Pneumonia

Question 1

What types of pathogens can cause pneumonia?

Answer 1

Viruses, bacteria, fungi, parasites

Question 2

What are predisposing factors for pneumonia?

Answer 2

Obstruction
Aspiration
Cigarette smoking
Immunosuppresion

Question 3

What types of pneumonia are there?

Answer 3

Lobar pneumonia (localised)
Bronchopneumonia (affecting lobules, bronchi and bronchioles- diffuse)

Question 4

What types of pneumonia are caused by bacteria?

Answer 4

Lobar pneumonia, bronchopneumonia or both

Question 5

What is a typical causative organism of classic lobar pneumonia?

Answer 5

Strep. pneumoniae

Question 6

List the symptoms of pneumonia

Answer 6

Malaise
Anorexia
Sweats
Rigors
Myalgia
Arthalgia
Headache 
Confusion
Cough
Pleurisy
Haemoptysis
Dysponoea
Preceding URTI
Abdominal pain (diaphragmatic pleurisy)
Diarrhoea

Question 7

What are clinical signs on examination of pneumonia?

Answer 7

Fever
Rigors
Herpes labialis
Tachypnoea
Crackles
Rub
Cyanosis
Hypotension
Diminished chest expansion
Dull percussion note
Increased tactile vocal fremitus/ vocal resonance
Bronchial breathing

Question 8

List some investigations that would help in a diagnosis of pneumonia.

Answer 8

CXR
Assess oxygenation
ABGs
Blood tests: FBC, U&E, LFT, CRP, blood cultures if septic.
Sputum microscopy and culture

Question 9

What would you look for on a CXR?

Answer 9

lobar or multilobar infiltrates
cavitation
Pleural effusion

Question 10

How is the severity of pneumonia assessed?

Answer 10

CURB-65.
C = new onset of confusion
U= Urea > 7
R = Respiratory rate >30/min
B= Blood pressure: systolic < 90 or diastolic < 61
65 = 65 years of age or older
1 point for each of the above.

Question 11

a) What does CURB 65 predict?

b) Which patients is it not useful in?

Answer 11

a) Mortality in normal well people who have a new pneumonia.
b) Patients with hospital acquired pneumonia or patients with a COPD exacerbation.

Question 12

What CURB 65 score indicates a severe pneumonia?

Answer 12

A score of more than 3.

Question 13

List some other severity markers of pneumonia which are not included in the CURB 65 score.

Answer 13

Temperature 40
Cyanosis, Pa02 < 8 kPa
WBC 30
Multi-lobar involvement

Question 14

What are complications of pneumonia?

Answer 14

Respiratory failure
Pleural effusion
Empyema
Death

Question 15

What vaccines are available for the prevention of pneumonia?

Answer 15

Influenza and pneumococcal vaccines

Question 16

Who are the influenza and pneumococcal vaccines available to?

Answer 16

Both:
Over 65
Chronic chest or cardiac disease
Diabetes
Immunocomprimised (e.g. splenectomy)

Infleunza vaccine: Healthcare workers

Question 17

What is the treatment for mild/moderate CAP?

Answer 17

Amoxicillin 1g tds (three times a day) Iv/PO (7 days)

If penicillin allergic: doxycycline PO 200mg then 100mg OD

Question 18

What is the treatment for severe CAP?

Answer 18

Co-amoxiclav IV + either Clarithromycin IV or Doxycycline PO bd (twice daily)
If penicillin allergic, IV Levofloxacin
Step down to Doxycycline 100mg bd for all severe CAP
Total IV/PO = 10 days

Question 19

Which pathogens cause CAP, in order of most common to least common?

Answer 19

Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae
Remainder: Staph aureus, Legionella, Moraxella catarrhalis, Chlamydophila psittaci, coxiella burnetti.
Viruses: 15%
Flu may be complicated by Community acquires MRSA pneumonia

Question 20

After how many hours since hospital admission is a new pneumonia defined as hospital acquired/nosocomial?

Answer 20

> 48 hours

Question 21

Which pathogens cause nosocomial pneumonia?

Answer 21

Most commonly gram negative enterobacteria or staph aureus.

Others: Psuedomonas, klebsiella, Bacteroides and Clostridia.

Question 22

What needs to be taken into account when treating aspiration pneumonia?

Answer 22

Need anaerobic cover

Question 23

What is particular about pnuemonia as caused by Legionella?

Answer 23

Chest symptoms may be absent

GI disturbance is common

Question 24

Who is most commonly affected by mycoplasma pneumoniae?

Answer 24

Older children and young adults

Question 25

As well as pneumonia, what other disease does coxiella burnetti cause?

Answer 25

Q fever (pyrexia of unknown origin)

Question 26

Which animals carry coxiella burnetti?

Answer 26

Sheep and goats

Question 27

What complication does coxiella burnetti cause?

Answer 27

Culture negative endocarditis

i.e. the culture does not grow any pathogen as the bacteria is a parasite and will only grow in living cells

Question 28

Which disease does chlamydophila psittaci cause, and how does this disease usually present?

Answer 28

Psittacosis, which usually presents as pneumonia

Question 29

What animals is chlamydophila psittaci caught from?

Answer 29

Pet birds such as parrots, budgies and cockatiels.

Question 30

Which is a more sensitive test, sputum culture or sputum microscopy?

Answer 30

Sputum microscopy.

Sputum culture is also limited as a test because mycoplasma is the only organism that can be grown with any ease.

Question 31

What are the most encountered clinical signs of pneumonia, bronchial breathing or crepitations?

Answer 31

Crepitations.

Question 32

Which organism occurs in large epidemics every 3-4 years?

Answer 32

Mycoplasma pneumoniae.

Question 33

What does streptococcus pneumoniae look like on microscopy?

Answer 33

Gram positive cocci in short chains/pairs

Question 34

Is strep. pneumoniae alpha, beta or gamma haemolytic?

Answer 34

Alpha haemolytic

Question 35

What antibiotics is strep. pneumonia generally sensitive to?

Answer 35

Penicillins

Question 36

a) Which pathogen is a cause of pneumonia in patients with AIDS?
b) How is it diagnosed?
c) What is the treatment?

Answer 36

a) Pneumocystitis carinii pneumonia
b) Bronchioalveolar lavage or induced sputum and identification of cysts
c) Cotrimoxazole, pentamidine

Question 37

Which fungus can cause a severe pneumonia?

Answer 37

Aspergillus fumigatus