Pneumonias (PEARLS)

The NCCPA™ PANCE Pulmonary System Content Blueprint (current edition) lists the following types of pneumonia under infectious disorders:



Bacterial pneumonia (ReelDx)	*Patient will present as →* a 40-year-old alcoholic male with sudden onset of severe chills, fever, dyspnea, and cough productive of red mucoid sticky sputum. He appears ill-looking with cyanosis. Examination reveals vital signs: Temp – 102 degrees F; Pulse – 120 /minute and regular; 89 RR – 28/min; BP 90/62 mm Hg. Lungs reveal minimal rales and dullness in the right upper lobe with decreased breath sounds. Chest x-ray reveals right upper lobe consolidation with a bulging fissure. Gram stain reveals many white blood cells and many gram-negative rods. (klebsiella pneumoniae) Common Pathogens and Key Clues Streptococcus pneumoniae – Most common overall; rust-colored sputum; higher risk in splenectomy patients Staphylococcus aureus – Post-influenza pneumonia; salmon-colored sputum; concern for MRSA → treat with vancomycin/linezolid Pseudomonas aeruginosa – Seen in ventilator-associated pneumonia, cystic fibrosis, or immunocompromised patients; requires dual antipseudomonal coverage Legionella pneumophila – Hyponatremia, diarrhea, high fever, confusion; treat with macrolide or fluoroquinolone Mycoplasma pneumoniae – Young, healthy (e.g., dorms, military); gradual onset, dry cough, bullous myringitis; confirm with PCR (cold agglutinins are an old, nonspecific clue) Klebsiella pneumoniae – Alcoholics, diabetics, aspiration risk; produces “currant jelly” sputum; classically causes upper lobe consolidation with bulging fissure DX: Requires both: Compatible clinical features (fever, cough, dyspnea, pleuritic chest pain, focal findings on lung exam) Radiographic evidence of a new infiltrate on chest x-ray A chest X-ray showing a very prominent wedge-shaped area of airspace consolidation in the right lung, characteristic of bacterial pneumonia. Image: James Heilman, MD, CC BY-SA 3.0, via Wikimedia Commons. TX: Risk-stratify CAP using CURB-65 or PSI) to determine outpatient vs inpatient management Outpatient, healthy, no comorbidities: Amoxicillin, doxycycline, or macrolide (if local resistance <25%) Outpatient with comorbidities: β-lactam (e.g., amox-clav, cefuroxime) plus macrolide/doxy, or respiratory fluoroquinolone monotherapy Inpatient, non-ICU: β-lactam (ceftriaxone, cefotaxime, ceftaroline, or amp-sulbactam) plus macrolide/doxy, or respiratory fluoroquinolone monotherapy ICU/severe CAP: β-lactam plus macrolide or fluoroquinolone Special risks: Add MRSA coverage (vancomycin/linezolid) or Pseudomonas coverage (piperacillin–tazobactam, cefepime, meropenem) when indicated
Viral pneumonia	Patient will present as → a 45-year-old male with a one-week history of hacking, non-productive cough, low-grade fever, malaise, and myalgias. The chest x-ray reveals bilateral interstitial infiltrates and a nasopharyngeal molecular test is positive for influenza A.Examination reveals scattered rhonchi and rales upon auscultation of the chest. Adults → The influenza viruses are the most common viral cause of pneumonia Primary influenza pneumonia manifests with a persistent cough, sore throat, headache, myalgia, and malaise for more than three to five days. The symptoms may worsen with time, and new respiratory signs and symptoms, such as dyspnea and cyanosis, appear. Kids → RSV, 1st episode of wheezing Respiratory syncytial virus (RSV) is the most frequent cause of lower respiratory tract infection in infants and children and the second most common viral cause of pneumonia in adults Patients with RSV pneumonia typically present with fever, nonproductive cough, otalgia, anorexia, and dyspnea. Wheezes, rales, and rhonchi are common physical findings. Parainfluenza virus pneumonia Parainfluenza virus (PIV) is second in importance only to RSV as a cause of lower respiratory tract disease in children and pneumonia and bronchiolitis in infants younger