1. CHAPTER 3 LOWER RESPIRATORY
TRACT INFECTIONS
Acute Bronchitis (“Chest
Cold”)
Photomicrograph Tracheobronchial infections
of Bordetella without pneumonia comprise a
(Haemophilus) spectrum of disorders with
pertussis bacteria different clinical implications:
using Gram stain acute bronchitis, chronic
technique. CDC bronchitis, and bronchiectasis.
Acute bronchitis or “acute simple
bronchitis” in otherwise-healthy
persons is extremely common,
usually of viral etiology, and a
BLOOD common reason for overuse of
LYMPHOCYTOSIS antibiotics. The term “acute
IN A PATIENT infectious bronchitis” is
WITH sometimes used to distinguish this
PERTUSSIS. The entity from other causes of cough,
lymphocytes in this and the term “tracheobronchitis”
blood smear from is sometimes used for accuracy
an 18-month-old since the trachea is also inflamed.
child with a However, “chest cold” is probably
Bordetella the best term for daily practice

2. pertussis infection since it implies that antibiotics are
have lobulated seldom necessary. Bordetella
nuclei. pertussis, the agent of whooping
Lymphocytosis is cough, is now recognized as a
characteristic of cause of acute bronchitis in adults.
this disorder and Infection by either Mycoplasma
the lymphocyte pneumoniae or Chlamydia
morphology is pneumoniae accounts for many of
often atypical. The the stubborn cases in which
cytology of the symptoms fail to resolve or recur
cells could be soon after treatment has been
mistaken for discontinued.
neoplastic
lymphocytes. Infection of the tracheobronchial
(Wright-Giemsa mucosa causes local
stain) © The Johns inflammation, increased secretion
Hopkins Autopsy of mucus, and damage to ciliated
Resource (JHAR). cells. Symptoms result both from
Image Archive. the inflammatory response and
also from the interruption of the
mucociliary blanket that normally
cleanses the lower respiratory
tract. Most cases of acute
bronchitis (95% by some
estimates) are caused by viruses.

3. All of the common viruses
affecting the upper respiratory
tract have been implicated:
rhinoviruses, coronavirus,
respiratory syncytial virus,
adenoviruses, coxsackieviruses,
influenza viruses A and B, and
parainfluenza virus. In 2 studies in
which attempts were made to
establish a precise diagnosis, the
etiology was established in only
16% and 29% of cases with
viruses being the most common
causes.
Mycoplasma pneumoniae and
Chlamydia pneumoniae probably
play minor roles in this illness, at
least in most populations.
However, M. pneumoniae
probably causes more cases of
bronchitis than pneumonia, and C.
pneumoniae may be an important
cause of acute bronchitis in
college-aged students. Whether S.

4. pneumoniae, H. influenzae, and
M. catarrahalis cause chest cold
in otherwise-healthy persons is
unclear, but there is little support
for the concept of quot;acute bacterial
bronchitisquot; as a community-
acquired disease. Recently it has
been emphasized that Bordetella
pertussis can infect adults, even
when vaccinated, providing a
reservoir for causing whooping
cough among infants. Bordetella
parapertussis causes a protracted
illness similar to whooping cough
but without systemic toxicity.
Whether these observations can be
generalized to other populations is
undetermined.
The onset is typically preceded by
a prodrome of at least 24 hours
with symptoms of coryza and
pharyngitis. A dry cough,
signifying early inflammation of
the upper airway, often evolves

5. into a cough productive of
moderate amounts of
mucopurulent sputum. Fever,
headache, myalgias, and
retrosternal chest pain or
discomfort may be present. Fever
is most common when an
influenza virus or Mycoplasma
pneumoniae is the causative agent.
The patient rarely looks toxic.
Tracheal tenderness is often
present. Auscultation may reveal a
few coarse crackles with
occasional wheezes in the chest,
but there are no signs of
consolidation.
Transmission electron
photomicrograph of a hamster trachea
ring infected with M. pneumoniae.
Note the orientation of the
mycoplasmas through their
specialized tip-like organelle, which
permits close association with the

