Respiratory System Infections - Schaechter's Mechanisms of Microbial Disease, 6e - Medical Education - Health Library

Respiratory System Infections | Schaechter's Mechanisms of Microbial Disease, 6e | Medical Education | Health Library 8/29/23, 7:47 AM
Medical Education
Schaechter's Mechanisms of Microbial Disease, 6e !
CHAPTER 61: Respiratory System Infections

Emily A. Abdoler
INTRODUCTION
The respiratory tract is the most common site for infection by pathogenic
microorganisms. Because respiratory infections are so common and typically
mild, their impact is often underestimated; however, they represent an
immense disease burden on our society, a fact that the COVID-19 pandemic has
brought into sharper focus. Upper respiratory infections (URIs) account for
more visits to physicians than any other diagnosis. It has been estimated in the
United States that pharyngitis alone accounts for 1.5% of all clinic visits
annually in the United States. Furthermore, some respiratory infections can
have severe consequences, especially in immunocompromised patients or
those with comorbid illnesses. Pneumonia, the most severe form of respiratory
infection, is the eighth leading cause of death in the United States and the
most common cause of death from infectious diseases. The COVID-19 pandemic
has only added to the morbidity and mortality of respiratory viruses
worldwide. The frequency with which the respiratory tract becomes infected is
not surprising, as it represents the greatest epithelial surface in continuous
contact with the external environment of any human organ. Nevertheless, most
microorganisms do not cause infection unless other factors interfere with host
defenses.
Paola Medina
https://meded.lwwhealthlibrary.com/content.aspx?sectionid=252084200&bookid=3159 Page 1 of 42
Paola Medina
The clinical syndromes and common pathogens associated with infection at
various locations within the respiratory tract are shown in Figure 61-1.
Infections of the middle ear and the paranasal sinuses are included because
these areas are contiguous with the respiratory tract and are lined by
respiratory epithelium. Several important diseases of the respiratory system
are also discussed in other chapters (see Chapters 13, 19, 23, 27, 29, 32, 33, 34,
and 67). The clinical manifestations of respiratory tract infections depend on
the causative pathogen and the site of infection. Viruses can invade the upper
respiratory tract and account for most cases of pharyngitis. Bacteria are
commonly implicated in otitis media, sinusitis, pharyngitis, epiglottitis,
bronchitis, and pneumonia, although there is growing recognition of the role
that viruses play in these syndromes as well. Fungi and protozoa rarely cause
serious respiratory tract infections in healthy individuals but are important
causes of pneumonia in patients with immunocompromising conditions (see
Chapter 69). It is important to remember that many of the common respiratory
pathogens can cause infections at various sites along the respiratory tract. The
COVID-19 pandemic also serves as a reminder that respiratory viruses can have
multisystem effects outside of the respiratory system.
FIGURE 61-1
Clinical syndromes associated with infection at different locations
within the respiratory tract.
ENTRY AND SPREAD
Pathogens can enter the respiratory tract by one of five routes: (1) direct
inhalation, (2) aspiration of upper airway contents, (3) spread along the
mucous membrane surface, (4) hematogenous spread, and, rarely, (5) direct
penetration. Of these, inhalation and aspiration are the most common.
Hematogenous spread and direct penetration are rare but important sources of
infection of the lung parenchyma.
DEFENSE MECHANISMS
The defense of the respiratory tract begins in the nose, where specialized hairs,
known as vibrissae, filter large particles suspended in inhaled air (Fig. 61-2).
Large particles (>10 μm in diameter) tend to settle at points where abrupt
changes in the direction of airflow occur, such as the posterior nasopharynx.
Smaller particles (<3 μm in diameter) are likely to elude those barriers and
reach the terminal bronchioles and alveoli. The structure of the larynx and the
cough reflex provide protection against gross aspiration of upper airway and
gastric contents, preventing transmission of associated bacteria to the lower
respiratory tract.
FIGURE 61-2
Defense mechanisms of the respiratory tract.

Aerodynamic
factors include the presence of vibrissae in the nasal passage and
abrupt changes in the direction of flow of the air column. The epiglottis and
cough reflex prevent introduction of particulate matter into the lower airway.
The ciliated respiratory epithelium propels the overlying mucus layer (red)
upward toward the mouth. In the alveoli, macrophages, humoral factors
(including immunoglobulins and complement), and neutrophils (when
inflammation is present) assist in preventing or clearing infection.
The respiratory epithelium itself has specialized defenses against infection.

