Pneumonia

Pneumonia is an inflammatory condition of the lungespecially affecting the microscopic air sacs
(alveoli)associated with fever, chest symptoms, and a lack of air space (consolidation) on a chest X-ray.
[1][2]

Pneumonia is typically caused by an infection but there are a number of other causes. [1]Infectious

agents include: bacteria, viruses, fungi, and parasites.[3]

Typical symptoms include cough, chest pain, fever, and difficulty breathing.[4] Diagnostic tools include xrays and examination of the sputum.Vaccines to prevent certain types of pneumonia are available.
Treatment depends on the underlying cause. Presumed bacterial pneumonia is treated with antibiotics.
Although pneumonia was regarded by William Osler in the 19th century as "the captain of the men of
death", the advent of antibiotic therapy and vaccines in the 20th century have seen radical improvements
in survival outcomes. Nevertheless, in the third world, and among the very old, the very young and the
chronically ill, pneumonia remains a leading cause of death. [5]
Signs and symptoms

Symptoms frequency in pneumonia[6]

Symptom

Frequency

Cough

7991%

Fatigue

90%

Fever

7175%

Shortness of breath

6775%

Sputum

6065%

Chest pain

3949%

People with infectious pneumonia often have a productive cough, fever accompanied by shaking
chills,shortness of breath, sharp or stabbing chest pain during deep breaths, confusion, and an
increasedrespiratory rate.[7] In the elderly, confusion may be the most prominent sign. [7] The typical signs
and symptoms in children under five are fever, cough, and fast or difficult breathing. [8] Fever, however, is
not very specific, as it occurs in many other common illnesses, and may be absent in those with severe
disease ormalnutrition. In addition, a cough is frequently absent in children less than 2 months old. [8] More
severe signs and symptoms may include: central cyanosis, decreased thirst, convulsions, persistent
vomiting, or adecreased level of consciousness.[8]
Some causes of pneumonia are associated with classic, but non-specific, clinical characteristics.
Pneumonia caused by Legionella may occur with abdominal pain, diarrhea, or confusion,[9] while
pneumonia caused byStreptococcus pneumoniae is associated with rusty colored sputum,[10] and
pneumonia caused by Klebsiellamay have bloody sputum often described as "currant jelly". [6]
Physical examination may sometimes reveal low blood pressure, a high heart rate, or a low oxygen
saturation. Respiratory rate is likely to be faster than normal. Examination of the chest may be normal, but
may show decreased chest expansion on the affected side. Harsh breath sounds from the larger airways
that are transmitted through the inflamed lung are termed bronchial breathing, and are heard
on auscultation with a stethoscope. Rales (or crackles) may be heard over the affected area
during inspiration. Percussion may be dulled over the affected lung, and increased, rather than
decreased, vocal resonance distinguishes pneumonia from a pleural effusion.[7] Struggling to breathe,
confusion, and blue-tinged skin are signs of a medical emergency.
Cause
Pneumonia is due primarily to infections, with less common causes including irritants and the unknown.
Although more than one hundred strains of microorganisms can cause pneumonia, only a few are
responsible for most cases. The most common types of infectious agents are viruses and bacteria, with it
being less commonly due to fungi or parasites. Mixed infections with both viruses and bacteria may occur
in up to 45% of infections in children and 15% of infections in adults. [11] A causative agent is not isolated in
approximately half of cases despite careful testing. [12] The term pneumonia is sometimes more broadly
applied to inflammation of the lung (for example caused by autoimmune disease, chemical burns or drug
reactions), however this is more accurately referred to as pneumonitis.[13][14]
Bacteria
Main article: Bacterial pneumonia
Bacteria are the most common cause of community acquired pneumonia, with Streptococcus
pneumoniae isolated

in

nearly

50%

of

cases.[15][16] Other

commonly

isolated

bacteria

include: Haemophilus

influenzae in

20%, Chlamydophila

pneumoniae in

13%, Mycoplasma

pneumoniae in 3%,[15]Staphylococcus aureus, Moraxella catarrhalis, Legionella pneumophila and gramnegative bacilli.[12]
Risk

factors

for

infection

depend

on

the

involved. [12] Alcoholism is

organism

associated

with Streptococcus pneumoniae, anaerobic organisms, andMycobacterium tuberculosis, smoking is

associated

with Streptococcus

pneumoniae, Haemophilus

influenzae, Moraxella

catarrhalis,

and Legionella pneumophila, exposure to bird with Chlamydia psittaci, farm animals with Coxiella burnetti,
aspiration

of

stomach

contents

with

anaerobes,

and cystic

fibrosis with Pseudomonas

aeruginosa and Staphylococcus aureus.[12] Streptococcus pneumoniae is more common in the winter.
[12]