than 6 months. The signs and symptoms include fever, cough, coryza, dyspnea with rales, and wheezing. DX: Chest radiography usually demonstrates bilateral lung involvement, but none of the viral etiologies of pneumonia result in pathognomonic findings with CXR Nasopharyngeal swab for molecular testing (RT-PCR or rapid molecular assay) for influenza, SARS-CoV-2 and RSV; rapid antigen tests have low sensitivity TX: Influenza can be treated with oseltamivir (Tamiflu) Oseltamivir (preferred) and zanamivir treat influenza A and B; best within 48 hours, but hospitalized, severely ill and high-risk patients are treated regardless of symptom duration Amantadine and Rimantadine treat only influenza A and are not recommended because of widespread resistance RSV pneumonia Treatment is supportive; ribavirin is not routinely used and is reserved for severely immunocompromised patients (evidence is limited) PIV pneumonia Treatment is mainly supportive, but aerosolized and oral ribavirin have been associated with a reduction in PIV shedding and clinical improvement in immunocompromised patients Chest radiograph from a patient with viral pneumonia showing widespread bilateral interstitial infiltrates. Image: Hellerhoff, CC BY-SA 4.0, via Wikimedia Commons.
Fungal pneumonia	Patient with valley fever will present as → a 38-year-old construction worker who recently moved to Phoenix, Arizona, for a new project. Over the past two weeks, he’s been experiencing fatigue, cough, and intermittent fevers. He also mentions having chest pain that worsens when he takes a deep breath. He recalls a dusty wind storm at the construction site about three weeks ago. On physical examination, you note a few erythematous, tender nodules on his shins. Chest radiography shows a nodular pattern in the right lung field. Given his symptoms and exposure history, a sputum sample is sent for fungal cultures. Coccidioides (valley fever): Look for this in a patient with non-remitting cough/bronchitis non-responsive to conventional treatments. Caused by fungal inhalation in western states. Serologic tests using enzyme-linked immunoassays (EIA) for IgM and IgG should be ordered first, if possible. If the EIA is positive, a confirmatory immunodiffusion test should be performed. Treatment: fluconazole or itraconazole Patient with Histoplasmosis will present with → a 21-year-old male presents with a cough and mild shortness of breath for three days. The cough is productive of yellowish mucus. He reports a low-grade fever with this episode but says that he has otherwise been healthy. He has spent the last month working in bat caves. He denies tobacco or alcohol use. Histoplasma capsulatum is an opportunistic fungus that is known to cause systemic disease in HIV patients that involves low-grade fevers, cough, hepatosplenomegaly, and tongue ulceration AIDS-defining illness - Highest risk is with a CD4+ cell count of < 150 cells/mm3 Histoplasma is commonly transmitted by bird or bat (animal) droppings, and should always be borne in mind in spelunkers presenting with tuberculosis-like symptoms Mississippi and Ohio River Valleys DX: Culture is the gold standard for diagnosis but requires a lengthy incubation period Histoplasma capsulatum causes mediastinal or hilar lymphadenopathy (looks like sarcoidosis) Treat with itraconazole orally for weeks to months or Amphotericin B if severe or failed Itraconazole In general antifungal prophylaxis with itraconazole is not administered to prevent primary infection without special indication Chest film showing diffuse pulmonary infiltration and hilar lymphadenopathy due to acute pulmonary histoplasmosis. Image: CDC/M. Renz, Public domain, via Wikimedia Commons. Patient with Cryptococcus will present as → a 49-year-old HIV-positive male with a CD4 count of 9. He lives alone and drinks daily. He presents to the hospital with a headache, neck stiffness, and confusion. A lumbar puncture (LP) shows that his intracranial pressure is