atypical pneumonia 21112

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a case study and a discussion

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AN INTERESTING CASE OF PNEUMONIA Dr Nishant Sagar M2 PG,Prof AR unit Institute of Internal Medicine MMC & RGGGH

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27 year old male presented with Cough without expectoration Fever Blood streaked sputum-occasional Breathlessness-Exertional in nature grade 1 no history of orthopnea,PND Generalised body ache all complaints of 5 days duration

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No prior history of TB/contact with TB. No other co morbidities Patient was a welder by occupation for the past 17 years.Used to weld metals in a relatively closed enviroment

O/E:

O/E conscious oriented obeys to oral commands No pallor/ icterus /cyanosis/ clubbing No Pedal edema/ lymphadenopathy PR - 84/min BP - 130/90 mmHg RR - 32/min tempreture - 100 F SpO2 -82 % At room air 96% with oxygen

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CVS – S1S2 heard no murmur RS - NVBS heard no added sounds no abnormalities detected P/A – soft no organomegaly CNS- No focal neurological deficit

Investigations:

Investigations CBC LFT TC – 12500 TB-1.8 DC P-80 L16 E4 DB-0.4 ESR - 8mm at 1 hr SGOT-86 Hb - 13.8 SGPT - 66 PCV - 42 ALP - 96 PLC - 1.82 Lakhs TP - 6.8 ALB – 4.3

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URINE ROUTINE albumin nil sugar nil deposits 1-2 pus cells

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RFT 18/9/12 20/9/12 22/9/12 BS 95 76 88 UREA 76 34 20 Creat 1.8 1.2 1.0 Na 143 142 138 K 4.7 3.8 3.7

Xray chest 18/09/12 conventional xray:

Xray chest 18/09/12 conventional xray

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Echocardiography-No RWMA Normal LV function normal study

CT chest 20/09/12:

CT chest 20/09/12

Differential diagnosis:

Differential diagnosis

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Pulmonary edema ARDS Acute interstitial pneumonia

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THORACIC MEDICINE opinion Acute interstitial pneumonia overlap occupational lung disease with early MODS To rule out disseminated Kochs/immunocompromised state(HIV) Suggested IV methyl prednisolone 500mg BD for 3 days Higher antibiotics

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Sputum could not be produced by patient HIV ELISA-NEGATIVE

Treatment :

Treatment IV ceftriaxone 1 gm iv bd* 7 days Tab azithromycin 500 mg * 5 days Inj rantac 50 mg IV BD Inj methyl prednisolone 500mg BD * 3 days Syp linctus codeine 15 ml tds Inj styptochrome 1amp sos

Digital xray 10 days after admission :

Digital xray 10 days after admission

CT CHEST REPEATED 10 DAYS AFTER ADMISSION:

CT CHEST REPEATED 10 DAYS AFTER ADMISSION

CT chest 27/09/12:

CT chest 27/09/12

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Resolution of the mosaic pattern Septal thickening with small centrilobar nodularities indicating chronic hyper-sensitivity pneumonitis/siderosis

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Condition at discharge Complete resolution of all symptoms Patient was advised to change his occupation

Final diagnosis:

Final diagnosis acute interstitial pneumonia probably atypical pneumonia in the background of welders lung

Atypical Pneumonia :

Atypical Pneumonia

Introduction::

Introduction: Pneumonia caused by atypical pathogens Typical pathogens usually includes: - Strep. pneumonia - Haemophilus pneumonia - Klebsiella pneumonia

ATYPICAL PNEUMONIA: WHAT IS IT???:

ATYPICAL PNEUMONIA: WHAT IS IT??? Infection of pulmonary parenchyma Community-acquired Classically—do not show up on Gram stain

Characteristics :

Characteristics Insidious onset The clinical onset of illness is generally subacute Nonproductive cough Severe constitutional symptoms Interstitial pattern on CXR- in comparison to the lobar pattern produced by typical pneumonia - fever and leucocytosis less common

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Does not respond to the usual antibiotics Causes a milder form of pneumonia (hence the term “walking pneumonia”) Characterized by a more drawn out course of symptoms

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Legionella + SARS are exceptions to the above – both can be very severe infections Typical pneumonia can come on more quickly + with more severe early symptoms The arbitrary classification of typical vs. atypical pneumonia is of limited clinical value Literature now shows that a primary pathogen may co-exist with a secondary one, further blurring this distinction

Causes :

Causes

Introduction::

Introduction: Causes: “ Classical” atypical pneumonias : 1.) Mycoplasma pneumonia 2.) Chlamydia pneumonia 3.) Legionella pneumonia 4.) viral pneumonia

Risk Factors::

Risk Factors: Mycoplasma + Chlamydia spread by person-to-person contact - spread most common in closed populations e.g. schools, offices + military barracks Legionellae found most commonly in fresh water + man-made H 2 O systems

Risk Factors::

Risk Factors: - sources of contaminated H 2 O includes: * showers * condensers * whirlpools * cooling towers * respiratory equipment * air conditioning systems

Risk Factors::

Risk Factors: Other risk factors include: - young, healthy people - cigarette smoking - lung disease (like COPD) - weakened immune system (e.g. chronic steroid use or HIV)

Presentation::

Presentation: Mycoplasma pneumonia: Gram neg bacteria with no true cell wall Frequent cause of CAP in adults + children Prevalence in adults with pneumonia 2 – 30% Tends to be endemic, occurring @ 4-7yr intervals

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Presentation: Mycoplasma pneumonia: Clinical Features: Symptomatic / asymp Prodrome of “flu-like” symptoms

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Presentation: Mycoplasma pneumonia: Clinical Features: Prodromal features: - headache - malaise - fever - non prod. Cough - sore throat URT involvement- otitis,bullous myringitis,non exudative pharyngitis

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Presentation: Mycoplasma pneumonia: Clinical Features: Objective AbN on physical exam are minimal in contrast to the pt’s reported symptoms. Present like many of common viral illnesses.