The use of acid suppressing medications (such as proton-pump inhibitors or H2 blockers) are

associated with an increased risk.[17]

Viruses
Main article: Viral pneumonia
In adults, viruses account for approximately a third of pneumonia cases. [11] Commonly implicated agents
include: rhinoviruses,[11]coronaviruses,[11]influenza virus,[18] respiratory syncytial virus (RSV),[18] adenovirus,
[18]

and parainfluenza.[18] Herpes simplex virus is a rare cause of pneumonia, except in newborns. People

with weakened immune systems are at increased risk of pneumonia caused by cytomegalovirus (CMV).
Fungi
Main article: Fungal pneumonia
Fungal pneumonia is uncommon,[12] but it may occur in individuals with weakened immune systems due
to AIDS, immunosuppressive drugs, or other medical problems. The pathophysiology of pneumonia
caused by fungi is similar to that of bacterial pneumonia. Fungal pneumonia is most often caused
by Histoplasma
and Coccidioides

capsulatum,

blastomyces, Cryptococcus

immitis. Histoplasmosis is

most

common

neoformans, Pneumocystis
in

the Mississippi

River

jiroveci,
basin,

and coccidioidomycosis is most common in the southwestern United States.[12]

Parasites
Main article: Parasitic pneumonia
A variety of parasites can affect the lungs. These parasites typically enter the body through the skin or the
mouth. Once inside the body, they travel to the lungs, usually through the blood. In parasitic pneumonia,
as with other kinds of pneumonia, a combination of cellular destruction and immune response causes
disruption of oxygen transportation. One type of white blood cell, theeosinophil, responds vigorously to
parasite infection. Eosinophils in the lungs can lead to eosinophilic pneumonia, thus complicating the

underlying parasitic pneumonia. The most common parasites causing pneumonia are Toxoplasma
gondii, Strongyloides stercoralis, and Ascariasis.
Idiopathic
Main article: Idiopathic interstitial pneumonia
Idiopathic interstitial pneumonia or noninfectious pneumonia [19] are a class of diffuse lung diseases. They
include: diffuse alveolar damage, organizing pneumonia, nonspecific interstitial pneumonia, lymphocytic
interstitial pneumonia, desquamative interstitial pneumonia, respiratory bronchiolitis interstitial lung
disease, and usual interstitial pneumonia.[20]
Pathophysiology
Pneumonia frequently starts as an upper respiratory tract infection that moves into the lower respiratory
tract.[21]
Viral
Viruses invade cells in order to reproduce. Typically, a virus reaches the lungs when airborne droplets are
inhaled through the mouth or nose. Once in the lungs, the virus invades the cells lining the airways and
alveoli. This invasion often leads to cell death, either from damage to the cell by the virus or from a
protective process called apoptosis in which the infected cell destroys itself before it can be used as a
conduit for virus reproduction. When the immune system responds to the viral infection, even more lung
damage occurs. White blood cells, mainly lymphocytes, activate certain chemicalcytokines that allow fluid
to leak into the alveoli. This combination of cell destruction and fluid-filled alveoli interrupts the normal
transportation of oxygen into the bloodstream.
As well as damaging the lungs, many viruses affect other organs and thus disrupt many body functions.
Viruses can also make the body more susceptible to bacterial infections; in this way bacterial pneumonia
can arise as a co-morbid condition.[18]
Bacterial
Bacteria typically enter the lung when airborne droplets are inhaled, but can also reach the lung through
the bloodstream when there is an infection in another part of the body. Many bacteria live in parts of
the upper respiratory tract, such as the nose, mouth, and sinuses, and can easily be inhaled into the
alveoli. Once inside, bacteria may invade the spaces between cells and between alveoli through
connecting pores. This invasion triggers the immune system to send neutrophils, a type of defensive
white blood cell, to the lungs. The neutrophils engulf and kill the offending organisms, and also
releasecytokines, causing a general activation of the immune system. This leads to the fever, chills, and

