QuestionSBA
QuestionChoice
Pneumothorax can present with pleuritic chest pain and shortness of breath. However, they would not present with a productive cough or pyrexia due to a pneumothorax. In addition, they would have hyperresonance to percussion and decreased vocal resonance on auscultation
33569
b
Pneumothorax
QuestionChoice
Pericarditis is caused by inflammation of the pericardial lining, typically due to a viral infection. Typical symptoms include pleuritic chest pain (typically worse on laying down and relieved on leaning forward) and fever. A pericardial rub may be heard on auscultation. In this case, this patient has a productive cough, and their pain does not change with posture, making a diagnosis of pneumonia more likely. Their examination findings would also not be present in pericarditis and are better explained by the diagnosis of pneumonia
33572
e
Pericarditis
QuestionChoice
Pneumonia typically presents with an acute history of productive cough, breathlessness, chest pain and fever. Other typical features include haemoptysis, septic shock, atrial fibrillation and confusion in the elderly. Rust coloured sputum suggests a _Streptococcus pneumoniae_ infection, which is the most common cause of pneumonia. Dullness to percussion, reduced breath sounds and increased vocal resonance are all typical examination features of pneumonia. The next step in the management of this patient is a CRB-65 score to determine the prognosis and management of this patient. Pneumonia is a radiological diagnosis, so for confirmation of this diagnosis, a patient must have a chest x-ray showing signs of consolidation
33568
a
Pneumonia
QuestionChoice
Pulmonary embolism can present with breathlessness, sudden onset pleuritic chest pain, haemoptysis and the presence of deep vein thrombosis, usually in a patient with other risk factors for pulmonary embolism. It may also present with pyrexia (which is usually mild). Physical examination of the chest is typically normal. As this patient has a history of productive cough, gradual onset pleuritic chest pain, high fever and physical examination suggestive of pneumonia, pneumonia is the more likely diagnosis
33571
d
Pulmonary embolism
QuestionChoice
Empyema is a collection of pus within the pleural cavity. This can be a complication following pneumonia, so it can initially present with symptoms of pneumonia. Specific symptoms indicating empyema include fever, chest pain, and breathlessness refractory to antibiotic treatment for pneumonia. Examination findings are similar to pleural effusion, including reduced breath sounds, dullness to percussion and reduced vocal resonance. The presence of productive cough and increased vocal resonance makes a diagnosis of pneumonia more likely
33570
c
Empyema
Concept
Chapter
# Summary 
 
Pneumonia is a radiological diagnosis, often due to a lower respiratory tract infection causing inflammation of the alveoli and terminal bronchioles, leading to consolidation of bronchopulmonary segment or lobe. Key signs and symptoms include rapid onset of high fever and productive cough for typical bacterial causes. Key investigations include blood tests, sputum culture, urinary antigen tests, and chest x-ray. Management strategies involve use of antibiotics, assessment of severity using CURB-65 score and inpatient treatment for severe cases.
 
 
# Definition
 
- Lower Respiratory Tract Infection/ Pneumonia is caused by infection and subsequent inflammation of the alveoli and terminal bronchioles.
- This leads to an entire bronchopulmonary segment or lobe becoming consolidated, which means that tissue is filled with inflammatory cells and oedema.
 
 
# Community Acquired Pneumonia (CAP)
 
 
## Bacterial Causes
 
 
- Typicals - so called because of the classical rapid onset of symptoms, including high fever and productive cough;
- Streptococcus pneumoniae (gram +ve cocci found in pairs, also known as 'Pneumococcus')
- Staphylococcus aureus
- Haemophilus influenzae (gram -ve rod, potent beta-lactamase producer)
- Moraxella catarrhalis (gram -coccus, potent beta-lactamase producer)
- Atypicals: so called because of the more gradual onset of symptoms, which may be non-specific initially (fever, myalgia, dry cough). The organisms are also intracellular;
- Mycoplasma pneumoniae
- Chlamydia pneumoniae
- Legionella pneumophila
- Coxiella burnettii
- Chlamydia psittaci
 
 
## Viral Causes 
 
- Most commonly Influenza A, which can predispose to superadded Staph aureus (or strep pneumoniae) pneumonia.
- Others: CMV, HSV, VZV
 
## Fungal Causes
 
Can be seen after silver staining and microscopy:
 
- Candida - dimorphic yeast
- Aspergillus - fungus with hyphae
- Cryptococcus - encapsulated yeast
 
 
## Specific Causes 
 
COPD: 
 
- Pneumococcus still most common
- Haemophilus influenzae
- Morexella catarrhalis
 
Cystic Fibrosis:
 
 
- Staph aureus
- Pseudomonas aeruginosa
- Burkholderia cepacia
 
Causes in Homeless people: malnourished, alcohol or drug dependent, immunosuppressed:
 
 
- Mycobacterium tuberculosis
- Aspiration pneumonia (infection with normal flora of mouth and anaerobes, also consider in any patient with an unsafe swallow or with depressed consciousness)
- Klebsiella pneumoniae (causes 'red-current jelly' sputum, and commonly causes lung abscess formation and empyema)
 
 
Occupational/travel situations:
 
- Aerosols from humidifiers and airconditioning (e.g. at holiday resorts) - Legionella pneumophila.
- Patients can present with diarrhoea and vomiting, develop hepatorenal syndrome and have a low sodium. Severe pneumonia develops, with other rare complications such as:
- Pancreatitis
- Peritonitis
- Myocarditis, endocarditis, pericarditis
- Glomerulonephritis
 
 
Closed populations e.g. schools, offices
 
- Mycoplasma pneumoniae
- Extra respiratory symptoms:
- Erythema multiforme, erythema nodosum
- Guillain-Barre Syndrome (and rarely other neurological complications e.g. aseptic meningitis, cerebellar disease, transverse myelitis).
- Cold agglutinin production with haemolytic anaemia
- Chlamydia pneumoniae
 
 
Zoonotic Causes: 
 
- In Abattoir worker, farmer, vets
- Coxiella burnettii
- Brucella spp.
 