very high (45 cm) and that his spinal fluid contains Cryptococcus (India Ink and CrAg positive). Baseline blood ordered: full blood count, creatinine, ALT, and RPR. The serum cryptococcal antigen (CrAg) test is positive. Cryptococcus: Caused by the fungus Cryptococcus neoformans, common in AIDS and immunocompromised states, is considered an AIDS-defining illness Budding yeast found in soil contaminated with pigeon/bird droppings Diagnose with CSF and serum serology India ink may be positive Treat with Amphotericin B + Flucytosine for 2 weeks, followed by Fluconazole for 10 weeks Screen with serum cryptococcal antigen when CD4 < 100 (preemptive fluconazole if positive); routine primary fluconazole prophylaxis is not recommended Pulmonary aspergillosis: Invasive disease occurs in immunocompromised patients (prolonged neutropenia, transplant, high-dose steroids); an aspergilloma (fungus ball) grows in an old cavity (prior TB); allergic bronchopulmonary aspergillosis (ABPA) occurs in asthma or cystic fibrosis Treatment: voriconazole for invasive disease (fluconazole has no Aspergillus activity); aspergilloma: observe or resect; ABPA: glucocorticoids plus itraconazole Patient with PJP Pneumonia will present as → a 32-year-old man with a two-week history of fever and dry, nonproductive cough. For the past five days, he has been having shortness of breath. There is no history of pleuritic chest pain or rigors. Past medical history is significant for HIV. His temperature is 100.4°F (38°C), pulse is 92/min, O₂saturation is 92%, respirations are 18/min, and blood pressure is 120/70 mmHg. Purified protein derivative (PPD) is negative. CD4 cell count is 190. The chest exam reveals bibasal crackles. The chest radiograph shows interstitial infiltrates bilaterally. The patient’s condition worsens on levofloxacin. Pneumocystis Jiroveci (formerly PCP Pneumonia, now called PJP) Pneumocystis jirovecii is a yeast-like fungus of the genus Pneumocystis Common in HIV-infected patients with a low CD4 count of less than 200 The radiograph shows diffuse interstitial or bilateral perihilar infiltrates Diagnose with bronchoalveolar lavage (PCR), labs, and an HIV test. Treat with Trimethoprim-sulfamethoxazole (BACTRIM), plus steroids if PaO2 is below 70 mmHg Prophylaxis for high-risk patients with a CD4 count of less than 200 or with a history of PJP infection. Daily Bactrim is the prophylaxis antibiotic of choice.
HIV-related pneumonia	Patient will present as → a 32-year-old HIV+ male with dyspnea and a nonproductive cough. He is tachycardic, tachypneic and febrile. Auscultation of his chest reveals scattered rhonchi. His chest x-ray demonstrates a diffuse interstitial infiltrate. His ABG demonstrates moderate hypoxemia, and his LDH is elevated Formerly PCP Pneumonia, now called (PJP) Pneumocystis jirovecii (there are other HIV-related types of pneumonia, but this is the one you will need to know for the test) Common in HIV-infected patients with a low CD4 count of less than 200 DX: CXR is often abnormal (it can be normal early), but the diagnosis is confirmed by finding the organism. The radiograph shows diffuse interstitial OR bilateral perihilar infiltrates Bronchoalveolar lavage (PCR) (Gold Standard), labs, and an HIV test Will often have very low O2 saturation despite supplemental O2 TX: Trimethoprim-sulfamethoxazole (Bactrim) for 21 days, plus steroids if PaO2 is below 70 mmHg; if allergic, IV pentamidine, primaquine plus clindamycin, or atovaquone (mild disease) Prophylaxis for high-risk patients with a CD4 count of less than 200 or with a history of PJP infection Daily Bactrim is the prophylaxis antibiotic of choice These chest radiographs are of two patients. Both show a ground-glass appearance. The left chest X-ray (CXR) shows a much more subtle ground-glass appearance, while the right CXR shows a much more gross ground-glass appearance mimicking pulmonary edema. Image: Carolyn M. Allen et al., CC BY 4.0, via Wikimedia Commons.