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Diagnosis of pneumonia of a long current

Table of contents
Diagnosis of pneumonia of a long current
Anamnesis of pneumonia of a long current
Physical inspection
Diagnostic testings at pneumonia of a long current
Assessment of pneumonia of a long current and diagnostic approach

Close concepts: pneumonitis, pulmonary infection

Pneumonia represents an inflammation of pulmonary fabric which most often is caused by microorganisms. Though this term is used for designation of damages of lungs and other etiology (allergic, eosinophilic, lipoid, beam), the present article is devoted to the pneumonia caused by an infection.

Till an era of antibiotics pneumonia was the most common cause of death. Such reasons of inflammatory diseases of lungs as a tuberculosis infection, some anaerobic and aerobic bacteria and an influenza virus were at that time known. Atypical pneumonia was described in 1942, and the infectious agent of Mycoplasma pneumoniae causing it was allocated in 1944. The problem of the pneumonia caused by gram-negative microorganisms, first of all hospital arose in the early sixties last century and continues to grow, despite wide use of germicides, corticosteroids, artificial ventilation of the lungs, inhalation therapy and intensive care units. Since the end of the 60th years of last century emergence of antineoplastic chemotherapy and an organ transplantation led to developing of the pneumonia caused by earlier being considered nonpathogenic viruses, mushrooms and parasites whose diagnosis requires usually performance of a biopsy of a lung. In 1976 it was revealed that Legionella pneumoniae causes epidemic pneumonia, and in the subsequent leads to a hospital infection and even more often is the activator at sporadic pneumonia. In 1981 qualitatively new forms of the saprophytic infections caused by Pneumocystis carinii, atypical mycobacteria, viruses (a cytomegalovirus, a herpes simplex virus), mushrooms (Cryptococcus, Aspergillus and Candida) and Toxoplasma gondii, were found in homosexuals, addicts and residents of Haiti whose possible cause the lymphopenia and changes of ratio T-helperov and T-suppressors were. These infections together with Kaposha's sarcoma; high-quality lymphadenopathy, lymphoma and autoimmune Werlhof's disease at this group of the population call acquired immunodeficiency syndrome (AIDS). A range, and, therefore, and differential diagnosis of pneumonia for the last 20 years considerably extended, and, seemingly, that this process will continue.

After establishment of the diagnosis and the beginning of antibacterial therapy of pneumonia the following options of a clinical current are possible: 1) the etiology of a disease is precisely defined as a result of bacteriological research, a biopsy or serological research, and under the influence of specific treatment there comes improvement of a condition of the patient; 2) the etiology is not defined, but as a result of antibacterial therapy the condition of the patient improves; 3) other reason, for example the lung heart attack, a system lupus erythematosus or diseases of lungs connected with reception of medicines is found; 4) despite treatment, pneumonia remains, extends or passes into a recurrent form, the reason to define it it is not possible. As in the present article the main attention is concentrated on the last category of the pneumonia which is badly giving in to treatment for the purpose of assistance by clinical physicians in it are provided both the extended, and seldom found pulmonary infections, and also some aspects of not germ diseases of lungs are covered.

Prevalence and reasons of long pneumonia

The pneumonia taking the fifth place among the leading reasons of mortality is observed approximately at 10% of inpatients. It is established that 15% of lethal outcomes in hospitals are caused by a hospital infection of lower parts of a respiratory path and that at 2/3 of these patients pneumonia develops against a basic disease at which the lethal outcome is possible within 6 months. It is revealed that at 51% of adult emigrants from Asia reaction to skin tuberkulinovy test of average degree of manifestation (diameter of a papule more than 10 mm), at 5% is noted at X-ray inspection of bodies of a thorax — the changes connected with an active or healed tuberculosis and at 1%, despite achievements in the organization of preventive X-ray inspections, active tuberculosis is defined (by 100 times more often than at Americans). High frequency of cases of tuberculosis (quite often resistant to therapy) and parasitic pulmonary infections is found also in emigrants from Caribbean countries. Essential increase of incidence of the infections caused by saprophytes is noted at patients with tumors, AIDS, and also at the persons who transferred transplantation, however the frequency of emergence of other forms of pneumonia remains rather stable within the last 10 — 15 years.