Epithelial cells from the nose to the terminal bronchioles are covered with cilia
that beat coordinately. Overlying these cilia is a covering of mucus containing
antimicrobial compounds such as lysozyme, lactoferrin, and secretory IgA
antibodies. The mucus traps foreign particles, including pathogens. The cilia
move the overlying mucus layer upward toward the larynx; together, they are
called the mucociliary escalator. Many patients with impaired ciliary function
have frequent respiratory infections that ultimately lead to bronchiectasis
(permanent abnormal dilation of the small airways). Evidence suggests that in
patients with cystic fibrosis, abnormal sodium and chloride transport in the
respiratory epithelial cells decreases the volume of the mucus layer and
impairs ciliary function. Impaired clearance of mucus predisposes these
patients to chronic infection and inflammation, making them particularly
susceptible to infections with Staphylococcus aureus and Pseudomonas
species.
The final lung defenses are found in the alveoli. The alveoli contain IgA
antibodies, complement components, and, most importantly, alveolar
macrophages. These phagocytic cells function as active scavengers, ingesting
and killing invading pathogens. When they cannot contain infection by
themselves, they are helped by other phagocytic cells that do not normally
reside in the lungs, especially neutrophils. Macrophages and neutrophils are
especially important in fighting bacterial infections. In viral infections,
histopathological studies of the lungs (or other affected tissues) show
infiltration by large numbers of lymphocytes and plasma cells, suggesting that
viral infection stimulates recruitment of lymphoid cells rather than
neutrophils. Lymphocytes contribute to host defense by producing antibodies
and attacking infected cells through cytotoxic T lymphocytes, natural killer (NK)
cells, and antibody-dependent cell-mediated cytotoxicity (ADCC).

CASE
Group A Streptococcal Pharyngitis

F., a 5-year-old boy who had been in good general health, was brought to the pediatrician
because of fever and sore throat that began 2 days earlier. On examination, F. had a
temperature of 38.3 °C. His oropharynx was erythematous. His tonsils were enlarged and
coated with patchy white exudates. His anterior cervical lymph nodes were also enlarged
and tender. The remainder of the examination was unremarkable. A rapid antigen detection
test (RADT) was positive for group A streptococcus. F. was treated with intramuscular
penicillin, and his symptoms resolved over the next week.
This case raises two questions:
1. What organisms commonly cause pharyngitis?
2. Why is it important to distinguish streptococcal pharyngitis from other forms of the
disease?
See Appendix for answers.
INFECTIONS OF THE NOSE AND THROAT
Group A streptococcal pharyngitis is most frequently seen in school-aged

children during the winter and is the most common bacterial cause of
pharyngitis. However, respiratory viruses as a group are the most common
cause overall. Fever, tonsillar exudates, and tender cervical adenopathy
increase the likelihood of group A streptococcal infection, whereas
conjunctivitis, cough, and coryza decrease the likelihood. That said, no clinical
features are diagnostic for a specific pathogen, and it can be difficult to
differentiate between viral and bacterial pharyngitis on the basis of clinical
findings. Unless viral symptoms are predominant, a rapid antigen detection
test (RADT; see Fig. 57-6) should be performed to detect group A streptococci,
which can be associated with several complications, including peritonsillar and
retropharyngeal abscesses, otitis media, sinusitis, pneumonia, acute
glomerulonephritis, and rheumatic fever (Table 61-1). In children, a negative
RADT should prompt a culture given the high prevalence of group A
streptococcal disease and the risks of complications from this pathogen, as
RADTs are not as sensitive as culture. In adults, confirmation of a negative RADT
with culture is not typically necessary, especially as the rate of complications
from group A streptococcal pharyngitis in adults is low.
TABLE 61-1
"
Pathogens Producing Disease at Various Levels of the
Respiratory Tract
Location Common Pathogens
Rhinovirus, coronaviruses, other respiratory viruses,

Nasopharynx
Staphylococcus aureus
Group A streptococcus (Streptococcus pyogenes),

Oropharynx Corynebacterium diphtheriae, Epstein-Barr virus,
adenovirus, enterovirus
Middle ear Streptococcus pneumoniae, Haemophilus influenzae,

and paranasal Moraxella catarrhalis, group A streptococcus
sinuses (Streptococcus pyogenes)
Haemophilus influenzae, Streptococcus pneumoniae,

