Lobar & Broncho-

-Pneumonia
Objectives:
● Understand that pneumonia is an
inflammatory condition of the lung
characterized by consolidation (solidification)
of the pulmonary tissue.
● Is aware of the pathogenesis of pneumonia and
its classification which principally include
bronchopneumonia, lobar pneumonia and
atypical pneumonia.
● Is able to appreciate the aetiology and
pathogenesis of lung abscess.
Index:
Important
NOTES
Extra Information
Rikabi’s content
 Pneumonia /
pulmonary infection

Pneumonia can be very broadly defined as any infection in

Definition the lung.
*inflammation of the lung parenchyma

Symptomes
Predisposing factors:.

● Loss or suppression of the cough reflex: as a result of coma,

anesthesia, neuromuscular disorders, drugs, or chest pain.
High fever in bacterial , ● Injury to the mucociliary apparatus: by either impairment of ciliary
mild in viral. function or destruction of ciliated epithelium e.g. cigarette smoke,
inhalation of hot or corrosive gases, viral diseases, chronic diseases or
genetic disturbances.
cough ● Decreased function of alveolar macrophages: by alcohol, tobacco
smoke, anoxia, or oxygen intoxication.
(mucopurulent/rusty/bloo
● Pulmonary congestion and edema.
d tinged
● Retention and accumulation of secretions: e.g. cystic fibrosis and
sputum).(productive).
bronchial obstruction.
● Immunologic deficiencies, treatment with immunosuppressive
agents, leukopenia.
chills. ● Chronic diseases.
*usually associated with consolidation of lung tissue.
*increased density in pulmonary tissue caused by inflammatory
exudate.
pleuritic chest pain.

sometimes : dyspnea, investigation

hemoptysis.

Respiratory tract infections are more *increased WBCs count

frequent than infections of any *very high neutrophils - the report will tell you
organ,why? that -( there is a shift to the left ).
Shift to the left : immature form of neutrophils
(band neutrophils ) the nucleus will become
(Helpful video) banded , because there is to much demand ‫ﻣﺎ‬
‫ ﺗﻠﺣق ﺗﻔﺻل اﻟﻠوﺑز ﻋن ﺑﻌﺿﮭﺎ‬.
D
lung epithelium is exposed to contaminated air
The vulnerability of the lung to infection despite these defenses is not
surprising because many microbes are airborne and readily inhaled into
the lungs.

Portal of entry for

nasopharyngeal flora are regularly aspirated
most pneumonias
during sleep, even by healthy individuals. is :
- Inhalation of air droplets.
Pneumonia can be
- Aspiration of infected
acute or chronic
secretions or objects.
- Hematogenous spread
lung diseases render the lung parenchyma from one organ to other
vulnerable to virulent organism. often lower organs can occur.
local immune defenses.
 Morphology- Anatomic classification of pneumonia :
Classification can be made according to causative agent or gross anatomic distribution of the disease as the
following :

Alveolar “ Typical “ : Interstitial “ Atypical” :

Bronchopneumonia: Interstitial (Atypical or Viral ) :
(Streptococcus pneumoniae, Haemophilus influenzae, 1-Influenza virus (children).
Staphylococcus aureus) Represent an extension from 2-Mycoplasma pneumoniae (The pattern is lobar).
preexisting bronchitis or bronchiolitis. 3-chlamydia ;
Extremely common tends to occur in two extremes of
- Concentrated in the interstitium of the lung.
life.
- inflammation of the bronchi and surrounding - Mostly mononuclear infiltrate.
alveoli. ( Patchy ). - obligate intracellular organism ،can cause 4
- Lobar pneumonia: diseases :
(Streptococcus pneumoniae) 1- interstitial pneumonia.
Acute bacterial infection of a large portion of a lobe or 2- Conjunctivitis (Chlamydial trachoma).
entire lobe (one or two entire lobes of the lung)
Classic lobar pneumonia is now infrequent. 3-Non-specific urethritis.
Note: Overlap of the two patterns often occur. 4-Cervicitis.

The clinical types of pneumonia :

Opportunistic
Community-Acqu Community-Acqu pneumonias
ired ired / Chronic Aspiration Nosocomial
Pneumonia in the Pneumonia Pneumonia Pneumonia
Acute Atypical Immunocompro
Pneumonia Pneumonia mised Host

The etiology of pneumonia :

● Streptococcus pneumoniae (Pneumococcal).