6. respiratory epithelium. M,
mycoplasma; m, microvillus; C, cilia.
Both images used with permission.
From Baseman and Tully, Emerging
Infection Diseases 3
Acute Infectious
Exacerbations of Chronic
Bronchitis
Figure Chronic bronchitis is defined by
Chlamydial the American Thoracic Society
inclusions © (ATS) as excessive sputum
Bristol Biomedical production with cough, present on
Archive. Used with most days for at least 3 months a
permission year and not less than 2 successive
years, without an underlying
etiology such as tuberculosis or
Figure bronchiectasis. This common
Chlamydial disorder, affecting up to 25% of
inclusions in an the adult population, can lead to
endothelial cell © full-blown chronic obstructive
Bristol Biomedical pulmonary disease (COPD), the
Archive. Used with fourth-leading cause of death in
permission the United States. The extent to

7. which acute exacerbations are due
to treatable infections remains
controversial.
Chronic bronchitis is caused
mainly by cigarette smoking. Air
pollution, cold and damp climates,
heredity, frequent lower
respiratory tract infections, and
immunodeficiency disorders (such
as common variable
hypogammaglobulinemia or
isolated IgA deficiency) play a
role in some patients. The
essential feature is anatomic
change in the larger airways,
including an increased number of
mucus-producing goblet cells and
mucosal gland hypertrophy in the
bronchial walls. Increased
bronchial secretions and impaired
ability to handle them lead to
chronic cough and disabling
complications.

8. Current opinion holds that most
acute exacerbations of chronic
bronchitis are caused by viruses or
by non-infectious agents. Viruses
have been found in as few as 7%
to as many as 64% of cases in
which they were sought. By
conservative estimate viruses
cause about one-third of cases, the
more common ones being
influenza viruses A and B,
parainfluenza virus,
coronaviruses, and rhinoviruses.
Cultures of sputum often show
non-typable strains of
Haemophilus influenzae,
Streptococcus pneumoniae, and/or
Moraxella catarrhalis. However,
the extent to which these bacteria
explain exacerbations in a given
patient is hard to determine since
they often colonize the damaged
lower respiratory tract on a more-
or-less permanent basis. Evidence
suggests that repeated episodes of

9. bacterial infections—especially
when caused by H. influenzae—
contribute to deterioration of
pulmonary function. S. aureus and
aerobic gram-negative rods
occasionally cause exacerbations
of chronic bronchitis. The
pathogens associated with
quot;atypical pneumoniaquot; such as M.
pneumoniae, C. pneumoniae, and
L. pneumophila probably cause
fewer than 10% of exacerbations.
Evidence to date suggests that
Chlamydia pneumoniae is more
strongly associated with the
underlying chronic bronchitis than
with its acute exacerbations.
However, Chlamydia pneumoniae
can cause a stubborn respiratory
illness lasting several weeks or
longer and tending to relapse after
each course of antibiotics.

10. Bronchiectasis
Bronchiectasis is an acquired
Figure
disorder characterized
This PA x-ray
anatomically by abnormal
depicts
dilatation of bronchi and
atelectatic, and
bronchioles and clinically by
bronchiectatic
chronic productive cough and
changes in this
child’s right frequent lower respiratory tract
infections. Its prevalence fell
upper pulmonary
dramatically after the introduction
lung field.
of broad-spectrum antibiotics and
Atelectasis (a
widespread immunization against
collapse of the
measles and pertussis. Although
lung) can be due
bronchiectasis is now uncommon,
to bronchiectasis
it often goes undiagnosed until
(an enlargement
far-advanced. Newer imaging
of the bronchial
studies now enable earlier
tubes) and a
diagnosis, and our understanding
decrease in the
of its causes continues to improve.
effectiveness of
their ciliated
Cigarette smoking, the major
mucosal lining,
cause of chronic bronchitis, plays
which renders
little role in bronchiectasis except
the lungs unable

11. to clear for predisposing to recurrent
themselves of infections. The basic problem in
clogging mucous bronchiectasis is permanent
build-up. structural damage to the walls of
CDC/ Dr. bronchi and bronchioles brought
Thomas Hooten about by the concerted action of
(1) infection and (2) impairment
of the pulmonary toilet, airway
obstruction, and/or a defect in host
defenses.
In the past, bronchiectasis was
associated especially with
frequent or severe lower
respiratory infections during
childhood. Bronchiectasis
continues to be associated with
such infections - especially
necrotizing pneumonias in which
treatment is delayed - but the list
of known causes has expanded.
Bronchiectasis can be the earliest
clue to cystic fibrosis presenting
during adolescence or early
adulthood. Staphylococcus