- Animal hide importers/sorters
- Bacillus anthracis
- Coxiella burnettii
 
 
- Following exposure to birds
- Chlamydia psittaci (causes psittacosis)
- Exposure to bats/bat droppings
- Histoplasma capsulatum (a fungus, classically affects cave-explorers)
 
 
## Investigations
 
 
- Bloods: including FBC, U+Es, CRP, WCC and blood cultures
- Sputum culture
- Urinary antigen tests for Legionella and pneumococcus
- Chest X-Ray
- Could assess pleural fluid aspirate in patients with pleural effusion
 
 
## CURB-65 
 
 
- Use the CURB-65 score to aid in deciding the severity of pneumonia and further management based on this
- Components (1 point for each if present):
- Confusion +/-
- Urea >7
- Respiratory Rate >30
- Blood pressure: systolic < 90 or diastolic <60
- More than 65 years old
 
 
CURB-65 mortality by score:
 
- 0 or 1 - 1.5%
- 2 - about 10%
- 3 or more - 10% or more 
 
 
 
 
## Management
 
If a patient is very unwell, adopt an A-E approach, initiate the sepsis six and seek early senior input.
 
- Management based on CURB-65 score:
- 0/1: home-based care, give oral amoxicillin for 5 days (macrolide e.g. clarithromycin, doxycycline or tetracycline if penicillin allergic).
- 2: hospital-based care, 7-10 day course of dual antibiotic therapy with amoxicillin (IV or oral) and a macrolide
- 3: Hospital/ITU-based care, 7-10 day course of dual antibiotic therapy with IV co-amoxiclav/ceftriaxone/tazocin and a macrolide.
 
 
- Atypical and typical community-acquired pneumonia are both managed in the same way initially.
- Liaise with microbiology to guide targeted antibiotics following culture results e.g. flucloxacillin for staph aureus pneumonia.
- A repeat chest x-ray is required after 6 weeks to assess for underlying pathology.
 
 
## Complications
 
 
- Pleural effusion
- Empyema (suspect if persistent, swinging fever with leucocytosis found after antibiotic therapy)
- Abscess (can be caused by S. pneumoniae, Klebsiella, staph aureus). Can develop pyopneumothorax.
- Pneumothorax
- Septicemia
- Atrial fibrillation
- Post-infective bronchiectasis
 
 
 
 
# Hospital Acquired Pneumonia
 
 
## Definition
 
 
Lower respiratory tract infection that develops more than 48 hours after admission to hospital
 
 
## Risk Factors
 
 
- Poor hand hygiene and hospital infection control
- Intubation and ventilation
 
 
## Causative Organisms
 
 
- Pseudomonas aeruginosa
- E. coli
- Klebsiella pneumoniae
- Acinetobacter species (can acquire high potency beta-lactamases, known as ESBLs)
- Serratia species (can acquire high potency beta-lactamases, known as ESBLs)
 
 
## Investigations
 
May include:
 
- Bloods: including FBC, U+Es, CRP, WCC and blood cultures
- Sputum culture
- Urinary antigen tests for Legionella and pneumococcus
- Chest X-Ray
- Could assess pleural fluid aspirate in patients with pleural effusion
 
 
## Management 
 
If a patient is very unwell, adopt an A-E approach, initiate the sepsis six and seek early senior input and discussion with microbiology. Empirical antibiotics are guided by severity and likelihood of resistant organisms:
 
- HAP within 5 days of admission: co-amoxiclav is usually first line for non-severe symptoms
- HAP more than 5 days after admission (associated with higher risk of resistance) or severe symptoms: tazocin or cephalosporin (e.g. ceftazidime) or quinolone first-line.
- If MRSA is suspected, add vancomycin
 
 
# Aspiration Pneumonia 
 
 
- Caused by any cause of depressed consciousness or impairment of the swallowing mechanism
- Infection caused by mixed aerobic and anaerobic mouth flora, which can cause cavitary pneumonia or empyema
- Same empirical therapy as for non-aspiration pneumonia, but later antibiotic choice made by pathogen and sensitivities. Metronidazole often added in to cover for anaerobic organisms. Local guidance should be sought.
 
 
# NICE Guidelines
 
 
[Click here for NICE CKS on chest infections](https://cks.nice.org.uk/topics/chest-infections-adult/)
 
[Click here for NICE guidance on antimicrobial prescribing in hospital-acqui
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2650
Pneumonia
Topic
20
Respiratory Physiology
6714
A 67-year-old female presents to her GP with a four-day history of worsening shortness of breath. This is associated with a cough productive of rust coloured sputum and gradual onset right-sided sharp chest pain that worsens with inspiration. She has a heart rate of 81/min, a respiratory rate of 22/min, a blood pressure of 111/78 and a temperature of 38.3ºC. On examination, there is dullness to percussion, reduced breath sounds and increased vocal resonance on the right side of the chest.

What is the most likely diagnosis?
a