● Staphylococcus aureus.
● Mycoplasma pneumoniae.
●chlamydia pneumoniae.
● klebsiella pneumoniae: “in chronic alcoholic people and who are debilitated”
●Viral pneumonia.
● legionella pneumonia: ”Especially in immunocompromised - posttransplant. the bacteria loves water
tanks or any wet things.”
● haemophilus influenzae: “is the most common bacterial cause of acute exacerbations of COPD”
● moraxella catarrhalis organisms: ”It is the second most common bacterial cause of acute
exacerbation of COPD in adults”.
 Community-Acquired Typical pneumonia

Definition
pneumonia acquired outside hospitals or extended-care facilities.

- more common : streptococcus pneumoniae ( Pneumococci).

- intravenous drug abuser : Staph. Aureus.
- Other Common Causes :
Haemophilus influenzae,
Cause Moraxella catarrhalis,
(usually bacteria)
Staphylococcus aureus,
Legionella pneumophila,
Klebsiella pneumoniae and Pseudomonas aeruginosa spp،Mycoplasma pneumoniae,
Chlamydia pneumoniae and Coxiella burnetii (Q fever)

More common on People 1- Chronic Diseases eg. DM, COPD and Congestive heart failure
Who have: 2- immune deficiency
3- Decreased or absent Splenic Functions

-Can follow URT infection

Abrupt onset of :
- high fever with sudden onset
- shaking chills
Clinical features :
- cough productive of mucopurulent sputum occasional patients may have hemoptysis.
- When fibrinosuppurative pleuritis is present, it is accompanied by pleuritic pain and
pleural friction rub , Reduced air entry and dullness by percussion.

- ** in lobar pneumonia there is a radio opaque (consolidation) well circumscribed

lobe.
- ***in bronchopneumonia there are multiple small opacities usually basal and
bilateral.
Radiology :
***
**

- Tissue destruction and necrosis (abscess).

- Spread of infection to the pleura leading to empyema.
- Organization of the exudate which converts the lung into solid tissue.
- Bacteremic (systemic) dissemination to heart valves (infective
endocarditis),pericardium, brain (meningitis), kidneys, spleen or joints (arthritis)
Complications :
Advanced organizing pneumonia,
featuring transformation of exudates to
fibromyxoid masses richly infiltrated by
macrophages and fibroblasts.
 Lobar Pneumonia
involves a large widespread area of lung and sometimes even an entire lobe of lung and could affect more than one
lobe. usually affects one entire lobe or two lobes ( diffused) most of the time caused by Streptococcus Pneumoniae.
(widespread fibrinosuppurative consolidation)

Caused by : (Streptococcus Pneumoniae (Pneumococci) type 1,3,7 & 2) 90-95% of the cases.
rarely by: K. pneumoniae (in elderly) - H. influenzae - Pseudomonas - Proteus - Legionella
pneumophila , staphylococci - streptococci

Common in : - debilitated people (‫ )ﻣﺿﻌف‬old age or small age , chronic illnesses. many time associated
with pleural effusion exudate very high LDH Protein ( enzyme ) very rich in fibrin and cells
come with lateral sided chest pain

Labor pneumonia occurs

in 4 stages:
1-vascular dilatation
Note from Prof rikabi:
because the advanced
antibiotics patients could
not reach all stages when
we treat them properly

3-less exudate here

4-alveoli open again

Complications - abscess is one of the major complications of pneumonia lobar or bronchial:

- pleuritis in addition to pneumonia in the area .

Streptococcus Pneumoniae capsule is rich in polysaccharide, so people with Splenectomy because

rupture of spleen are more prone to develop Pneumococcal Pneumonia ( spleen has a lot of
Predisposed factors
macrophages and phagocytic cells that are avid and take the polysaccharide ) this is a major predisposing
factor

Morphology

Radiology: there is a radio opaque (consolidation)

well circumscribed lobe.
 Bronchopneumonia
Is focal/patchy areas of consolidated acute suppurative inflammation in
one or more lobes.
Bronchopneumonia Usually it involves lower lobes (basal) bilaterally . WHY? because there is a
tendency of the secretions to gravitate into the lower lobes.
- Well developed lesions are 3 to 4 cm dry grey red ill defined nodules.

Microscopy: neutrophil rich exudate filling the

bronchi, bronchioles and adjacent alveolar
spaces.
Radiology:there are multiple small opacities
usually basal and bilateral.