12. aureus, Pseudomonas aeruginosa,
and Pseudomonas cepacia are
often isolated from these patients.
Mycobacterium avium-
intracelluare complex (MAC)
infection is not infrequently
associated with bronchiectasis,
especially in older women and/or
thin women. Allergic
bronchopulmonary aspergillosis
often leads to bronchiectasis,
which might be prevented by early
recognition of this syndrome.
Immunodeficiency disorders, both
congenital
(hypogammaglobulinemia) and
acquired (AIDS) predispose to
bronchiectasis. The dyskinetic
cilia syndromes are sufficiently
common (about 1 in every 20,000
to 60,000 persons) that a case is
likely to occur in every medium-
sized city.
Patients with advanced
bronchiectasis experience daily

13. cough productive of large
amounts of mucopurulent, thick,
tenacious sputum. However, most
patients produce lesser amounts of
sputum, at least during the early
stages, and cough may be
nonproductive (quot;dry
bronchiectasisquot;) or even absent.
Dyspnea and hemoptysis are
common. Patients often give a
history of repeated respiratory
infections and sometimes give a
history of recurrent pleuritic chest
pain. Hard crackles are heard
locally over the lung fields in
about 70% of patients. Rhonchi
and widespread expiratory
wheezes are also common.
Clubbing is present in only about
3% of patients. Plain chest x-rays
(PA and lateral views) are usually
abnormal.

14. Acute Community-acquired
Pneumonia: Overview
Figure Pneumonia accounts for an
This AP chest x- estimated 45,000 deaths in the
ray shows United States each year. It is the
pneumonia of the 6th most common cause of death
left lower lobe and the most common infectious
with early cause of death. Since it is not a
consolidation, reportable disease, the precise
the etiology of incidence is unknown. Estimates
which was suggest that 4 million cases occur
unknown. each year, prompting 10 million
Pneumonia can physician visits and 600,000 to 1.2
be caused by a million hospitalizations and
variety of agents adding $23 billion to health care
including costs. Data suggest a 28-fold
bacteria, viruses, increased cost for managing the
and disease on an inpatient basis
mycoplasmas, ($7,517 versus $264 for outpatient
among others. therapy). However, the mortality
Pneumonia rate is 1% or less for patients
remains an managed as outpatients versus
important cause 14% to 25% for those admitted to
of morbidity and the hospital. Physicians often

15. mortality in the overestimate the short-term
United States as mortality risk, but erring toward
both a primary, hospitalization is understandable
and secondary given the potentially fatal nature
infection. of the disease.
CDC/Dr. Microorganisms can enter the
Thomas Hooten lungs by aspiration, inhalation, or
by way of the bloodstream
(hematogenous pneumonia).
Figure Aspiration of bacteria that have
This colonized the oropharynx is by far
anteroposterior the most common mechanism.
x-ray reveals a Most humans aspirate small
bilaterally amounts of oropharyngeal
progressive secretions on a nightly basis.
plague infection Microorganisms that are not
involving both removed by the mucociliary
lung fields. blanket are taken up and killed by
The first signs of pulmonary alveolar macrophages,
plague are fever, the last line of defense. This
headache, process, called pulmonary
weakness, and clearance, is impaired by viral
rapidly respiratory infections, tobacco
developing smoke, chronic lung disease,
pneumonia with alcohol, and many other factors

16. shortness of associated with debilitating
breath, chest diseases. One or more chronic
pain, cough, and diseases are present in the
sometimes majority of adult patients with
bloody or watery pneumonia (58% to 89% of
sputum, patients in various studies).
eventually Alcoholism predisposes to
progressing for 2 aspiration, but cigarette smoking
- 4 days into is the main avoidable risk factor
respiratory for community-acquired
failure and pneumonia in adults.
shock.
CDC/Dr. Jack Inhalation of aerosolized particles
Poland is an important route of entry for
many viruses including the
influenza viruses and, most
recently, the Hantaviruses.
Bacteria that cause pneumonia by
airborne transmission include M.
tuberculosis, Yersinia pestis
(plague), Bacillus anthracis
(anthrax), and probably
Legionella pneumophila
(Legionnaire’s disease) and
Francisella tularensis (tularemia).