fatigue common in bacterial and fungal pneumonia. The neutrophils, bacteria, and fluid from surrounding
blood vessels fill the alveoli and interrupt normal oxygen transportation.
Diagnosis
Pneumonia is typically diagnosed based on a combination of physical signs and a chest X-ray.
[22]

Confirming the underlying cause can be difficult, however, with no definitive test able to distinguish

between bacterial and not-bacterial origin. [11][22] The World Health Organizationhas defined pneumonia in
children clinically based on either a cough or difficulty breathing and a rapid respiratory rate, chest
indrawing, or a decreased level of consciousness. [23] A rapid respiratory rate is defined as greater than 60
breaths per minute in children under 2 months old, 50 breaths per minute in children two months to one
year old, or greater than 40 breaths per minute in children one to five years old. [23]In children, an
increased respiratory rate and lower chest indrawing are more sensitive than hearing chest crackles with
a stethoscope.[8]
In adults, investigations are in general not needed in mild cases [24] as if all vital signs and auscultation are
normal the risk of pneumonia is very low.[25] In those requiring admission to a hospital,pulse
oximetry, chest radiography, and blood tests including a complete blood count, serum electrolytes, Creactive protein, and possibly liver function tests are recommended.[24] The diagnosis of influenza-like
illness can be made based on the presenting signs and symptoms however verification of an influenza
infection requires testing.[26] Thus treatment is frequently based on the presence of influenza in the
community or a rapid influenza test.[26]
Imaging
A chest radiograph is frequently used in diagnosis.[8] In people with mild disease, imaging is needed only
in those with potential complications, those who have not improved with treatment, or those in which the
cause in uncertain.[8][24] If a person is sufficiently sick to require hospitalization, a chest radiograph is
recommended.[24] Findings do not always correlate with severity of disease and do not reliably distinguish
between bacterial infection and viral infection.[8]
X-ray signs of bacterial community acquired pneumonia classically show lung consolidation of one lung
segmental lobe.[15] However, radiographic findings may be variable, especially in other types of
pneumonia.[15] Aspiration pneumonia may present with bilateral opacities primarily in the bases of the
lungs and on the right side. [15] Radiographs of viral pneumonia cases may appear normal, hyper-inflated,
have bilateral patchy areas, or present similar to bacterial pneumonia with lobar consolidation. [15] A CT
scan can give additional information in indeterminate cases. [15]
Radiologic findings often lag behind clinical findings, especially in the presence of dehydration, thus many
clinicians make a diagnosis of "clinical pneumonia" on the basis of history and crackles on examination.

[27]

This lag is more often remarked in Pneumocystis carinii pneumonia, where chest radiograph findings

may be normal in 10-39% of patients.[28]

Microbiology
For people managed in the community figuring out the causative agent is not cost effective, and typically
does not alter management.[8] For those not responsive to treatment, sputum cultureshould be
considered, and culture for Mycobacterium tuberculosis should be carried out in those with a chronic
productive cough.[24] Testing for other specific organisms may be recommended during outbreaks, for
public health reasons.[24] In those who are hospitalized for severe disease both sputum and blood
cultures are recommended.[24] Viral infections can be confirmed via detection of either the virus or
its antigens with culture or polymerase chain reaction (PCR) among other techniques.[11] With routine
microbiological testing a causative agent is determined in only 15% of cases. [7]
Classification
Main article: Classification of pneumonia
Pneumonitis refers to lung inflammation; pneumonia refers to pneumonitis, usually due to infection but
sometimes non infectious, that has the additional feature of pulmonary consolidation.[29]Pneumonia can be
classified in several ways. It is most commonly classified by where or how it was acquired (communityacquired,aspiration, healthcare-associated, hospital-acquired,
[15]

but

may

also

be

classified

by

the

area
[15]

of

lung

andventilator-associated
affected

pneumonia),

(lobar

pneumonia, bronchial

[30]