Caused by:

1-Streptococcus pneumoniae
2- Staphylococcus aureus
3-Klebsiella (and other gram-ves sometime)
4-Streptococcus viridans
5-Streptococcus pyogenes
6-coliform bacteria
7-Haemophilus Influenzae (in COPD)
8-Pseudomonas Aeruginosa (in Cystic Fibrosis)
9- Staphylococci (secondary bacterial pneumonia
Most common in:
in children and healthy adults after viral
respiratory illnesses) Common cold ( viral
infection ) → secondary infection of Staph 1- terminal patients ( ‫) ﻗﺎب ﻗوﺳﯾن او ادﻧﻰ وﻏﺎﻟﺑﺎ أدﻧﻰ ﻟﻠﻣوت‬
Aureus. Sometimes Strep. pyogenes underlying advance disease.
eg. malignancy or diabetes.
we write that the cause of Death is
BronchoPneumonia
(‫ ﻏﺎﻟﺑﺎ ﺗﻛون‬Final Event ‫ﻗﺑل اﻟذھﺎب ﻟﻣﻘﺎﺑر أم اﻟﺣﻣﺎم‬.)
7-as above,Haemophilus Influenzae loves to cause
pneumonia in children (even causes Epiglottitis)
And quite commonly cause acute exacerbation of
chronic bronchitis in people who have COPD (3rd
respiratory acute medical emergency that we mentioned
throughout the respablock)
So If you know he has COPD you must make sure you
give him antibiotic that attacks Haemophilus influenzae.
 Community Acquired Atypical Pneumonia
Also called Primary atypical pneumonia/interstitial pneumonitis

• Characterized by patchy inflammation in the lungs confined to the alveolar septae and pulmonary
interstitium and therefore it is called interstitial pneumonitis.
•The major inflammatory cell is lymphocyte , so when we find neutrophils it means there's a
characteristics secondary infection.
• It is also called atypical pneumonia because it not the typical pneumonia in which the inflammation is
primarily in the alveolar spaces.

- the most common cause is Mycoplasma pneumonia.

- Others :
- Chlamydia spp. (C. pneumonia etc.) and Coxiella burnetii (Q fever).
Chlamydia is transmitted by inhalation of dried excreta of infected birds and causes
ornithosis/psittacosis.
Etiology

Predisposing malnutrition,alcoholism and any underlying debilitating disease.

factors
Test for Mycoplasma pneumoniae (Cold Agglutination test)
Positive in Mycoplasma (primary atypical pneumonia
It’s called cold because we do the test under a low temperature.
•The mycoplasma will lead to the formation of some IgM in the circulation.
•We take a blood sample from the patient and add RBC’s form a sheep (lamb) to it.
Diagnosis •The RBC’s of the lamb will agglutinate because of the IgM.
-serological assays.
- polymerase chain reaction (PCR) .

•Predominantly there is inflammation in the interstitium/alveolar wall.

•Alveolar septa are widened and edematous with mononuclear inflammatory infiltrate (and
neutrophils in acute cases only).

•Server cases: Intra-alveolar proteinaceous material with pink hyaline membrane lining the alveolar
walls (diffuse alveolar damage)

Microscopy

Server cases
 Other types of Pneumonia

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 1- Community Acquired Viral Pneumonia

•influenza types A and B

•Respiratory syncytial viruses(H.metapneumovirus)

•Adenovirus

•Rhinoviruses
Etiology •Rubeola virus

•Varicella

(all of these agents also cause upper-respiratory tract infections)

*Briefly all viruses that cause URTI

• The virus damage respiratory epithelium, producing an inflammatory

response.
The process may extends to alveoli (interstitial inflammation), but some outpouring of
fluid into alveolar spaces may also occur.
Mechanism • so that on chest films the changes may mimic those of bacterial
pneumonia .

The thickened alveolar walls are infiltrated with lymphocytes and some plasma cells
which are spilling edema over into alveolar spaces.

Morphology
In severe cases full-blown diffuse alveolar damage
with hyaline membranes may develop

The clinical course of viral pneumonia is extremely varied.