17. Spore-producing fungi such as
Histoplasma capsulatum,
Blastomyces dermatitidis, and
Coccidioides immitis also cause
inhalation pneumonia.
Hematogenous pneumonia
classically develops from septic
pulmonary emboli, frequently
resulting in patchy or nodular
bilateral pulmonary infiltrates
sometimes accompanied by
pleural effusions. In inner-city
populations, a familiar scenario
consists of bilateral pneumonia
associated with S. aureus
endocarditis on the tricuspid or
pulmonic valves of injecting drug
users. Another scenario consists of
emboli from septic
thrombophlebitis: for example, of
the pelvic veins (pelvic
inflammatory disease, septic
abortion), internal jugular vein
(the Lemierre syndrome) or any

18. large vein where a catheter has
been inserted. Hematogenous
seeding of the lungs possibly
explains some pneumonias caused
by gram-negative bacteria and by
unusually virulent organisms such
as F. tularensis (tularemia).
The microbial cause of
community-acquired pneumonia
is usually difficult to determine. In
prospective studies of patients
requiring hospitalization, a cause
is found in only 40% to 70% of
cases. In primary care practice, a
far greater fraction of cases are
never diagnosed. Most of these
cases respond to empiric therapy.
Published data concerning the
causes of pneumonia vary from
one region to another, but some
generalizations are possible.
Mycoplasma pneumoniae has
been determined to be the most
common cause in some

19. communities, when presumptive
diagnoses were taken into
account, followed by
Streptococcus pneumoniae and
Chlamydia pneumoniae. Adults
with compromised host defenses
are likely to have pneumococcal
pneumonia, but can also have
pneumonia due to H. influenzae,
Moraxella catarrhalis, S. aureus,
or aerobic gram-negative rods.
There is wide agreement that S.
pneumoniae is the most common
cause of community-acquired
pneumonia requiring
hospitalization. An emerging and
controversial area concerns the
frequency of pneumonia caused
by more than one microorganism.
In one study, a second pathogen
was found in about 10% of
patients with pneumonia due to a
conventional bacterial pathogen,
but in 55% of patients in whom an
quot;atypicalquot; pathogen was found.

20. In 1938, the term quot;atypical
pneumoniaquot; was introduced to
describe quot;an unusual form of
tracheobronchopneumonia with
severe constitutional symptomsquot;.
It later became customary to
distinguish between quot;classical
bacterial pneumoniaquot; and
quot;atypical pneumoniaquot;. This
distinction was challenged during
the 1990s when researchers found
it difficult if not impossible to
differentiate these illnesses on
clinical grounds. Some authorities
now suggest abandoning the term
quot;atypical pneumoniaquot;. Others
keep the term since it enriches our
appreciation of the disease, forces
us to consider unusual etiologies,
and reminds us that the quot;atypical
pneumoniasquot; do not respond to β-
lactam antibiotics. For these latter
reasons and for the sake of clarity,
we keep the terms here even while

21. agreeing that in some cases it may
be impossible to distinguish
between quot;classic bacterial
pneumoniaquot; and quot;atypical
pneumoniaquot; in actual clinical
practice.
quot;Typical pneumoniaquot; is an
alveolar disease whereas quot;atypical
pneumoniasquot; affects mainly the
tracheobronchial mucosa and
interstitium of the lung; hence, the
different clinical manifestations.
Classical bacterial pneumonia
begins with sudden onset of fever,
chills, pleuritic chest pain, and
productive cough. In the absence
of impaired consciousness or
inebriation, patients usually seek
medical care within 6 hours of the
onset of symptoms. Chills occur
in about 50% and chest pain in
about 30% of patients. Most
patients are febrile although some,

22. especially the elderly, may have
normal or subnormal
temperatures. The respiratory rate
is usually increased. Physical
examination often reveals signs of
consolidation such as dullness to
percussion, pectoriloquy, and
egophony (e to a change). Lobar
consolidation is present on chest
x-ray in about one-third of
patients. The white blood count is
usually elevated with a shift-to-
the-left. However, leukopenia
rather than leukocytosis may be
present and portends a poor
prognosis.
Atypical pneumonia, on the other
hand, usually begins gradually.
The insidious onset is often
brought out by asking, quot;When was
the last time you were in your
usual good health?quot; Constitutional
symptoms are usually more
prominent than the pulmonary

