Pneumonia

Question 1

Pneumonia

Answer 1

This patient has been acutely unwell for 3 days, with shortness of breath and a productive cough.
Please examine his chest.

Question 2

Clinical signs of Pneumonia

Answer 2

• Tachypnoea, O2 mask, sputum pot (rusty sputum associated with pneumococcus)
• Reduced expansion
• Dull percussion note
• Focal coarse crackles, increased vocal resonance and bronchial breathing
• Ask for the temperature chart
• If dull percussion note with absent tactile vocal fremitus, think parapneumonic effusion/ empyema

Question 3

Investigation

Answer 3

• CXR: consolidation (air bronchogram), abscess and effusion
• Bloods: WCC, CRP, urea, atypical serology (on admission and at day 10) and immunoglobulins
• Blood (25% positive) and sputum cultures
• Urine:
  ⚬⚬ Legionella antigen (in severe cases)
  ⚬⚬ Pneumococcal antigen
  ⚬⚬ Haemoglobinuria (mycoplasma causes cold agglutinins → haemolysis)

Question 4

Community acquired pneumonia (CAP)

* Common organisms:

Answer 4

⚬⚬ Streptococcus pneumoniae 50%
⚬⚬ Mycoplasma pneumoniae 6%
⚬⚬ Haemophilus influenzae (especially if COPD)
⚬⚬ Chlamydia pneumoniae.

Question 5

Community acquired pneumonia (CAP)

* Antibiotics:

Answer 5

⚬⚬ 1st line: penicillin or cephalosporin + macrolide

Question 6

Special considerations in pneumonia
* Immunosuppressed:
* Aspiration
* Post‐influenza:

Answer 6

• Immunosuppressed:
  ⚬⚬ Fungal Rx Amphotericin
  ⚬⚬ Multi‐resistant mycobacteria
  ⚬⚬ Pneumocystis carinii Rx Cotrimoxazole/Pentamidine
  ⚬⚬ CMV Rx Ganciclovir
• Aspiration (commonly posterior segment of right lower lobe):
  ⚬⚬ Anaerobes Rx + Metronidazole
• Post‐influenza:
  ⚬⚬ Staph. aureus Rx + Flucloxacillin

Question 7

Severity score for pneumonia:

Answer 7

CURB‐65 (2/5 is severe)
* Confusion
* Urea >7
* Respiratory rate >30
* BP systolic <90 mm Hg or diastolic <60 mm Hg
* Age >65

Severe CAP should receive high‐dose IV antibiotics initially plus level 2 care (HDU/ITU)

Question 8

Prevention of pneumonia

Answer 8

Pneumovax II® to high‐risk groups, e.g. chronic disease (especially nephrotic and asplenic patients) and the elderly

Question 9

Complications of pneumonia

Answer 9

• Lung abscess (Staph. aureus, Klebsiella, anaerobes)
• Para‐pneumonic effusion/empyema
• Haemoptysis
• Septic shock and multi‐organ failure