It may appear as a severe upper-respiratory tract infection with respiratory distress or
clinical course manifest as a fulminant, life-threatening infection (in immunocompromised)

Epithelial damage leading to necrosis of the respiratory epithelium inhibits

mucociliary clearance and predisposes to secondary bacterial infections. Such serious
complications of viral infection are more likely in infants, older adults, malnourished
Complication patients, alcoholics, and immunosuppressed individuals.
The most likely organism which cause secondary bronchopneumonia is S.aureus.
 2- Nosocomial Pneumonia
(Hospital acquired Pneumonia)
Acquire terminal pneumonias while hospitalized (nosocomial infection)

Gram-negative organisms like Klebsiella, Pseudomonas aeruginosa and E. coli And methicillin
Etiology resistant Staphylococcus aureus (MRSA).

severe underlying conditions e.g. immunosuppression, prolonged antibiotic therapy,

intravascular catheter and pt. with mechanical ventilator
Epidemiology

3- Aspiration pneumonia

Chemical injury due gastric acid and bacterial infection (anaerobic bacteria admixed with
aerobic bacteria, e.g. Bacteroides, Fusobacterium and Peptococcus)

Etiology

Occur in debilitated patients, comatose, alcoholic, or those who aspirated gastric contents
Epidemiology

Is aspiration pneumonia with fulminant clinical course,common complication (abscess) and

Necrotizing pneumonia frequent cause of death.

4- Chronic pneumonia

❖is most often a localized lesion in an immunocompetent person and systemic dissemination in immunocompromised, with
or without regional lymph node involvement.
❖ There is typically granulomatous inflammation.
❖Tuberculosis is by far the most important entity within the spectrum of chronic pneumonias.

M. tuberculosis) or fungi (Histoplasma capsulatum, Coccidioides. immitis,Blastomyces

Etiology

immunocompromised , immunocompetent
Epidemiology
 5- Opportunistic pneumonias
- Cytomegalovirus ‫ﯾﺧﻠﻲ اﻟﺧﻼﯾﺎ أﻛﺑر ﻣن ﺣﺟﻣﮭﺎ اﻟطﺑﯾﻌﻲ ﻧﻔس ھذي اﻟﺑﺳﺔ‬

- Pneumocystis jiroveci (formerly P. carinii)

- Mycobacterium avium-intracellulare
- Invasive aspergillosis
- Invasive candidiasis
Etiology - "Usual" bacterial, viral, and fungal organisms

Epidemiology immunosuppressed patients (AIDS, cancer patients and transplant recipients)

Pneumocystis Pneumonia
Etiology Pneumocystis jiroveci (formerly P. carinii) which is an opportunistic infectious agent
considered as a fungus.
- Seen in immunocompromised individuals especially AIDS.

Diagnosis ❖ Identify the organism in bronchoalveolar lavage fluids or in a transbronchial biopsy

specimen.

❖ Immunofluorescence antibody kits and PCR-based assays.

- characteristic intra-alveolar foamy (‫) رﻏوي‬, pink- staining exudate on H&E stains

organism is trapped in the foamy material and can be seen on silver stain as oval cup
Microscopically -
shaped structures
 Lung abscess

Clinical features:
Features:
●Prominent cough producing copious
● Tissue necrosis Features
amount of foul smelling and bad-tasting
● marked acute inflammation.
purulent sputum.
●Abscess is filled with necrotic
●Change in position evoke paroxysm of
suppurative debris
cough.
●Fever malaise and clubbing of fingers.
●Radiology shows fluid filled cavity.

Lung abscess
Localized suppurative necrotic
process within the pulmonary
parenchyma.
cavity containing bacteria, fibrin,and Abscess is filled with
neutrophils and lined usually with necrotic suppurative debris
Single fluid filled
cavity
inflammatory granulation tissue.

There are 3 organisms that love to make abscess (‫ﻣﻣﻛن أي اورﻗﺎﻧزﯾم ﻟﻛن ھذول‬
‫)اﻛﺛر ﻣن ﻏﯾرھم‬:
Pathogenesis:
Causative organisms:
A-staphylococcus ● Can follow aspiration.
B-streptococcus ● As a complication of
C-anaerobes bronchopneumonia.
D-gram-ev organisms (klebsiella pneumonia ●Septic emboli.
,very common in chronic alcoholics) ●Tumors.
Prognosis: ●Direct infection.
with antibiotic therapy 75% of abscess resolve

Complications
1-Bronchopleural fistula and pleural
involvement resulting in empyema in the
pleura which is a purulent inflammation
(purulent pleuritis ) .
2-Massive hemoptysis, spontaneous rupture
into uninvolved lung segments
3-Non-resolution of abscess cavity
4-Bacteremia could result in brain abscess and
meningitis