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Presentation: Mycoplasma pneumonia: Extrapulm . Manifestations/Complications: Can involve : Blood, Skin, Joints, GIT

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Presentation: Mycoplasma pneumonia: Extrapulm . Manifestations/Complications: Neurological compl .- very rare Aseptic meningitis Cerebellar ataxia Transverse myelitis Peripheral neuropathy

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Presentation: Mycoplasma pneumonia: Extrapulm. Manifestations/Complications: Neurological manifestations are infrequent Usually found in kids, if seen Associated with increased morbidity + mortality Antecedent resp. infection not always present

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Presentation: Mycoplasma pneumonia: Extrapulm. Manifestations/Complications: Hematological compl. Hemolytic anemia IgM antibodies to erythrocyte membrane I antigen are present Produces a cold agglutinin response that leads to hemolysis

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Presentation: Mycoplasma pneumonia: Extrapulm. Manifestations/Complications: Dermatological compl. Include rashes such as: Erythema multiforme Erythema nodosum Urticaria

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Presentation: Mycoplasma pneumonia: Extrapulm. Manifestations/Complications: Joint involvent: (occationately described) Arthralgia Arthritis

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Presentation: Mycoplasma pneumonia: Extrapulm . Manifestations/Complications: GIT symptoms: Nausea vomiting Diarrhea Pancreatitis (rarely)

A 38-year-old patient with Mycoplasma pneumonia. Chest radiograph reveals patchy areas of nonsegmental air-space opacification in both lower lobes. .:

A 38-year-old patient with Mycoplasma pneumonia. Chest radiograph reveals patchy areas of nonsegmental air-space opacification in both lower lobes. .

Identification of mycoplasma:

Identification of mycoplasma M. pneumoniae is an acute infectious disease Mycoplasma has a predilection for the upper, as well as the lower, respiratory tract and thus patients with CAP who have upper respiratory tract involvement are most likely to have M. pneumoniae . Rarely involve CVS,CNS,renal,hepatic systems or cause electrolyte abnormalities. Watery diarrohea without abdominal pain Skin involvement- EMF,erythema nodosum,urticaria Patients with CAP plus upper respiratory tract involvement and highly elevated cold agglutinin titres , i.e., ‡ 1 : 64, should be considered as having M. pneumoniae CAP until proven otherwise

IDENTIFICATION OF CHLAMYDIA:

IDENTIFICATION OF CHLAMYDIA C. pneumoniae may be acute but is typically a chronic disease. Although all patients with C. pneumoniae CAP donot have laryngitis, the majority of them do.Patients presenting with a ‘mycoplasma-like illness with pneumonia-associated hoarseness should be considered as having C. pneumoniae until proven otherwise

Diagnosis::

Diagnosis: CXR findings are usually non-specific and difficult to distinguish from other pneumonias Chest signs on examination minimal

Management::

Management: Antibiotics used in treatment of atypical pneumonia include-. Macrolides Doxycycline rifampin quinolones telithromycin .

Empirical therapy of CAP:

Empirical therapy of CAP All hospitalised patients should receive a combination of a beta lactam like ceftriaxone 1gm IV BD or cefotaxime 1gm IV TDS plus either 1) Macrolide like azithromycin or clarithromycin. 2) respiratory fluoroquinolone like levofloxacin

DURATION OF TREATMENT :

DURATION OF TREATMENT IDSA RECOMMENDATION- At least 5 days of therapy Patient should be afebrile for 48-72 hrs no evidence of clinical instability

Welders lung :

Welders lung The toxic risks in arc welders arise from the gaseous fumes produced and inhaled particles at the alveolar level. The pulmonary siderosis due to inhalation of iron particles. pulmonary siderosis is currently considered as a simple pneumoconiosis with a good prognosis. Some recent studies suggest the possibility of a more serious outcome with fibrosis in the prescence of any associated silicosis.

Postero-anterior chest radiograph , showing fine reticular shadowing and small opacities consistent with siderosis.:

Postero -anterior chest radiograph , showing fine reticular shadowing and small opacities consistent with siderosis .

Computed tomography of the thorax , showing fine reticular shadowing and multiple small opacities consistent with siderosis:

Computed tomography of the thorax , showing fine reticular shadowing and multiple small opacities consistent with siderosis

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Usually asymptomatic Chronic bronchitis Occupational asthma Rarely fibrosis Rarely carcinoma lung Rarely can cause haemochromatosis

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THE END