortality is high (40%) and subsequent respiratory disability common.
 The bacillus is not penicillin or ampicillin sensitive. It responds to streptomycin, chloramphenicol and with some strains, tetracyclines. Lung abscess and bronchiectasis are common complications.
Staphylococcal pneumonia This produces widespread infection with abscess formation. It occurs in patients with underlying disease which prevents normal response to infection, e.g. chronic leukaemia. Hodgkln's disease, cystic fibrosis, and patients on steroid therapy. It may complicate influenzal pneumonia and this makes it relatively common during epidemics of influenza. The organism may not be penicillin sensitive, so flucloxacillin is the drug of choice. Lung abscess, empyema and subsequent bronchlectasis are relatively common complications.

In the absence of chronic bronchitis, recurrent pneumonia arouses the suspicion of: (1) Bronchial carcinoma preventing drainage of infected areas of the lung. (2) Bronchiectasis (including fibrocystic disease). (3) Achalasia of the cardia, 25% of which present as chest disease; pharyngeal pouch and neuromuscular disease of the oesophagus, e. g. bulbar palsy, (4) Hypogammaglobulinaemia and myeloma.
The most common virus producing pneumonia in children in this country and the USA is the respiratory syncytial virus (so called as it is a respiratory virus which produces syncytium formation when grown in tissue culture). The agent is not responsive to antibiotics and it may be indistinguishable from acute bacterial bronchitis or bronchiolitis in children and infants. The presence of an associated skin rash supports the likelihood of RSV infection.

Acute virus pneumonia in adults is very rare and occurs during epidemics of influenza A (Asian' flu). The picture is of rapid and progressive dyspnoea. Death may occur within hours from acute haemorrhagic disease of the lungs. The most common cause of pneumonia during epidemics of influenza results from secondary bacterial infection, the most serious being staphylococcal pneumonia. The viruses of measles, chickenpox, and herpes zoster may directly affect the lung. The diagnosis is confirmed by a rise in specific antibody titre.
This is caused by Mycoplasma pneumoniae, the only mycoplasma definitely pathcgenic to man. The clinical picture resembles bacterial pneumonia although cough and sputum are absent in one-third of cases.

Respiratory symptoms and signs and. X-ray changes (patchy consolidation with small effusions) are usually preceded by several days of flu-like symptoms. Polyarthritis occurs and may persist for months. Malaise and fatigue may persist long after the acute illness is over. The diagnosis is confirmed by a rise of specific antibody titre, the presence of cold agglutinins and antibodies to Mycoplasma in the serum and/or isolation of the organism. Tetracycline (0.5--1.0gqds) is the antibiotic choice. Psittacosis and ornithosis (Bedsoniae) may cause a similar picture and also respond to tetracycline, though diarrhea is commoner.

This is seen in immunosuppressed patients usually on steroids, azathioprine, or cytotoxic agents following transplantation or for leukaemia or lymphoma. The range of organisms found is very wide and includes bacteria (Pseudomonas M. tuberculosis, E. coli), fungi (Aspergillus, Monilia, Cryptococcus). Viruses (Cytomegalo-Virus. Herpes zoster) and Pneumocystis carinii. It is important to attempt to isolate the organism from the sputum and to carry out blood culture, endobronchial brush biopsy, and/or percutaneous lung biopsy. Treatment should not be delayed, because the prognosis is very poor.
There are two main varieties differentiated from each other by the type of fluid aspirated and the circumstances in which it occurs.
Aspiration of gastric contents may produce a severe chemical pneumonitis with considerable pulmonary oedema and bronchospasm (Mendelson's syndrome). The acute respiratory distress and shock can be rapidly fatal and very difficult to treat. It tends to occur in states of reduced consciousness such as general anaesthesia, drunks, and when gastric lavage (for drug overdose) has been performed inexpertly.
Aspiration of bacteria from the oropharynx may follow dental anaesthesia and can occur in bulbar palsies. The bacteria, apart from bacteroides, are nearly all penicillin sensitive and crystalline penicillin with metronidazole are the antibiotics of choice initially until sensitivities are known. Recurrent episodes occur in some oesophageal diseases includinghiatus hernia, stricture, achalasia of the cardia, and in patients with diverticula or pharyngeal pouch.

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