Epiglottitis
Staphylococcus aureus
Larynx-
Parainfluenza viruses, S aureus
trachea
S pneumoniae, H influenzae, Mycoplasma pneumoniae,

Bronchi
influenza viruses, other respiratory viruses, measles virus
Bronchioles Respiratory syncytial virus (RSV)
Lungs See Table 61-3
Various respiratory viruses frequently cause pharyngitis, including

rhinoviruses, adenoviruses, coronaviruses, influenza viruses, and parainfluenza
viruses (Table 61-2). The presence of conjunctivitis suggests infection by
adenovirus, while coxsackieviruses—especially the group A coxsackieviruses—
sometimes produce small vesicles on the mucous membranes of the throat, a
clinical picture known as herpangina. In the adolescent and young adult age
group, Epstein-Barr virus is a common cause of pharyngitis, one of the
manifestations of infectious mononucleosis. It is also important to consider
acute HIV in patients with risk factors.
TABLE 61-2
"
Common Causes of Pharyngitis
Agent Relative Importance
Streptococcus pyogenes (group A β-hemolytic) ++++
Rhinovirus ++
Adenovirus ++
Coronavirus ++
Epstein-Barr virus ++
Herpes simplex virus +
Parainfluenza virus +
Influenza virus +
Coxsackie virus +
Chlamydia pneumonia +
Mixed anaerobic bacteria +
Neisseria gonorrhoeae +
Corynebacterium diphtheriae +
Corynebacterium hemolyticum +
Mycoplasma pneumoniae +
Unknown ++++
Often in patients with pharyngitis, a pathogen is not identified. Non–group A β-

hemolytic streptococci account for a small proportion of cases, as do
gonococci in sexually active individuals. Another organism, Arcanobacterium
haemolyticum, has been found to cause some cases of pharyngitis in older
children and young adults. Fusobacterium necrophorum, which can cause
suppurative thrombophlebitis of the jugular vein—otherwise known as
Lemierre syndrome—is an increasingly recognized cause in patients who are
teenage or older. Mycoplasma pneumoniae, although more commonly an agent
of bronchitis and pneumonia, can cause pharyngitis as well. All of these agents
can be easily overlooked or difficult to detect in a routine throat culture. The
key is to determine whether a bacteria or virus is more likely, as the former
often requires antimicrobial therapy while the latter does not.
Infections of the nasopharynx are generally caused by viruses and give rise to
the signs and symptoms known collectively as the common cold.
Approximately 30%-50% of colds are caused by the rhinovirus group (see
Chapter 34). Coronaviruses are the next most common group of agents,
accounting for ~7%-18% of colds before the emergence of SARS-CoV-2, which in
mild cases can manifest in this way. The agents of the remaining percentage of
colds are various respiratory viruses, including parainfluenza viruses,
respiratory syncytial virus (RSV), influenza viruses, adenoviruses, and
metapneumoviruses (see Chapters 32, 33, and 34). Although the patient with a
cold may experience a “scratchy” throat, nasal symptoms are usually more
prominent, including cough caused by postnasal drip. Bacterial infection of the
nose occurs occasionally but is not common.

CASE
Acute Epiglottitis
P., a 3-year-old girl who had not received any childhood vaccines, was put to bed by her
parents with a low-grade temperature. In the middle of the night, she awoke crying, and her
parents found that her fever was higher and that she was having trouble breathing. The
family pediatrician told the parents to take P. immediately to the local hospital. On
examination in the emergency department, P. had a temperature of 38.9 °C. She appeared
anxious and was sitting upright, drooling. Nasal flaring was noted. A presumptive diagnosis
of epiglottitis was made, and P. was taken to the operating room, where an endotracheal
tube was inserted. A radiograph of the lateral neck that was taken on the way to the
operating room revealed swelling of the epiglottis (Fig. 61-3). When her throat was examined
as she was being intubated, her epiglottis was noted to be quite erythematous (red) and
edematous (swollen). She was treated with ceftriaxone. The next day, the laboratory
reported that blood and epiglottis cultures grew H influenzae sensitive to ampicillin, so her
antibiotics were narrowed accordingly. She responded promptly to treatment and recovered
completely.