Rikabi’s lone notes

Click here
 Quiz
1- A 63-year-old man with small cell carcinoma of the left mainstem bronchus begins chemotherapy. During the
treatment period, he becomes febrile and develops a productive cough. The temperature is 38.7°C (103°F),
respirations are 32 per minute, and blood pressure is 125/85mmHg. A CBC shows leukocytosis (WBC = 18,500/μL).
The patient’s cough worsens, and he begins expectorating large amounts of foul- smelling sputum. A chest X-ray
shows a distinct cavity with an air/fluid level distal to the tumor area. Which of the following is the most likely
diagnosis?

a- Atelectasis b- Bronchiectasis c- Lobar pneumonia d- Pulmonary Abscess

2- Which one of the following will cause patchy infiltration of the alveolar spaces with neutrophils especially
around the Bronchioles ?

a- Tuberculosis Pneumonia b- Lobar Pneumonia c- BronchoPneumonia d- Mycoplasma Pneumonia

3- A 65 Years old diabetic man was presented to his doctor clinic by history of sudden fever , chills, and pleuritic
chest pain, also he has mucopurulent sputum he was diagnosed as having Community Acquired Pneumonia, what
pathogen most likely cause of this condition

a- Staph Aureus b-Pneumococci c- Mycoplasma d- RSV virus

4-A 64-year-old man presents with fever, chills, and increasing shortness of breath. The patient appears in acute
respiratory distress and complains of pleuritic chest pain. Physical examination shows crackles and decreased
breath sounds over both lung fields. The patient exhibits tachypnea, with flaring of the nares. The sputum is
rusty-yellow and displays numerous neutrophils and erythrocytes. Which of the following pathogens is the most
common cause of this patient’s pulmonary infection?

a- Legionella pneumophila b- Mycoplasma pneumoniae c- Pseudomonas aeruginosa d- Streptococcus pneumoniae

5-causative agent of lung abscess:A 36-year-old man with AIDS presents with fever, dry cough, and dyspnea. A
chest X-ray shows bilateral and diffuse infiltrates. Laboratory studies reveal a CD4+ cell count of less than 50/µL. A
lung biopsy discloses a chronic interstitial pneumonitis and an intra-alveolar foamy exudate.
A silver stain of a bronchoalveolar lavage is shown in the image. Which of the following organisms is the most
likely pathogen responsible for these pulmonary findings?

a- Invasive aspergillosis b- Cytomegalovirus C-Pneumocystis jiroveci d-none

6- after recovering from bronchopneumonia a 71 year old man returned to the hospital because of mild fever, chills,
and fuel purulent smelling. On X-Ray examination show A cavity filled with PUS in the lower right lobe what is the
most possible diagnosis of the patient.

a- Lung Abscess b- Hypersensitivity C- Lobar pneumonia d- pleuritis

Pneumonitis

1- D 2-C 3-B 4-D 5-C 6-A

Summary
from Pathoma :
‫‪special thanks to :‬‬
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‫ﻏﺎدة اﻟﻌﺒﺪي‬ ‫ﺻﺎﻟﺢ اﻟﻘﺮﻧﻲ‬
‫ﻓﺮح اﻟﺴﯿﺪ‬ ‫أﺣﻤﺪ اﻟﺨﯿﺎط‬
‫رﯾﻨﺎد اﻟﺤﻤﯿﺪي‬ ‫ﺑﺴﺎم اﻷﺳﻤﺮي‬
‫ﻓﺎطﻤﺔ آل ھﻼل‬ ‫أﺣﻤﺪ اﻟﺤﻮاﻣﺪة‬
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‫ﺳﺎره اﻟﻤﻘﺎطﻲ‬ ‫ﺻﺎﻟﺢ اﻟﻘﺮﻧﻲ‬
‫ھﯿﺎ اﻟﻌﻨﺰي‬ ‫ﯾﺰﯾﺪ اﻟﻘﺤﺎﻧﻲ‬
‫ﻟﻤﻰ اﻷﺣﻤﺪي‬ ‫أﺣﻤﺪ ﺧﻮاﺷﻜﻲ‬
‫ﻣﺮﯾﻢ اﻟﺮﺣﯿﻤﻲ‬ ‫ﻣﺤﻤﺪ اﻟﻮھﯿﺒﻲ‬
‫اﻟﺠﻮھﺮة اﻟﺒﻨﯿﺎن‬ ‫ﺑﻨﺪر اﻟﺤﺮﺑﻲ‬
‫ﻣﻨﻰ اﻟﻌﺒﺪﻟﻲ‬ ‫ﺣﻤﺪ اﻟﻤﻮﺳﻰ‬
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