PNUEMONIA

DEFINITION:
AN ACUTE LOWER RESPIRATORY TRACT ILLNESS
CHARACTERIZED BY FEVER, COUGH WITH FAST
RESPIRATION WITH OR WITHOUT DIFFICULT BREATHING.

AETIOLOGY =

IT DEPENDS UPON AGE, IMMUNE STATUS, PRESENCE

OF CHRONIC DISEASE
  1) Viral  5) Metazoal

 2) Bacterial  6) Aspiration

 3) Atypical organisms  7) Kerosene

 4) Fungi  8) Hypersensitivity
pneumonitis

Certain infectious agents are more common at particular age

but bacterial & viral are found in 44% to 85% of children
It is broadly classified as –

Community acquired = Pnumococci, streptococcia, staphylococci

Nosocomial = Klebsiella, pseudomonas, staphylococci

Anatomically classified as

= Lobar / Lobular

= Bronchopneumonia

= Interstitial
PATHOGENESIS

1) Inhalation

2) Aspiration

3) Hematogenous spread

4) Direct spread
5) FACTORS AFFECTING THE DEFENSE MECHANISM

HOST FACTORS
a) Altered conscious
b) Depressed cough & glottic reflexes
c) Impaired mucocilliary transport
d) Impaired alveolar macrophage function
e) Endobronchial obstruction
f) Leukocyte dysfunction

MICROBIAL HOST FACTORS

a) Microplasma pneumoniae - sheaf off cilia
b) Pneumacoccal capsule- inhibits phagocytosis
 PNEUMONIA

BRONCHO
LOBAR
PNEUMONIA

INTERSTITIAL
 PATHOLOGY

LOBAR PNEUMONIA

- Involves part of a lobe,

- whole lobe or 2 lobe
- Affection of lower lobes
A] STAGE OF CONGESTION
(initial phase – 1 to 2 days)
- Macroscopic- Lobe is enlarged
heavy & congested
- Microscopic –
-Dilation & congestion of
the capillaries in the alveolar
wall
-edema fluid in airspaces
- few neutrophills & red cells
- numerous bacteria
B) RED HEPATISATION ( Early
consolidation 2 to 4 days)
Lobe is red, firm, consolidated,
cut surface is airless, dry, granular,
liver like consistency

Microscopic-
- Appearance of strands of
fibrin,
- Marked cellular exudates
Neutrophils & red cells
- Neutrophils with ingested
bacteria
- Alveolar septi less prominent
C) GRAY HEPATISATION (
Late Consolidation 4 To 8
days)

Macroscopic –
-Lobe is firm, heavy
- Cut surface dry, granular
grey color from hilum to
periphery
- Fibrinous pleurisy

Microscopic
- Dense fibrin strands,
- few neutrophils, red cells
- macrophage begin to
appear
- less bacteria
D) RESOLUTION ( 1 to
3 weeks)
Macroscopic –
- Solid fibrinus constituent is
liquefied by enzymatic action
- Softening begin from centre to
periphery
- Cut surface grey red or dirty
brown, frothy yellow fluid on pressing

Microscopic –
- Macrophages as predominant
cells
- Granular & fragmented strands of
fibrin
- Engorged alveolar capillaries
- Neutrophills degenerate &
bacteria digested
BRONCHOPNEUMONIA
( LOBULAR PNEUMONIA )

-Infection of terminal bronchioles – patchy consolidation

Macroscopic –
- Patchy red & grey consolidation
- Bilateral involvement
- Lower zones of the lungs
Microscopic –
- Suppurative exudate consisting of neutrophills in
peribronchiolar alveoli
- Thickening of alveolar septa by congested capillaries
- Edema fluid in alveoli
HISTOLOGY OF BRONCHOPNEUMONIA
INTERSTITIAL

Macroscopic –
- Lungs are heavy congested, subcrepitant
- Cut surface exudates frothy or bloody fluid
- Patchy to widespread consolidation of one or both the lungs

