QuestionSBA
QuestionChoice
With a CURB 65 score of 2, at this moment in time, he can be managed on the general medical/respiratory ward and does not need ICU, which is normally indicated at CURB 65 score over 3.
10015868
c
Admit to ICU and adminster IV Tazocin
QuestionChoice
This man has a community acquired pneumonia with a CURB 65 Score of 2. He needs admission to the general medical/respiratory ward to be commenced on combination antibiotic therapy.
10015866
a
Admit to respiratory ward and adminster amoxicillin + clarithomycin
QuestionChoice
This is inappropriate as the patient is unwell and requires intravenous antibiotics in hospital.
10015870
e
Discharge with outpatient follow up
QuestionChoice
Alteplase may be indicated in the treatment of massive PE, however the CXR and clinical picture point towards a pneumonia.
10015867
b
Thrombolyse with alteplase
QuestionChoice
This is the management for tuberculosis. Although he has returned from India, the absence of night sweats, haemoptysis and acuity of symptoms are more typical of pneumonia.
10015869
d
Admit to infectious diseases ward, isolate in a negative pressure room and adminster rifampicin, isionazid, pyrizanamide and ethambutol
QuestionComment
Is the image not showing for anyone else?
34898
QuestionComment
if u click it, it says xr of lobar pneumonia
36602
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Headie Oneeee
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Migraine Body
QuestionComment
yes all images on quested since the new update 
34971
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Shayan Abdallah 🍓
QuestionComment
Am I not seeing ghon lesions?
41737
QuestionComment
i thought the same thing, at the right hilum there appears to be a clear lesion imo
42167
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Hematoma Haemophilus
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Hypertension Quaternary
QuestionComment
CURB-65 of 2 which means that the treatment is amoxicillin  ( not co-amoxiclav) + clarithromycin 
42904
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Supine Bladder
QuestionComment
surely you would test for tb with a history like that?
44169
QuestionComment
You could test but his history isn't really suggestive of TB. He's not reported to have night sweats, haemoptysis, etc. TB often also doesn't come on acutely like the above case, it generally presents as a cough for > 3 weeks. 

44429
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The Spleen 
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Al
QuestionComment
i liked this q - challenging the stereotype that all questions mentioning india must be TB-related
49425
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Loose Myopathy
QuestionComment
is this not a PE???? My finals are tomorrow pls help
52285
QuestionComment
Hope they went well! 
52366
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Intravenous Hereditary
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Habib Ali
QuestionComment
Bruh i thought this was a wedge infarct
53725
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Ali Abdaal
QuestionComment
Is there not bilateral hilar lymphadenopathy?
59043
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Inpatient Bradykinin
QuestionComment
I thought it was a lobar collapse bc the trachea looks weird 
61562
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Epidermis Benign
Concept
Chapter
# Summary

Pneumonia is a common infection of the lung parenchyma that involves the alveoli becoming consolidated with inflammatory cells and microorganisms. Key symptoms include fever, malaise, a productive cough and pleuritic chest pain. Investigations include a chest X-ray to detect consolidation, blood tests for inflammatory markers and blood and sputum cultures to look for an underlying cause. Management involves oxygen if hypoxic, IV fluids if required and antibiotics targeted to the causative organism. 

# Definition

Pneumonia is an inflammatory condition of the lung parenchyma caused by infection. Alveoli become filled with inflammatory cells and microorganisms, leading to consolidation of the lung tissue. This impairs gas exchange and can lead to hypoxia.

# Epidemiology

Community-acquired pneumonia has an incidence of 5-10 per 1000 adults in the UK per year. Approximately 22-42% of these cases require admission to hospital. Mortality estimates range from 5 to 14%, with half of these being in people aged over 84 years. 

# Aetiology

The commonest cause of pneumonia is Streptococcus pneumonia, which is usually community-acquired, followed by Haemophilus influenzae and Moraxella catarrhalis. These are referred to as typical pneumonias (as they tend to present with the classic symptoms listed below).

Atypical pneumonias have a variety of atypical features, e.g. a more insidious onset, extra-pulmonary symptoms such as headache and varying appearances on chest imaging. These include Mycoplasma pneumoniae, Legionella pneumophila and Chylmydophila psittaci. 

Hospital-acquired pneumonias are defined as pneumonia that started 48 hours or longer after admission. Gram negative organisms such as Pseudomonas aeruginosa, as well as Staphylococcus aureus are more common in these environments.

Aspiration pneumonias are covered in a separate chapter. 

**Specific features of some of these microbiological causes are as follows:**

**Staphylococcal pneumonia**

- A bilateral cavitating bronchopneumonia due to staphylococcal aureus, a gram-positive cocci found in clusters.
- Commoner in intravenous drug users, elderly patients, or as a superadded bacterial infection in those with influenza.

**Klebsiella pneumonia**

- Usually a cavitating pneumonia affecting the upper lobes presenting with red-currant sputum.
- It is caused by a gram-negative anaerobic rod.
- Increased risk in the immunocompromised, elderly and in alcohol excess.

**Mycoplasma pneumonia**

- Presents with flu-like symptoms of arthralgia, myalgia, dry cough and headache.
- Primarily affects younger patients.
- Associated with an autoimmune haemolytic anaemia caused by cold agglutinins.
- May lead to erythema multiforme, Stevens-Johnson syndrome, Guillain-Barre syndrome and meningoencephalitis.