Clinical displays of pneumonia are various, however usually it is easy to reveal them. Considerable difficulties are presented by definition of a microbic or not microbic etiology of pneumonia during its emergence or when becomes obvious that pneumonia will badly respond to treatment. The reasons of it are that data of the anamnesis, physical inspection, primary laboratory inspection, research of the smear of a phlegm painted across Gram, and a X-ray analysis of bodies of a thorax are not rather specific and sensitive in order that on their basis it was possible to judge a disease etiology. The majority of microorganisms, pathogenic for the person can cause damage of lungs. Therefore, considerable narrowing of number of the diagnostic options connected with a huge number of the reasons of infectious pneumonia can be promoted by their differentiation on the basis of epidemiological and clinical signs of a disease. First of all it is possible to allocate patients with normal (tab. 1) and the broken immunity (tab. 2). The group with the changed immunity is made by persons with disturbance of cellular immunity, for example patients with limforetikulyarny malignant tumors, the receiving corticosteroid and cytotoxic drugs, and homosexuals.

 

Table 1. The pneumonia reasons at patients with a normality of immune system

Pneumonia type

The patients who do not have the diseases preceding pneumonia

Patients with the diseases preceding pneumonia

Bacterial

Widespread
Less widespread

 

Streptococcus pneumoniae

 

Hemophylus influenzae
Staphylococcus aureus
Streptococcus pyogenes

 

Streptococcus pneumoniae
Hemophilus influenzae
Staphylococcus aureus
Klebsiella pneumoniae

Gram-negative aerobes
Bacilli, especially at the use of medicines
Century of sphaericus
Century of subtilis

Unusual

Klebsiella pneumonia
Neisseria meningitidis
Francisella tularensis

The same, as at the patients who did not have the diseases preceding pneumonia except

Yersinia
Y. pestis
Y. enteroeolitiea Salmonella
S. typhosa
S. choleraesius
S. typhimurium, etc.
Bacillus anthracis

Klebsiella pneumoniae

Not bacterial pneumonia stimulating bacterial

Entamoeba histolytica Blastomyces dermatitidis

No

Atypical
Widespread

Less widespread

 

 

 

Mycoplasma pneumoniae

Legionella pneumophila and
other strains of a legionella
Viruses
Flu
Adenovirus
Chicken pox
Rubeola

The same, as at the patients who did not have the diseases preceding pneumonia

Unusual

Rickettsiae
R. rickettsii
R. prowazekii
R. tsutsugamushi
Coxiella burnetii
Viruses
Koksaki And yes In
ECHO
Epstein — Barre

Aspiration

Chronic

Histoplasma mushrooms (acute) Coccidioides (mainly pulmonary)
Blastomyces (acute)
Anaerobic bacteria, more often
Bacteroides melaninogenicus
Fusobacterium nuclearum Anaerobic streptococci

 

 

 

Mycobacterium tuberculosis Mushrooms
Coccidioides
Blastomyces
Cryptococcus
Sporothrix schenckii of the Bacterium
Actinomyces
Nocardia
Brucella
Pseudomonas pseudomallei Parasites
Paragonimus westermani Are absent

Gram-negative aerobes
Anaerobe bacterias
Staphylococcus aureus

Chronic obstructive

Hospital

Mycobacterium:
kansasii m
intracellulare m, etc.
Histoplasma eapsulatum (formation of chronic cavities)
Gram-negative aerobes
Staphylococcus aureus
Streptococcus (pneumoniae Staphylococcus epidermidis (especially when using systems for intravenous infusions)
Legionella pneumophila and other strains of a legionella  
Listeria monocytogenes

 

 

Table 2. The pneumonia reasons at patients with the broken immunity


Bacterial pneumonia

Gram-negative aerobes

Streptococcus pneumoniae

Nocardia asteroides

Listeria monocytogenes

Atypical pneumonia

Pneumocystis carinii

Legionella strains

Cytomegalovirus

Virus of chicken pox

Herpes simplex

Toxoplasma gondii

Cryptococcus neoformans

Strongyloides stercoralis

Fungal pneumonia (with clinical signs of a heart attack of a lung)

Aspergillus

Mucor

Chronic pneumonia

Mycobacterium tuberculosis

Atypical mycobacteria (numerous strains)

Mushrooms

Cryptococcus

Coccidioides

Histoplasma

 

The addicts sick with hemophilia and residents of Haiti can belong to this category. Patients with normal immune system are subdivided into those which were healthy before developing of pneumonia, and at what pneumonia arose against any disease. At the last any reasons of pulmonary infections are possible. However the infectious damages of a throat caused by gram-negative bacteria are more probable at the weakened persons, alcoholics, a diabetes mellitus, and also at the persons which are long staying in a hospital.

Further division of patients depending on character of pneumonia (bacterial, atypical, aspiration, hospital, chronic and recurrent) is also reasonable as these groups usually differ on a clinical current, are caused by different pathogenic microorganisms, and the range of germicides for each of groups is rather limited.



 
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