FIGURE 61-3
Radiograph of the neck taken in a lateral projection reveals
marked swelling of the epiglottis (arrow).
This case raises a two-part question:
1. Why is H influenzae type b currently a relatively rare cause of epiglottitis?
2. Why was P. at risk?

CASE
Laryngotracheitis
H., a 19-month-old boy, developed a runny nose, hoarseness, cough, and a low-grade
temperature. His pediatrician diagnosed a viral URI and prescribed no specific treatment.
That night, H. had a barking cough. His breathing was forced and noisy, especially with
inspiration. Alarmed, the parents called the pediatrician, who told them that the child
probably had a viral infection called croup. He advised them to take H. into the bathroom
and to fill the room with steam by running the hot water in the shower.
He also advised them to call back 15 minutes later if the respiratory difficulty worsened. In
fact, it subsided, and H. fell back to sleep. A similar but milder episode occurred the next
night. Over the next few days, all the symptoms gradually resolved.
This case raises one question:
1. Why did the pediatrician suspect a viral pathogen?
INFECTIONS OF THE EPIGLOTTIS
Acute epiglottitis, also called supraglottitis, is probably the most serious form
of URI. This distinct clinical syndrome can lead to rapid swelling of the
epiglottis and surrounding structures and can be rapidly fatal if the airway is
compromised due to this swelling. Acute epiglottitis occurs most often in
children under the age of 5. In the past, the most common cause was
Haemophilus influenzae type b but since immunization of infants against this
entity has become universal, this feared clinical entity has become less
common. Now, typical etiologies include Streptococcus pneumoniae, beta-
hemolytic Streptococcus, and S aureus, especially in adults. Despite the current
rarity of this condition, the practitioner must remain vigilant because early
recognition of acute epiglottitis can make the difference between life and
death. Why H influenzae type b displays a marked tropism for the epiglottis is
not well understood.
If a child presents with the characteristic manifestations of epiglottitis as

described in the case of P., ensuring maintenance of the airway should be the
physician's first priority. Early in the course of diagnosis, radiographs of the
lateral neck may show an enlarged epiglottis protruding from the anterior wall
of the hypopharynx (see Fig. 61-3). In adults, nasopharyngolaryngoscopy can
aid the diagnosis. If airway compromise is suspected, the first and most
important intervention is securing the airway with endotracheal intubation.
Epiglottitis usually responds readily to treatment with antibiotics, and the
outcome is generally good if appropriate support has been implemented.
INFECTIONS OF THE LARYNX AND TRACHEA
Laryngotracheitis in small children, commonly referred to as “croup,” is

characterized by the sudden onset of a barking cough and difficult respiration,
which may also resolve suddenly. Mucous membrane edema is more likely to
result in narrowing of the tracheal lumen in children due to their smaller
airways and the presence of nonexpandable rings of cartilage present in the
tracheal wall. This narrowing is more significant during inspiration and results
in inspiratory stridor. Almost all cases are caused by viruses, especially the
parainfluenza viruses. Infection with parainfluenza virus types 1 through 3 is
common in young children, and repeated infections can occur. Typically, mild
upper respiratory symptoms such as nasal discharge and dry cough are present
days before the signs of airway obstruction become evident. In most cases, the
illness is self-limited and resolves after 5-7 days. No specific drug treatment for
parainfluenza virus infection currently exists. Management of croup consists of
providing oxygen and supporting the airway as needed. Although there is no
direct antiviral therapy, corticosteroids and inhaled aerosolized epinephrine
can be used to reduce airway tissue inflammation and edema. In rare cases,
bacteria, particularly S aureus, can cause clinical findings similar to those of
viral croup.
In adults, the major clinical manifestation of infection of the larynx is

hoarseness. As in children, most acute laryngeal infections in adults are self-
limited conditions caused by respiratory viruses. Moraxella catarrhalis and H
influenzae have also been reported to cause acute laryngitis in adults.
Although antibiotic therapy can sometimes shorten the duration of illness, the
hoarseness generally resolves over the course of a week, regardless of therapy.

