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BY Annerie Hattingh 26/08/09. Atypical Pneumonia. Introduction:. Pneumonia caused by atypical pathogens Typical pathogens usually includes: - Strep. pneumonia - Haemophilus pneumonia - Klebsiella pneumonia Does not respond to the usual antibiotics

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atypical pneumonia
BY

Annerie Hattingh

26/08/09

AtypicalPneumonia

introduction
Introduction:

Pneumonia caused by atypical pathogens

Typical pathogens usually includes:

- Strep. pneumonia

- Haemophilus pneumonia

- Klebsiella pneumonia

Does not respond to the usual antibiotics

Causes a milder form of pneumonia (hence the term “walking pneumonia”)

Characterized by a more drawn out coarse of symptoms

slide3
Legionella + SARS are exceptions to the above –

both can be very severe infections

Typical pneumonia can come on more quickly + with more severe early sx

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

Introduction:

introduction4
Introduction:

Causes:

“Classical” atypical pneumonias:

1.) Mycoplasma pneumonia

2.) Chlamydia pneumonia

3.) Legionella pneumonia

introduction5
Introduction:

Causes:

Other micro-organisms that cause similar patterns

of presentation:

1.) Chlamydia psittaci (exposure to birds)

2.) Coxiella burnetti (presenting as Q fever)

3.) Viral pneumonias - Influenza A

- SARS

- RSV

- Adenoviridae

- Varicella pneumonitis

epidemiology
Epidemiology:

It is thought that the 3 main atypical pathogens might be implicated in up to 40% of CAP

The precise incidence is not known

Often not identified in clinical practice due to lack of readily available, reliable standardized tests to confirm dx

By age 20, 50% of people in the USA have detectable levels of Antibodies to Chlamydia

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 H2O systems

risk factors8
Risk Factors:

- sources of contaminated H2O includes:

* showers

* condensers

* whirlpools

* cooling towers

* respiratory equipment

* air conditioning systems

risk factors9
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

presentation11
Presentation:

Mycoplasma pneumonia:

Clinical Features:

Symptomatic / asymp

Gradual onset (over few days – weeks)

Prodrome of “flu-like” symptoms

presentation12
Presentation:

Mycoplasma pneumonia:

Clinical Features:

Including: - headache

- malaise

- fever

- non prod. Cough

- sore throat

presentation13
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 BUT persistence + progression of sx help to mark it out

presentation14
Presentation:

Mycoplasma pneumonia:

Extrapulm. Manifestations/Complications:

Can involve: CNS, Blood, Skin, CVS, Joints, GIT

presentation15
Presentation:

Mycoplasma pneumonia:

Extrapulm. Manifestations/Complications:

Neurological compl.

Aseptic meningitis

Cerebellar ataxia

Transverse myelitis

Peripheral neuropathy

presentation16
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

presentation17
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

presentation18
Presentation:

Mycoplasma pneumonia:

Extrapulm. Manifestations/Complications:

Dermatological compl.

Include rashes such as:

Erythema multiforme

Erythema nodosum

Urticaria

presentation19
Presentation:

Mycoplasma pneumonia:

Extrapulm. Manifestations/Complications:

Cardiac involvement:

Pericarditis

Myocarditis

presentation20
Presentation:

Mycoplasma pneumonia:

Extrapulm. Manifestations/Complications:

Joint involvent: (occationately described)

Arthralgia

Arthritis

presentation21
Presentation:

Mycoplasma pneumonia:

Extrapulm. Manifestations/Complications:

GIT symptoms:

N + V

Diarrhea

Pancreatitis (rarely)

presentation22
Presentation:

Chlamydia:

Genus Chlamydia includes 3 species that infect humans: - C. psittaci

- C. trachomatis

- C. pneumonia

Small, coccoid, Gram neg bacteria that resemble rickettsiae

presentation23
Presentation:

Chlamydia:

Chlamydia trachomatis - seen in newborn infants

during delivery

- has been ass. with

pneumonia in adults

presentation24
Presentation:

Chlamydia:

Chlamydia psittaci:

Ornithosis is a systemic infection often acc. by pneumonia

Common in birds + some domestic animals

Pet shop employees + poultry workers @ risk

Other systems involved: CNS (meningoencephalitis) + CVS (cult. neg. endocarditis)

presentation25
Presentation:

Chlamydia pneumonia:

Prevalence varies by yr + geographic setting

Causes 5-15% of all CAP

Repeat infection is common

Gradual onset which may show improvement before worsening again

Incubation 3-4 weeks

Initial non-specific URTI Sx lead to bronchitic/

pneumonic features

presentation26
Presentation:

Chlamydia pneumonia:

Most infected remains quite well + asymptomatic

Can cause prolonged, acute bronchitis with

prod. cough

Hoarseness + headache are common features

Fever relatively uncommon

Sx may drag on for weeks/months despite course of appropriate antibiotics

presentation27
Presentation:

Chlamydia pneumonia:

Clinical severity usually caused by a secondary pathogen or co-existing illness e.g. diabetes

Complications:

Sinusitis, otitis media

New onset asthma after acute infection

Endocarditis, myocarditis

presentation28
Presentation:

Legionella pneumonia:

Aerobic, motile, non-encapsulated, Gram neg bacilli

Tends to be the most severe of the atypical pneumonias

Focal outbreaks centered around poorly maintained air conditioning / humidification systems

Incubation 2-10 days

Initial mild headache, myalgia leading to fever, chills + rigors

presentation29
Presentation:

Legionella pneumonia:

Minimally prod. cough

Dyspnoea, pleuritic pain + hemoptysis are not uncommon

Extra pulmonary legionellosis is rare but can be severe

CVS most common extrapulm. site causing myocarditis, pericarditis + endocarditis

Also pancreatitis, peritonitis, glomerulonephritis + focal neurological deficit

diagnosis
Diagnosis:

CXR findings are usually non-specific and difficult to distinguish from other pneumonias

Chest signs on examination minimal

Rx of suspected atypical pneumonias should be empirical

Cultures + serologic tests are not routinely available in laboratories

diagnosis31
Diagnosis:

A 53yr old patient with severe

Legionella pneumonia.

CXR shows dense consolidation in both lower lobes.

diagnosis32
Diagnosis:

A 40yr old patient with Chlamydia pneumonia.

CXR shows multifocal, patchy consolidation in the right upper, middle and lower lobes.

diagnosis33
Diagnosis:

A 38yr old patient with Mycoplasma pneumonia.

CXR shows a vague, ill defined opacity in the left lower lobe.

management
Management:

Severe cases should be admitted

Atypical pneumonias usually Rx as for other

CAP, at least initially

No evidence that routinely giving antibiotics active against atypical organisms leads to better outcomes in non-severe CAP

management36
Management:

Macrolides, such as Erythromycin, Clarithromycin + Azithromycin have been shown to be effective in the Rx of all 3 organisms

Erythromycin tends to be less well tolerated + only few trails demonstrates its efficacy in the Rx of Legionella

Severe Legionella infections may require rifampicin + a macrolide

Tetracycline, Doxycycline + Fluoroquinolones are also effective

Recommened duration of therapy usually 2-3 weeks

slide37

THE END

QUESTIONS??

references
References:

Shakeel Amanullah: Atypical Bacterial Pneumonia; eMed. March 2008.

www.patient.co.uk: Atypical Pneumonias; Jan. 2007.

www.thirdage.com: Encyclopedia – Atypical Pneumonia (Mycoplasma and Viral) (Walking Pneumonia); May 2008.

Rosen’s Emergency Medicine Online: Community Acquired Pneumonia

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