23. symptoms. Chest pain is
experienced as substernal
discomfort. Cough is non-
productive or productive of only
scanty amounts of sputum.
Relative bradycardia is frequently
present. The trachea may be
tender but the lung fields are
essentially clear to auscultation,
prompting one to be surprised by
the extent of infiltrate present on
chest x-ray. The white blood
count is often normal or near
normal. Modest elevation of liver
enzymes (specifically, the
aminotransferases - AST (SGOT)
and ALT (SGPT) - is often
present. Atypical pneumonia, in
summary, seldom presents as an
acute, life-threatening medical
problem but forces the physician
to expand the differential
diagnosis.
Pneumococcal Pneumonia

24. Streptococcus pneumoniae
remains the major cause of severe
community-acquired pneumonia
and, worldwide, a leading cause of
death. It accounts for about two-
thirds of cases of bacteremic
pneumonia, and is the most
common cause of pneumonia
leading to hospitalization in all
age groups. Some authorities
believe that S. pneumoniae may
cause up to one-half of all
community-acquired pneumonias.
There is concern that the
incidence of pneumococcal
disease may be increasing at the
same time that drug resistance is
becoming much more common.
Primary care clinicians should
strive to make pneumococcal
vaccination an imperative for
patients at increased risk.
S. pneumoniae is a common

25. colonizer of the nasopharynx.
Invasive pneumococcal disease
occurs most often after a new
serotype has been acquired,
typically after an incubation of
one to three days. Viral illness
increases the incidence of disease
presumably by interfering with
normal host defenses. Risk factors
for invasive pneumococcal disease
include extremes of age,
alcoholism, HIV disease, end-
stage renal disease, sickle cell
disease, diabetes mellitus,
dementia, malnutrition,
malignancies, diseases affecting B
lymphocyte function (notably,
multiple myeloma and
hypogammaglobulinemia), and
immunosuppressive disorders.
Patients with asplenia are
susceptible to fulminant
pneumococcal disease. The
pneumococcus does not invade
cells as readily as do some of the

26. other streptococci. However once
in the lungs, it passes easily from
one alveolus to another through
the pores of hence the basis Cohn
until stopped by the dense
connective tissue of a fissure for
lobar consolidation.
As classically described by
previous generations of clinicians,
S. pneumoniae causes a lobar
pneumonia with by the sudden
onset of fever with a single, hard-
shaking chill, cough productive of
rusty-colored mucopurulent
sputum, and pleuritic chest pain.
The patient presents with systemic
toxicity including tachypnea.
Physical examination reveals
crepitant râles, tubular breath
sounds, and signs of lobar
consolidation (dullness to
percussion, egophony with e to a
change, and pectoriloquy). Today,
however, pneumococcal disease is

27. often a more subtle illness. Patchy
infiltrates and bronchopneumonia
are relatively common. It is often
difficult to say precisely what
represents pneumococcal
pneumonia and what does not
unless blood cultures are positive.
Bacterial Pneumonia due to
Agents other than S.
pneumoniae
Figure
Haemophilus
Among the numerous bacteria
influenzae as
other than S. pneumoniae that
seen using a
sometimes cause acute
Gram-stain
community-acquired pneumonia,
technique.
the most common are H.
During the flu
influenzae, S. aureus,
outbreak of 1918
Streptococcus pyogenes,
H. influenzae
miscellaneous aerobic gram-
was termed
negative rods, and anaerobic
Pfeiffer's
quot;mouth floraquot; bacteria. Patients
Bacillus, where it
with these pneumonias often have
was found in the
significant underlying disease,
sputum of many
severe pneumonia, or both.
influenza

28. patients, and Therefore, hospitalization is
thought to be the usually indicated.
cause of
influenza. H. influenzae is a frequent cause
CDC of pneumonia in elderly patients
and in patients with serious
underlying diseases including
chronic obstructive lung disease.
The pneumonia usually has a
patchy or segmental distribution
characteristic of
bronchopneumonia as opposed to
lobar pneumonia. A sputum
Gram’s stain showing small,
pleomorphic gram-negative
coccobacilli can be virtually
diagnostic.
Staphylococcus aureus
pneumonia, when community-
acquired, tends to be an acute,
fulminant about 1% of cases,
except during influenza
epidemics. Influenza virus
infection markedly predisposes to

29. staphylococcal colonization of the
respiratory mucosa.
Staphylococcal pneumonia tends
to be a necrotizing process with
abscess formation. The chest x-ray
sometimes shows air pockets
known as pneumatoceles,
especially in children.
Streptococcus pyogenes (group A
streptococcal) pneumonia is also
uncommon except during
influenza epidemics. This
pneumonia is often accompanied
by the rapid development of large
empyemas. Chest tube drainage is
often necessary, resulting in
prolonged hospitalization.
Klebsiella pneumoniae is a
relatively common cause of
pneumonia in patients suffering
from alcoholism. The pneumonia
often assumes a lobar distribution.
Classically, this pneumonia