Pneumonia in children

pneumonia and acute interstitial pneumonia), or by the causative organism.

may additionally be classified based on signs and symptoms as non-severe, severe, or very severe. [31]
Differential diagnosis
Several diseases can present similar to pneumonia, including: chronic obstructive pulmonary
disease (COPD), asthma, pulmonary edema, bronchiectasis, lung cancer, and pulmonary emboli.[7]Unlike
pneumonia, asthma and COPD typically present with wheezing, pulmonary edema presents with an
abnormal electrocardiogram, cancer and bronchiectasis present with a cough of longer duration, and
pulmonary emboli presents with acute onset sharp chest pain and shortness of breath.[7]
Prevention
Prevention includes vaccination, environmental measures, and appropriately treating other diseases. [8]
Vaccination
Vaccination is effective for preventing certain bacterial and viral pneumonias in both children and
adults. Influenza vaccines are modestly effective against influenza A and B. [11][32] The Center for Disease
Control and Prevention (CDC) recommends that everyone 6 months and older get yearly vaccination.

[33]

When an influenza outbreak is occurring, medications such as amantadine orrimantadine may help

prevent influenza.[34] It is unknown if zanamivir or oseltamivir are effective due to the fact that the company
that manufactures oseltamivir have refused to release the trial data for independent analysis. [35]
Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae have good evidence to
support their use.[21] Vaccinating children against Streptococcus pneumoniae has also led to a decreased
incidence of these infections in adults, because many adults acquire infections from children. A vaccine
against Streptococcus pneumoniae is also available for adults, and has been found to decrease the risk
of invasive pneumococcal disease.[36]
Environmental
Reducing indoor air pollution is recommended[8] as is smoking cessation.[24]
Other
Appropriately treating underlying illnesses (such as HIV/AIDS) can decrease a person's risk of
pneumonia.[37] In

those

with

HIV/AIDS

and

CD4

count

of

less

than

200

cells/uL the

antibiotictrimethoprim/sulfamethoxazole decrease the risk of Pneumocystis pneumonia.[38] This practice

may also be useful in those who are immunocomprised but do not have HIV.[39]
There are several ways to prevent pneumonia in newborn infants. Testing pregnant women for Group B
Streptococcus and Chlamydia trachomatis, and giving antibiotic treatment, if needed, reduces pneumonia
in infants. Suctioning the mouth and throat of infants with meconium-stained amniotic fluid has not been
found to decrease the rate of aspiration pneumonia and may cause potential harm.[40] Thus this practice is
not recommended in the majority of situations. [40] In the frail elderly good oral health care may decrease
the risk of aspiration pneumonia.[41]
Management
Typically, oral antibiotics, rest, simple analgesics, and fluids suffice for complete resolution.[24] However,
those with other medical conditions, the elderly, or those with significant trouble breathing may require
more advanced care. If the symptoms worsen, the pneumonia does not improve with home treatment, or
complications occur, hospitalization may be required. [24] Worldwide, approximately 713% of cases in
children result in hospitalization[8]while in the developed world between 22 and 42% of adults with
community-acquired pneumonia are admitted.[24] The CURB-65 score is useful for determining the need
for admission in adults.[24] If the score is 0 or 1 people can typically be managed at home, if it is 2 a short
hospital stay or close follow up is needed, if it is 35 hospitalization is recommended. [24] In children those
with respiratory distress or oxygen saturations of less than 90% should be hospitalized. [42] The utility
of chest physiotherapy in pneumonia has not yet been determined. [43] Non-invasive ventilation may be

beneficial in those admitted to the intensive care unit.[44] Over-the-counter cough medicine has not been
found to be effective[45] nor has the use of zinc in children.[46]
Bacterial
Antibiotics improve outcomes in those with bacterial pneumonia. [47] Antibiotic choice depends initially on
the characteristics of the person affected, such as age, underlying health, and the location the infection
was acquired. In the UK, empiric treatment with amoxicillin is recommended as the first line
for community-acquired pneumonia, withdoxycycline or clarithromycin as alternatives.[24] In North America,
where the "atypical" forms of community-acquired pneumonia are more common, macrolides (such
as azithromycin), and doxycycline have displaced amoxicillin as first-line outpatient treatment in adults. [16]
[48]

