Pneumonia (the ancient Greek word for lungs) is defined as an infection involving the alveoli of the lungs. It occurs in patients of all age groups, but young children and the elderly, as well as immunocompromised and immune deficient patients, are especially at risk. Causal therapy is with antibiotics.

Signs and symptoms

Symptoms may include:

• Common
  • Cough with greenish or yellow mucus
  • Fever with shaking chills (rigors)
  • Sharp or stabbing chest pain, worsened by deep breaths or coughs
  • Rapid, shallow breathing (painful quick breathing)
  • Shortness of breath
  • Fever of 39.5°C (103°F) and higher
  • Painful cough
• Rarer
  • Bloody mucus
  • Headache, including migraine headache
  • Excessive sweating and clammy skin
  • Loss of appetite
  • Excessive fatigue
  • Cyanosis

Pneumonia can progress to sepsis ("blood poisoning") and acute respiratory distress syndrome if untreated. These are the main causes of death in patients with untreated pneumonia.

Diagnosis

For the diagnosis of pneumonia, an infiltrate on an X-ray of the chest is the gold standard. Supportive diagnostic tests are microbiological culture of sputum and/or blood. Blood tests are generally performed when a pneumonia is suspected: a full blood count often shows neutrophilia (except in some immunocompromised and all neutropenic patients). Renal function may have deteriorated if there is sepsis. Electrolytes can show hyponatremia (low sodium levels); this is often due to secretion of antidiuretic hormone by pulmonary tissue.

In nosocomial (hospital-acquired) pneumonia and the pneumonias of the immunocompromised, diagnosis can be difficult, and CT scanning of the lungs can be required to differentiate possible causes (e.g. pulmonary embolism). CT scanning is also used when the symptoms and physical examination point at possible different causes for the complaints (e.g. vasculitis, sarcoidosis, lung cancer).

Classification

There are several different classification schemes: microbiological, radiological, age-related, anatomical, point of acquiring infection. Generally, the following types are used:

• lobar - pneumonia that results in the consolidation of a pulmonary lobe (generally due to Streptococcus pneumoniae)
• multilobar - pneumonia that results in the consolidation of more than one lobe
• community-acquired - pneumonia in a patient who is not or has not recently been in the hospital
• hospital-acquired or nosocomial - pneumonia in a patient in a hospital (or recently discharged)
• "walking" - outdated term, pneumonia in a patient who is still able to walk, a mild pneumonia, usually due to mycoplasma
• pneumococcal - pneumonia due to S. pneumoniae.
• atypical - pneumonia due to either Mycoplasma, Chlamydia or Legionella.

The main classification used in medical journals is that between the point of infection: community-acquired and hospital-acquired. Furthermore, infections in the immunocompromised, as well as aspiration pneumonia, are usually treated as separate disease entities as they have other causal agents, as well as a different clinical course.

Types of pneumonia

Community-acquired pneumonia

• Epidemiology - Community-acquired pneumonia (CAP) is a serious illness. It is the fourth most common cause of death in the UK, and sixth in the USA. 85% of cases of CAP are caused by the typical bacterial pathogens, namely, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. The remaining 15% are caused by atypical pathogens, namely Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella species. Unusual aerobic gram-negative bacilli (for example, Pseudomonas aeruginosa, Acinetobacter, Enterobacter) rarely cause CAP.
• Clinical features - typical symptoms include cough, purulent sputum production, shortness of breath, pleuritic chest pain, fevers and chills. On examination, one notes rapid respiratory rate and heart rate and signs of pulmonary consolidation. In the elderly, symptoms and signs are vague and non-specific. They may consist of headache, malaise, diarrhea, confusion, falling, and decreased appetite. Diagnosis is confirmed by chest x-ray. In general, patients who present with what appears to be CAP, with findings confined to the lungs and no laboratory evidence of extrapulmonary involvement, have CAP caused by a typical pathogen. Patients who have pneumonia plus extrapulmonary physical findings or laboratory features (such as elevations in liver function test results) have an atypical pneumonia.

Hospital-acquired pneumonia

Hospital-acquired pneumonia, also called nosocomial pneumonia, is a lung infection acquired after hospitalization for another illness or procedure. It is considered a separate clinical entity from CAP because the causes, microbiology, treatment and prognosis are different. Hospitalized patients have a variety of risk factors for pneumonia, including mechanical ventilation, prolonged malnutrition, underlying cardiac and pulmonary diseases, achlorhydria and immune disorders. Additionally, pathogens thrive in hospitals that could not survive in other environments. These pathogens include resistant aerobic gram-negative rods, such as Pseudomonas, Enterobacter and Serratia, resistant gram positive cocci, such as MRSA. Because of risk factors, underlying morbidity and resistant bacteria, hospital-acquired pneumonia tends to be more deadly than its community counterpart. Antibiotics used for hospital-acquired pneumonia include aminoglycosides, fluoroquinolones, carbapenems, and vancomycin. Multiple antibiotics are administered in combination in order to cover all the possible organisms effectively and rapidly, before the infectious agent can be known. Antibiotic choice varies from hospital to hospital as the likely pathogens and resistance patterns vary similarly.