30. affects the upper lobes and causes
a “bulging fissure” on chest x-ray.
E. coli and other aerobic gram-
negative rods are relatively
common causes of pneumonia in
the frail elderly. Pseudomonas
aeruginosa, although a common
cause of nosocomial pneumonia,
is rarely associated with
community-acquired pneumonia
in patients without underlying
lung disease or severe debility.
Pneumonia due to quot;mouth floraquot;
bacteria - by which is meant a
combination of anaerobic and
aerobic bacteria with the
anaerobes usually predominating -
occurs most frequently in patients
suffering from alcoholism and
poor oral hygiene and results from
aspiration. The sputum is usually
copious and often foul smelling.
quot;Mouth floraquot; pneumonia in an
edentulous patient should prompt

31. suspicion of underlying lung
cancer. A foul odor to the breath
is present in many but not all of
these patients. This form of
pneumonia is often associated
with lung abscess and with
empyema due to bronchopleural
fistula.
Mycoplasma pneumoniae
pneumonia
Formerly known as the quot;Eaton
agentquot;, Mycoplasma pneumoniae
is the most commonly identified
cause of atypical pneumonia
although its precise incidence is
unknown. Various investigators
have determined this
microorganism to be the cause of
13% to 27% of community-
acquired pneumonias. It can also
cause hospital-acquired
pneumonias, and it has caused as
many as 50% of pneumonias

32. during epidemics in closed
populations. Mycoplasma
pneumoniae pneumonia becomes
less common after age 40, but
older persons may experience
more severe manifestations.
M. pneumoniae is a cell-wall-
deficient organism with particular
affinity for the respiratory tract
epithelium. Many of the disease
manifestations are now thought to
be immune-mediated. Close,
prolonged contact promotes
transmission by respiratory
secretions. There is currently
interest in the extent to which M.
pneumoniae accompanies other
agents as a co-pathogen. In one
study, an additional pathogen was
found in about two-thirds of
patients with M. pneumoniae
pneumonia who required
hospitalization; S. pneumoniae
was most commonly found, but

33. Legionella species and Chlamydia
pneumoniae were also identified.
It is estimated that of persons
infected with M. pneumoniae,
about 20% are symptomatic, about
70% develop a mild respiratory
illness (pharyngitis and/or
tracheobronchitis), and fewer than
10% develop pneumonia. The
disease occurs in all age groups
including toddlers and the elderly
but peaks between ages 5 to 15
years.
After an incubation period of
about 3 weeks, symptoms begin
gradually with fever, headache,
malaise, chills, sore throat,
substernal productive, and cough.
The cough is initially non-
productive, paroxysmal, and
worse at night. It commonly
becomes productive later in the
illness. Physical examination is

34. usually unimpressive. Bullous
myringitis (inflammation of the
tympanic membrane with bullae)
is uncommon, occurring at most
in about 5% of patients, but has a
high positive predictive value for
M. pneumoniae infection. More
commonly there is mild
tenderness over the paranasal
sinuses, mild erythema of the
posterior pharyngeal mucosa, soft
cervical lymphadenopathy, and
tracheal tenderness. Scattered
râles and wheezes may be present
but are usually unimpressive.
The white blood count is normal
in 75% or more of cases.
Thrombocytosis can occur as an
acute-phase response. Liver
enzymes, notably the
aminotransferases (AST and
ALT), are often mildly elevated.
The chest x-ray commonly shows
infiltrates that are much more

35. extensive than one would have
suspected from physical
examination. The most common
pattern is a peribronchial
pneumonia in which thickened
bronchial shadows are surrounded
by streaky interstitial infiltrates
and patchy atelectasis. Other
patterns include nodular infiltrates
and hilar lymphadenopathy. The
lower lobes are most commonly
involved, and pleural effusions -
which can be especially severe in
patients with sickle cell disease -
occur in up to 20% of patients
when carefully sought.
Extrapulmonary manifestations of
M. pneumoniae pneumonia
sometimes dominate the clinical
picture and include hemolytic
anemia, rashes including the life-
threatening Stevens-Johnson
syndrome, central nervous system
complications (about 0.1% of