In children with mild or moderate symptoms amoxicillin remains the first line. [42] The use

offluoroquinolones in uncomplicated cases is discouraged due to concerns about side effects and
resistance.[16] The duration of treatment has traditionally been seven to ten days, but increasing evidence
suggests that short courses (three to five days) are similarly effective. [49] Antibiotics recommended for
hospital-acquired

pneumonia

include

third-

generation cephalosporins,carbapenems, fluoroquinolones, aminoglycosides,

and
and vancomycin.

fourth[50]

These

antibiotics, often given intravenously, may be used in combination.

Viral
Neuraminidase inhibitors may be used to treat viral pneumonia caused by influenza viruses (influenza
A and influenza B).[11] No specific antiviral medications are recommended for other types of community
acquired viral pneumonias including SARS coronavirus, adenovirus, hantavirus, and parainfluenza virus.
[11]

Influenza A may be treated with rimantadine or amantadine, while influenza A or B may be treated

with oseltamivir, zanamivir or peramivir.[11] These are of most benefit if they are started within 48 hours of
the onset of symptoms.[11] Many strains of H5N1 influenza A, also known as avian influenza or "bird flu,"
have shown resistance to rimantadine and amantadine. [11] The use of antibiotics in viral pneumonia is
recommended by some experts as it is impossible to rule out a complicating bacterial infection.
[11]

The British Thoracic Society recommends that antibiotics be withheld in those with mild disease. [11] The

use of corticosteroids is controversial.[11]

Aspiration
In general, aspiration pneumonitis is treated conservatively with antibiotics indicated only for aspiration
pneumonia.[51] The choice of antibiotic will depend on several factors, including the suspected causative
organism and whether pneumonia was acquired in the community or developed in a hospital setting.
Common options include clindamycin, a combination of a beta-lactam antibiotic and metronidazole, or
an aminoglycoside.[52] Corticosteroids are commonly used in aspiration pneumonia, but there is no
evidence to support their effectiveness.[52]

Prognosis
With treatment, most types of bacterial pneumonia can be cleared within two to four weeks [53] and
mortality is very low.[11] Viral pneumonia may last longer, and mycoplasmal pneumonia may take four to
six weeks to resolve completely.[53] The eventual outcome of an episode of pneumonia depends on how ill
the person is when he or she was first diagnosed. [53] Before the advent of antibiotics mortality was
typically 30% for hospitalized patients.[12]
In the United States, about 5% of those diagnosed with pneumococcal pneumonia will die. In cases
where the pneumonia progresses to blood infection, just over 20% will die.[54]
The death rate (or mortality) also depends on the underlying cause of the pneumonia. Pneumonia caused
by Mycoplasma, for instance, is associated with lower mortality. However, about half of the people who
develop methicillin-resistant Staphylococcus aureus (MRSA) pneumonia while on a ventilator will die. [55] In
regions of the world without advanced health care systems, pneumonia is even more deadly. Limited
access to clinics and hospitals, limited access to x-rays, limited antibiotic choices, and inability to
diagnose and treat underlying conditions inevitably lead to higher rates of death from pneumonia. For
these reasons, the majority of deaths in children under five due to pneumococcal disease occur in
developing countries.[56]
Adenovirus can cause severe necrotizing pneumonia in which all or part of a lung has increased
translucency radiographically, which is called Swyer-James Syndrome.[57] Severe adenovirus pneumonia
also may result in bronchiolitis obliterans, a subacute inflammatory process in which the small airways are
replaced by scar tissue, resulting in a reduction in lung volume and lung compliance.[57] Sometimes
pneumonia can lead to additional complications. Complications are more frequently associated with
bacterial pneumonia than with viral pneumonia. The most important complications include respiratory and
circulatory failure and pleural effusions, empyema or abscesses.