Microscopic –
- Interstitial inflammatory reaction is the hallmark
a) Interstitial inflammation – congestion, edema of the alveolar
walls
b) Necrotizing bronchiolitis – foci of necrosis of bronchiolar
epithelium
c) Reactive changes – epithelial cells proliferates to form
multinucleate giant cells
d) Alveolar changes – edema fluid, fibrin scanty inflammatory
exudates in the alveolar lumina.
Bronchopneumonia Lobar Pneumonia
• When the process is restricted to • Involment of the large portion of
the alveoli contiguous to bronchi. a lobe or of an entire lobe
• Patchy consolidation of the lung is
dominate characteristic.
•Extension of preexisting bronchitis
or bronchiolitis.
• Common age: infancy & old age.
• Uncommon in infancy & in late
• Common agents: life.
Staphylococci.
Streptococci. • Common agents:
Pneumococci. 90-95% - Pneumococci –
Streptococcus pneumoniae.
BRONCHOPNEUMONIA LOBAR PNEUMONIA
Bronchopneumonia  Lobar Pneumonia.
PATHOLOGY:  PATHOLOGY:
Consolidated area of Acute
 Widespread of
Suppurative Inflammation.
FIBRINOSUPPURATIVE
• Patchy consolidation of lung CONSOLIDATION of large area &
through one lobe, more often even whole lobes.
multilobar & frequently bilateral &
Base b/c of tendency of secretion  4 stages of inflammatory response.
to gravite into lower lobes.
1. Congestion
• Well developed lesion – 3-4 cm in
2. Red Hepatization.
dia; slightly elevated, dry, granular,
3. Gray Hepatization
gray – red to yellow & poorly
4. Resolution.
delimited at the margin.
• Neutrophil rich exudates
 Viral
 Common in infants &children
 Age 2-3 yrs
 Preceded by several days of RS
symptom rhinitis & cough
 Low Temp.
 Invest
WBC- N or mild inc
< 20000/cmm
Predominantly –Lymphocytes
ESR, CRP – N or mild incr
CxR- Hyperinflation with bilateral
interstitial infiltration
Prognosis- Good, No Sequale
Bacterial
Common in older children
History of mild URTI, skin lesion
or abrupt onset of high fever,
cough & RS distress
High Temp.
WBC- Increases
15000 to 40000
Predominantly – Polymorphs
ESR, CRP – Increased
CxR - Consolidation
Prognosis- Bad,
Complication- Empyema,
Bronchiectasis
 Pnumococcal Staphylococcal Streptococcal H
influenza
Age Older children Infant 3 to 5 yrs 3 mths to
3 yrs

Organi S.Pnumonia S.Aureus Gr.A H

sm streptococci influenza
Pathol -Lobar Bronchoalveolar Interstitial Bronchial
ogy Consolidatn destruction – Infiltrate, destruction
Congestion unilateral, multiple Necrosis- , interstitial
-Grey & Red abscesses, infiltrate
Pneumatoceles Tracheo -
Hepatisation bronchial
-Resolution Mucosa
C.F Abrupt onset, Insidious
Rapid progress onset
 VIRAL PNEUMONIA

Viruses – RSV, Influenza,

Para influenza

Pathology –

1) Interstitial inflammation
congestion edema of
alveolar walls
2) Foci of necrosis of
bronchial epithelium
3) Proliferation of epithelium
to multinucleate giant cell
4) Edema fluid fibrin, scanty
inflammatory exudates
Primary Atypical Pneumonia

Mycoplasma Pneumoniae – school children > 4 yrs

Pathology –

‘Absence of alveolar exudates’

1) Interstitial infiltration – Edematous alveolar septae

2) Necrosis & Ulceration of bronchiole

X ray – Hazy or fluffy exudates, Enlargement of hilar lymph

nodes, pleural effusion.
Nosocomial Or Hospital acquired Pneumonia

Pneumonia occurring at least 48 hrs after hospital admission &

not incubating at the time of admission

Etiology – Staph aurus, E coli, Klibsiella

Incidence – 5 to 10 cases per 1000 hospital discharges appox

3,00,000 cases annually

VAP ( Ventilator acquired Pneumonia )

Occurs after 48 hrs after of ventilation

Aspiration pneumonia
 Infant
 Symptoms of mild URTI
with fretfulness, stuffy nose,
reduced appetite precede the
onset
 Abrupt onset of fever
 Restlessness, apprehension
 RS distress
 Air Hunger, Cyanosis
 Flaring of alae nasi
 Retraction of chest muscle
 Tachycardia, Tachypneoa
 Children
 Shaking chill with fever
 Drowsiness, Restlessness,
Anxiety
 Dry Hacking cough
 Occasionally Delirium
 Circumoral cyanosis
 Pain on affected side
 Infant Children