36. patients, especially children),
cardiac complications, and
polyarthritis.
Chlamydia pneumoniae
pneumonia
Chlamydia pneumoniae, described
in 1986 as the TWAR agent, has
been determined by some
researchers to be the third or
fourth most common cause of
community-acquired pneumonia,
explaining perhaps 10% to 14% of
cases (up to 28% in some series).
Pneumonia is recognized most
frequently among the elderly, in
whom it can be severe.
Chlamydia pneumoniae is
classified as a bacterium on the
basis of its cell wall and growth
properties. Unlike most bacteria,
however, it grows only as an
intracellular parasite. Serologic

37. studies suggest that most humans
gain experience with C.
pneumoniae at some point in their
lives, although immunity is short-
lived. About 50% of all persons
have antibodies by age 20, and up
to 75% of elderly persons are
seropositive. It is also thought that
most infections (up to 90%) are
asymptomatic. Transmission is
probably person-to-person by
respiratory secretions.
After an incubation period of
several weeks, most patients
experience gradual onset of non-
specific upper and lower
respiratory symptoms including
those of sinusitis, otitis, and
pharyngitis. Sore throat with
hoarseness is often prominent
among the initial symptoms and
tends to be the dominant symptom
in college-aged persons.
Symptoms of pneumonia tend to

38. develop slowly. Often, patients
have experienced symptoms for
several weeks before seeking
medical care. The history
sometimes suggests a biphasic
illness, as follows: (1) upper
respiratory infection with sore
throat that resolved, then (2) lower
respiratory infection with cough.
The severity is age-dependent.
Children under age 5 seldom have
evidence of significant disease.
University students often present
with a 10-day history of sore
throat or hoarseness with minimal
fever. The mean age of patients
with pneumonia is about 56 years.
Ronchi and râles are present on
physical examination more
frequently than in M. pneumoniae
pneumonia, even among patients
who do not complain of cough.
The white blood count is usually
normal. Chest x-ray may show

39. one or more infiltrates, the most
common finding being a single,
patchy, subsegmental infiltrate.
Wheezing is sometimes present.
Accumulating evidence suggests
that C. pneumoniae sometimes
precipitates adult-onset asthma.
Reported extrapulmonary
manifestations of C. pneumoniae
infection include
meningoencephalitis, cerebellar
dysfunction, Guillain-Barré
syndrome, reactive arthritis, and
myocarditis. The possibility that
C. pneumoniae might cause
coronary artery disease has
received much attention. High
antibodies to C. pneumoniae have
been observed in patients with
chronic obstructive lung disease,
sarcoidosis, and lung cancer but
an etiologic link is unclear.
Chlamydia psittaci

40. (Psittacosis; Ornithosis)
About 100 to 200 cases of
psittacosis are reported in the U.S.
each year, but the true incidence is
thought to be much higher.
Mortality can be high if the
diagnosis is not suspected.
Chlamydia psittaci infects many
and perhaps all species of birds,
which may remain asymptomatic
or show symptoms and signs of
illness such as anorexia, dyspnea,
and ruffled feathers. Strains of C.
psittaci that are most virulent for
humans tend to be those
associated with psittacine birds
(from the Latin psittacus, or
parrot), such as parrots, parakeets,
macaws, cockatoos, and
budgerigars, and also with
turkeys. Humans who develop
psittacosis are commonly bird
fanciers or work in poultry farms

41. (notably, turkey farms), abattoirs,
processing plans, pet shops, or
veterinarians’ offices. The
organism is usually acquired by
inhalation, but human-to-human
transmission occurs on rare
occasions.
After an incubation period of 5 to
15 days, patients develop
symptoms and signs of illness
ranging in severity from mild to
life threatening. Atypical
pneumonia, the most
characteristic form of the disease,
is manifest by headache, fever,
and non-productive cough. Chest
x-ray is usually abnormal (75%)
of cases, most commonly showing
consolidation of one lower lobe.
The radiographic findings are
usually much more striking than
the findings on auscultation of the
chest. Psittacosis can also present
as a typhoidal illness (fever,