Other pneumonias

• Severe acute respiratory syndrome (SARS)
• Pneumocystis carinii pneumonia
• Bronchiolitis obliterans organizing pneumonia
• Eosinophilic pneumonia

Pathophysiology

Pneumonia is an infectious disease by definition, and whether a patient is prone to develop pneumonia depends on the presence of pathogens but equally on the patient's immune system and other factors. Most pneumonias are not epidemic, although infection with influenza virus can be so defined.

Breathing problems, as often present in patients after a stroke, in Parkinson's disease, hospitalisation or surgery and mechanical ventilation can all increase the likelihood of pneumonia. Similarly, inability to clear sputum (as in cystic fibrosis) or retention of sputum (as in bronchiectasis) can lead to pneumonia.

After splenectomy (removal of the spleen), a patient is more prone to pneumonia due to the spleen's role in developing immunity against the polysaccharides on pneumococcus bacteria.

Prevention

Vaccination with the pneumococcal polysaccharide vaccine is recommended for adults older than 65 and persons with chronic disease (except asthma). Also for Native Alaskans and certain Native Americans¹². Pneumoccocal pneumonia kills more Americans than all other diseases combined that could be partially prevented by vaccination¹.

Therapy

Antibiotics are the only causal therapy for pneumonia. The antibiotics that are used depend on the nature of the pneumonia and the immune status of the patient. Amoxicillin is used as first-line therapy in the vast majority of community patients, sometimes with added clarithromycin. In North America, where the atypical forms of community acquired pneumonia are becoming more common, clarithromycin, azithromycin, and the fluoroquinolones have displaced the penicillin-derived drugs as first line therapy. In hospitalized patients and immune deficient patients, local guidelines generally determine which combination of (generally intravenous) antibiotics is used.

Prognosis and mortality

The clinical state of the patient at time of presentation is a strong predictor of the clinical course. Many clinicians use the Pneumonia Severity Score to calculate whether a patient requires admission to hospital, based on the severity of symptoms, underlying disease and age³. In the United States mortality from pneumococcal pneumonia is 1 in 20, in cases where the disease progresses to blood poisoning, bacteremia, 2 of 10 die and where the disease affects the brain, meningitis, 3 of 10 die. ¹

History of pneumonia

Before the advent of antibiotics, pneumonia was often fatal. When penicillin was discovered in the 20th century, it was the first causal therapy. Most community-acquired strains of S. pneumoniae are still penicillin-sensitive.

Notable pneumonia sufferers

Many famous people throughout the years have succumbed to pneumonia and its complications. As it is a common cause of death in the chronically ill, this is not always reported in the press.

• A well known and tragically sudden death due to pneumonia was that of Muppets creator Jim Henson in the early 1990s.
• 19th Century Sharpshooter Calamity Jane.
• In 1989, Actor Jim Backus died of pneumonia, after suffering for years with Parkinson's Disease. Backus was best known for his roles as the voice of animated character, Mr. Magoo, and as Thurston Howell III on television's Gilligan's Island.
• Television producer and director, Bruce Paltrow, 58, died of the disease while traveling in Rome in 2002. Paltrow was survived at the time by his wife, actress Blythe Danner, and his daughter, actress Gwyneth Paltrow.
• In the late 30s, movie mogul Irving Thalberg was finally felled by pneumonia after suffering for years from heart problems. Thalberg died before even reaching his 40th birthday, and some say Louis B. Mayer, let alone Norma Shearer, never recovered from the loss of MGM's creative "boy wonder."
• In 2005, John Raitt, Broadway star of the 50s and 60s in such hits as The Pajama Game and Carousel, passed away due to complications from pneumonia. His daughter is pop and blues singer, Bonnie Raitt.

Notes

• 1: National guideline clearninghouse (http://www.guideline.gov/summary/summary.aspx?doc_id=5616&nbr=3786&string=) clinical practice guideline (USA): adult preventive health care - immunizations
• 2: Center for Disease Control, United States, regarding vaccination with the pneumococcal polysaccharide vaccine (PDF (http://www.cdc.gov/nip/publications/VIS/vis-ppv.pdf))
• 3: Halm EA, Teirstein AS. Management of community-acquired pneumonia. N Engl J Med 2002;347:2039-45. PMID 12490686.