**Legionella pneumonia**

- Fever, myalgia and malaise followed by dyspnoea and a dry cough are typical presenting features.
- Caused by a gram-negative coccobacillus.
- Occurs in those exposed to contaminated water e.g. in humidifiers or cooling systems.
- Typically causes hyponatraemia and deranged liver function tests. 

**Chlamydophila psittaci pneumonia**

- An intracellular bacteria acquired from contact with infected birds such as parrots.
- Features include lethargy, arthralgia, headache, anorexia, dry cough and fever.

# Classification

Community-acquired pneumonias are classified using the CURB-65 score to determine severity and guide management.

One point is awarded for each of the following:

- Confusion 

- Urea > 7mmol/L

- Respiratory rate > 30 breaths/min

- Blood pressure < 90 systolic and/or < 60mmHg diastolic

- 65 years or older

This can be used to estimate 30 day mortality from pneumonia:

- CURB-65 0 - **0.7%** 

- CURB-65 1 - **3.2%** 

- CURB-65 2 - **13%** 

- CURB-65 3 - **17%** 

- CURB-65 4 - **41.5%** 

- CURB-65 5 - **57%** 

A CURB-65 score of 0-1 requires home treatment, 2 should consider hospital admission, 3-5 admit to hospital and consider ITU referral.

# Symptoms

- Fever
- Malaise
- Rigors
- Cough
- Purulent sputum
- Pleuritic chest pain
- Haemoptysis

# Signs

- Tachypnoea
- Tachycardia
- Hypotension
- Cyanosis
- Pyrexia
- Dullness to percussion over the consolidated area
- Increased vocal resonance/ tactile vocal fremitus over the consolidated area
- Bronchial breathing over the consolidated area
- Pleural rub may be heard due to inflammation of the adjacent pleura

# Differential Diagnosis

- **Bronchiectasis** - chronic productive cough with copious sputum, may be triggered by a severe lower respiratory tract infection or another condition (e.g. cystic fibrosis)
- **Tuberculosis** - suspect in patients with risk factors (e.g. TB contact, from endemic area, no fixed abode), haemoptysis and weight loss more common
- **Lung cancer** - may lead to pneumonia e.g. by obstructing a bronchus with downstream infection, important to consider especially in patients with a history of smoking, weight loss, chronic cough and haemoptysis
- **Bronchitis** - infection of the bronchi rather than the lower respiratory tract, usually viral and self-resolving 

# Investigations

**Bedside:**

- Sputum for microscopy, culture and sensitivity
- Consider arterial blood gas if hypoxaemic 
- Urinary legionella and pneumococcal antigens
- ECG to look for complications e.g. atrial fibrillation

**Bloods:**

- Blood cultures if febrile
- FBC and CRP for inflammatory markers
- U&Es to look for an AKI
- LFTs may be deranged e.g. in Legionella, baseline important when giving antibiotics
- Mycoplasma serology if atypical pneumonia suspected
- HIV testing should be offered to all patients with recurrent pneumonia (and all patients in a high prevalence area such as London)

**Imaging:**

- Chest X-ray: may show lobar consolidation or bilateral consolidation in atypical infections, parapneumonic effusions may also be seen.
- CT chest may be indicated in some cases (e.g. suspected underlying malignancy, suspicious findings on X-ray)

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# Management

**Conservative:**

- Oxygen if low saturations
- IV fluids if dehydrated
- Analgesia for myalgia or chest pain
- Escalate for respiratory support (e.g. continuous positive airway pressure or intubation and ventilation) if patients are severely unwell - consider escalation status and patient wishes

**Medical:**

- Oral antibiotics for patients managed in the community (e.g. amoxicillin 500mg three times a day for 5 days)
- IV antibiotics for those admitted with more severe pneumonia (e.g. co-amoxiclav and clarithromycin)
- Different regimens are indicated for those with penicillin allergies and local guidelines should be consulted
- Antibiotics should be tailored to antimicrobial sensitivities when these are resulted

Patients with pneumonia should be followed up with a repeat chest X-ray after 6 to 8 weeks to screen for an underlying lung cancer (as this may be masked on initial imaging by infective changes).

# Complications

- Parapneumonic effusion
- Empyema
- Lung abscess
- Sepsis

# NICE Guidelines

[NICE - Pneumonia in adults](https://www.nice.org.uk/guidance/cg191)

[NICE CKS - Chest Infections](https://cks.nice.org.uk/topics/chest-infections-adult/)

# References

[Radiopaedia - Lobar Pneumonia](https://radiopaedia.org/articles/lobar-pneumonia)
1985
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A right sided basal pneumonia seen on chest x-ray.
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Elderly patients with shortness of breath, productive cough, fever, and an abnormal chest X-ray require admission for antibiotic treatment to manage community-acquired pneumonia.
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Respiratory
A 67 year old man has shortness of breath and a productive cough for 2 days. He is alert. His temperature is 38 degrees Celcius, his blood pressure is 118/79mmHg and his respiratory rate is 32. He has recently come back from visiting family in India. He has no allergies. A chest X ray is performed and shown below. Bloods show urea levels of 6.9mmol.

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What is the most appropriate course of action?
a