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COMMUNITY ACQUIRED PNEUMONIA - TYPICAL OR ATYPICAL ?


Rajinder Singh Bedi
Lung India 2006; 23: 130-131

A number of studies have concluded that there


is little use of classifying CAP into atypical or typical
one, on the basis of clinical features of radiology, as this
classification often can not predict microbial aetiology
and thus help in planning the management. In one study,
clinical features were only 40 percent accurate in telling
the difference between pneumococcal, mycoplasma and
other pneumonic infections2. Similarly, in a study of 196
patients with CAP, multilobar disease, pleural effusion,
lobar collapse and cavitations were sufficient common
in patients with pneumococcal pneumonia, Legionnaires
disease, mycoplasma and psittacosis so that the radiology
could not be used to determine bacterial aetiology3.

Pneumonia continues to play an important role in


medicine. It denotes inflammation of the lung parenchyma
caused by a microbial agent. Community acquired
pneumonia (CAP) is the most important infection in clinical
medicine world wide.
Clinically, CAP is often classified as typical or
atypical. In typical pneumonia. There is sudden onset
of fever, chills, pleuritic chest pain and productive cough.
Typical pneumonia is usually caused by bacterial pathogens
like Streptococcus pneumoniae, Staphylococcus aureus.
Klebsiella pneumoniae, Haemophilus influenzae etc. In
contrast, atypical CAP is characterized by preceeding
upper airway symptoms, myalgias, fever without chills,
headache and unproductive cough. The causative organisms
responsible for atypical pneumonia include Viruses,
Mycoplasma pneumoniae, Legionella pneumophilia,
Chlamydia psittaci and Coxiella burnetli etc.

There are two main reasons why clinical features


correlate poorly with the microbial aetiology. Certain
pathogens such as legionella and C psittacci often produce
clinical picture that mimics both typical and atypical
syndromes. Secondly, if the hosts immune response is
impaired because of comorbid illness or advanced age,
even then the clinical features may be changed. Here
even bacterial pathogens can produce atypical clinical or
radiological features.

In typical pneumonia total leucocyte counts,


ESR and CRP are mostly raised ; in contrast to atypical
pneumonia, where these parameters are usually normal or
only slightly raised. Radiologically, chest radiograph will
show lobar or segmental homogeneous opacity in over 80%
of typical bacterial pneumonias. But this finding can also be
seen in nearly half the cases of atypical infection. In atypical
pneumonias, diffuse patchy or ground glass shadows are
more commonly observed.

For guiding therapy for CAP, knowledge of the


potential pathogen is very important. As discussed above, in
clinical practice it is often difficult to predict the microbial
aetiology on the basis of clinico-radiological picture.
The typical pneumonias often respond well to lactam
antibiotics where as atypical pathogens, being intracellular,
do not respond to lactams but respond to antibiotic such
as macrolides, tetracyclines and some quinolones.

In Western countries, nearly 60 - 80% of CAP are


caused by bacteria, 10 - 20-% by atypical organisms and
a similar proportion by viruses. Over the past few years,
several studies have shown that atypical organisms are
common, being present in upto 40% of all CAP patients,
often as copathogens along with bacterial organisms1.
From India, atypical organisms have rarely been isolated
from patients with CAP, mainly due to lack of facilities for
culture/serology of these organisms.

In view of these observations, it seems that


classifying CAP into typical and atypical may not be very
helpful in planning the effective management of CAP. A
judicious use of epidemiology, laboratory data and clinical
findings is needed to achieve this target.

Correspondence: Dr. Rajinder Singh Bedi, Bedi Clinic & Nursing Home, Sher-e-Punjab Market, Patiala - 147001 (Pb.), , E-mail : rsbedi@sancharnet.in,
Recieved : December 2004
Accepted : March 2005

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Community Acquired Pneumonia - Typical Or Atypical ?

REFERENCES:

3.

1.

Porath A, Schaeffer F, Lieberman D. The epidemiology of


community acquired pneumonia among hospitalized adults.
J Infect 1997 ; 34 : 41 - 48.

2.

Farr B M, Kaiser D L, Harrison B D W et al. Prediction of


microbial aetiology at admissin to hospital for pneumonia
from presenting clinical features. Thorax 1989 ; 44 : 1031
- 1035.

MacFarlane J T, Miller A C, Smith W H et al. Comparative


radiographic features of community - acquired Legionnaires
disease, pneumococcal pneumonia, mycoplasma pneumonia,
and psittacosis. Thorax 1984 ; 39 : 28 - 33.

Nominations Invited For Indian Chest Society


Orations/Awards
Nominations are invited from members of the Indian Chest Society for the following Orations and Awards for
the year 2006 for excellence in scientific and meritorius contributions in the field of pulmonary sciences.
1. ICS Oration
2. Silver Jubilee ICS Oration
3. O.A. Sarma Oration (for TB),
Both the Indian Chest Society Orations (1 and 2) are awarded for any subject related to respiratory medicine and
are open only for members of the Indian Chest Society. The OA Sarma Oration is meant for distinguished contribution
in tuberculosis made by any eminent person.
Each nomination must include the consent letter of the nominee along with 5 copies of his/her brief curriculum
vitae and a summary of the contributions for which the nomination is being made. A nominee (for Oration 1 and 2)
must be a member of the ICS at least for the preceding 3 years.
All nominations should reach the office of the Secretary of Indian Chest Society at following address on before
31st August, 2006.

Dr. J. K. Samaria
Hon. Secretary

Indian Chest Society


Plot No. 36-A, Kabir Nagar
Durgakund, Varanasi - 221 005
Tel : (0542) 2310333,
E-mail : jks@satyam.net.in

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