42. malaise, relative bradycardia,
hepatosplenomegaly), a non-
specific flu-like quot;viral syndromequot;,
a mononucleosis-like syndrome,
or as fever of unknown origin.
Legionnaire’s disease
Figure First identified in 1976 during an
This micrograph outbreak at an American Legion
of a biopsied Convention in Philadelphia,
lung tissue Legionnaire’s disease is now
specimen stained recognized as a relatively
with the CDC's common cause of both
modified community-acquired and hospital-
Dieterle silver acquired pneumonia. The
impregnation incidence exhibits wide
procedure, geographic variation - from less
revealed small, than 1% to more than 16% of
blunt, community-acquired pneumonias
pleomorphic - reflecting to a large extent the
intracellular, and degree of contamination of water
extracellular reservoirs by the causative
bacilli, which organisms. Unlike pneumonias
stain brown to due to M. pneumoniae and C.

43. black against a pneumoniae, cases that can be
pale yellow treated on an outpatient basis tend
background; to be the exception rather than the
Mag. 500x. rule.
Dieterle’s stain is
a preparation Legionella species are gram-
used when negative bacteria that stain poorly
and survive intracellularly. More
Legionella
than 40 species, and more than 60
pneumophila
bacteria are serogroups, of Legionella are now
suspected. recognized. Legionella
Uranyl nitrate is pneumophila is the most
applied in order commonly encountered species,
to first sensitize causing at least 80% of clinical
the slide mount, infections.
which is
subsequently Legionellosis seems to be a
treated with gum disease of human progress
mastic, followed brought about by devices that
by an incubation maintain water at warm
period, after temperatures and produce
which the slide is aerosols. In water, the organisms
soaked in silver multiply within amebas; in
nitrate. Lastly, humans they multiply within
the slide is alveolar macrophages. The

44. “developed” in a disease is spread by water rather
hydroquinone, than by person-to-person contact.
sodium sulfite, Contamination of water sources
acetone, has been associated with
formaldehyde, numerous outbreaks in settings
pyridine, and ranging from inner-city hospitals
gum mastic bath. to luxury cruise liners.
The Legionella
Clinically severe cases of
pneumophila
Legionnaire’s disease tend to
bacteria, if
present, will occur in persons with
stain black. CDCcompromised host defenses, most
often in the setting of chronic
obstructive pulmonary disease,
Figure immunosuppression, or advanced
age. A mild form of Legionellosis,
This silver-
known as Pontiac fever, is a self-
stained
micrograph of a limited disease presenting as
fever, malaise, headaches, and
lung tissue
chills without pneumonia. Pontiac
specimen
fever resolves within a few days
revealed the
without antibiotic therapy.
presence of
Legionnaire’s disease, the more
Legionella
familiar and more severe form of
pneumophila
Legionellosis, affects persons of
bacteria. The

45. specimen was all ages and presents with
taken from a symptoms that overlap those of
victim of the quot;classic bacterialquot; and quot;atypicalquot;
1976 pneumonia.
Legionnaires’
disease outbreak After an incubation period of 2 to
in Philadelphia. 10 days, patients experience the
CDC onset of fever, headache, anorexia,
malaise, and myalgia. At this
point, respiratory symptoms are
usually not prominent, the cough
Figure
being only minimally productive.
Legionella
Some patients have chest pain
pneumophila
and, if the sputum is blood-tinged,
multiplying
pulmonary embolism is often
inside a cultured
suspected. Gastrointestinal
human lung
symptoms with nausea, vomiting,
fibroblast
diarrhea, and abdominal pain can
CDC
also dominate the clinical picture.
Alternatively, neurologic
Figure symptoms can be the presenting
Anteroposterior complaint, variably manifested as
headache, lethargy, and change in
x-ray reveals
mental status.
bilateral
pulmonary

46. infiltrates in a Fever is usually present. Relative
patient with bradycardia is found more often in
Legionnaires' older patients and in those with
disease CDC severe pneumonia. Examination
of the chest usually shows râles
and, later in the illness, signs of
consolidation. The peripheral
blood commonly shows
leukocytosis and
thrombocytopenia. Hyponatremia
(serum sodium < 130 mEq/L) is
more common in Legionnaire’s
disease than in most other
pneumonias. Hypophosphatemia
also occurs. There is frequently
evidence of liver and renal
dysfunction. Hematuria and
proteinuria are common. There is
no characteristic feature on chest
x-ray. The most common pattern
is a patchy infiltrate involving one
lobe, which progresses to
consolidation. Infiltrates can
assume a diffuse or interstitial
pattern, and pleural effusions are

47. common.