 O/E- Lethargic, on arousal  O/E- child tilting on

irritable toxic affected side with the knee
 RS Distress, Moaning, SCR drawn up
 Dullness in later stage,  RS distress
Diminished breath sounds, fine
crepts affected side, Breath
sound tubular
COMPLICATIONS –

A) Pleural effusion

B) Empyema

C) Lung Abscess

D) Bronchiectasis

E) Metastatic infection – Purulent pericarditis

Bacterial endocarditis
Purulent arthritis
otitis media
 DIAGNOSIS:

1. CXR:
i) Presence & Location of pulmonary infiltrate.
ii) Assess extent of the pulmonary infection.
iii) Detect pleural involvement, pulmonary cavitations or hilar
lymphadenopathy.
iv) Gauge response to Rx.
2. Sputum examination.
3. CBC & ESR.
CASE OF BRONCHOPNEUMONIA IN AN INFANT
 Background:
 40 days old male baby was referred to me by a senior faculty member on
19/03/2010.
 DAMA(discharge against medical advice) from a private hospital as the
paediatrician had suspected a congenital heart disease in the baby while
he was under treatment for bronchopneumonia.
 Received antibiotics but was not improving. When the baby was seen in
the casualty, the baby was crying continuously, had a noisy respiration
and was coughing intermittently. There was a pansystolic murmur on
examination.
 2D echocardiography - no abnormality in the heart and the murmur
could be a mild ejection systolic murmur.
 The Baby was admitted in our hospital and treated.
Chief complaints:
 Cough since 5 days.

 Fever since 5 days.

 Breathlessness since 3 days.

 Excessive crying since 2days.

 History of C/C:
 Baby was alright 6 days back and suddenly had onset of
cough and fever on 15/03/10 for which treatment was
taken from a local GP. But the complaints were not better
so the child was taken to a paediatrician where it was
admitted, investigated and treated for bronchopneumonia.
 Observations:
 Cough was in long bouts, with occasional scanty
expectoration. The respiration was very rapid(RR-
80/min,HR-180/min).there was no fever on admission.
But there was excessive crying3(a loud shrieking cry)
which was not better by any means. The child was
breastfeeding very vigourously and used to vomit after
sometime(but this was there since birth).
 The clinical diagnosis was clear. Now the picture
pointed out to Ant.tart. But the main concern now
was the excessive crying. In
repertory(complete,kents,synthesis) under the
rubric- quieted, cannot be- Cina is 3marks.So Cina
200 was prescribed in evening on 19/03/10.Within
2 hours baby had quietened down and hence Cina
was continued 4 hourly.Mother commented that
baby had slept peacefully after 2-3 days.
 The baby was kept under observation without
cina for a day and few other features were noted:
vomiting sometime after breastfeed,sweating
over scalp, sleeping with eyes partially
open,thermally towards chilly. Based on this
Lycopodium 30 was given and observed for a
day.The remaining symptoms of cough,vomiting
were better.baby was discharged on 25/03/10.
 Learnings from the case
 The importance of timely investigations in cases of
suspicion of concurrent congenital diseases which
might have a bearing on the current illness.
 The relevance of observations in infants’ casetaking
and its weightage in the totality.
 Role of proper use of knowledges of understanding
susceptibility, repertory and materia medica references.
 The importance of following up an acute remedy with
a deep acting constitutional remedy to cover the
remaining symptoms and establish a cure.
BORLAND’S PNEUMONIA

1) Indication of drugs used in different stages of pneumonia

a) Incipient stage – Aconite, Belladonna, Ferrum Phos
b) Frankly developed – Bryonia, Phos, Chelidinium
c) Complicated – Baptisia, Hepar, Lachesis
d) Late – Kali carb, Lyco & Sulphur

Author's remark

‘ In Homoeopathic prescribing our endeavour is to find a drug

which will cover not only actual pathological picture but also
the reaction of individual patient to that disease’

SUSCEPTIBIITY