CASE
Acute Tracheobronchitis
Dr. V., a 28-year-old physician, developed symptoms of cough, myalgias (aches and pains in
the muscles), headache made worse by coughing, substernal chest pain, and high fever. She
suspected influenza because an outbreak was in progress and she had recently cared for
several patients with similar symptoms. During the next 3 days, she was bedridden because
of weakness and a persistent temperature of 38.9 °C. The symptoms gradually resolved over
the next few days without specific treatment. After 10 days, Dr. V. was able to resume her
usual activities. A nasopharyngeal RT-PCR test taken on the first day of illness confirmed the
diagnosis of influenza A.
1. Do most cases of tracheobronchitis resolve on their own, or are antibiotics usually
required?
INFECTIONS OF THE LARGE BRONCHI

Acute tracheobronchitis is one of the most common causes of office visits to
family practitioners. Infection is the major cause, but inhalation of irritants can
also lead to this clinical syndrome. Viruses that have been implicated include
rhinoviruses, coronaviruses, RSV, influenza viruses, and adenoviruses. Bacterial
infections that can cause bronchitis include M pneumoniae, Chlamydophila
pneumoniae, and Bordetella pertussis. B pertussis causes whooping cough,
which is a highly contagious disease characterized by paroxysmal, productive
cough occurring primarily in infants and young children (see Chapter 19). In the
United States, whooping cough occurs infrequently because of vaccination,
although its incidence is increasing, with a disproportionately high number of
cases occurring in adolescents and adults in whom vaccine-induced immunity
has waned over time.
In general, acute tracheobronchitis tends to run a short, self-limited course

requiring only symptomatic treatment. The role of antibiotics in patients with
no underlying lung disease has been controversial because most cases result
from viral infections. Studies have shown little to no benefit from antibiotics,
yet antibiotic prescriptions for acute bronchitis account for a significant
percentage of all prescriptions written in adult practice. Patient education is an
important first step in decreasing the use of unnecessary antibiotics.
A critical distinction should be made between bronchitis in otherwise healthy

patients and those with underlying structural lung disease. Patients with
chronic obstructive pulmonary disease (COPD) (a disease usually related to
smoking) may have excessive sputum production, also known as chronic
bronchitis. Acute infection in these patients can lead to acute exacerbation of
chronic bronchitis (AECB), and viral infection has been recognized as a common
cause of exacerbations. AECB is a clinical diagnosis based on the patient's
history of increased cough and sputum production, increased sputum
purulence, and increased shortness of breath. The presence of at least two if
not all three of these symptoms increases the likelihood of a bacterial
infection as the etiology, particularly in the presence of sputum purulence. The
role of bacterial infection as the causative agent of AECB has been
controversial; however, when viewed collectively, studies show a modest but
significant improvement in clinical recovery for patients treated with
antibiotics. Thus, treatment for AECB usually includes supportive care and
antibiotics effective against H influenzae, M catarrhalis, and S pneumoniae. In
selected patients, coverage of Gram-negative enteric pathogens may be
important.
INFECTIONS OF THE BRONCHIOLES
Bronchiolitis is a common clinical syndrome in the first 2 years of life and is

usually associated with respiratory syncytial virus. This topic is covered in
depth in Chapter 32.
INFECTIONS OF THE LUNGS

Pneumonia, infection of the lung parenchyma, represents a variety of diseases
that share a common anatomic location. Many diverse pathogens can cause
pneumonia, and clinical manifestations can vary greatly. Although pneumonias
can be categorized in various ways, this chapter uses clinical and
epidemiological classification (Table 61-3). Because its perspective is from that
of the clinician, this classification can form the basis for managing the patient's
illness even if a specific microbiologic cause has not been proven.
TABLE 61-3
"
Classification of Pneumonia Syndromes
Pneumonia Method of
Organisms
Syndrome Transmission
Streptococcus pneumoniae,
Mycoplasma pneumoniae,
Haemophilus influenzae,
Chlamydia pneumoniae,
Person-to- Staphylococcus aureus, Klebsiella
person pneumonias, and other enteric
transmission Gram-negative rods, Moraxella
catarrhalis, Streptococcus
pyogenes, influenza viruses,
other respiratory viruses
(including SARS-CoV-2)
Animal or
environmental See Table 61-4
exposure
Acute, community
RSV, influenza, other respiratory
acquired
viruses, S pneumoniae, H
viruses, S pneumoniae, H
Pneumonia in influenzae, Mycoplasma, group B
infants and streptococci, cytomegalovirus,
young Ureaplasma urealyticum (?),
children Pneumocystis jiroveci (?), S
pneumoniae, Mycoplasma, S.
aureus, Chlamydia trachomatis
S aureus, Enterobacteriaceae
species, K pneumonia,
Escherichia coli, Serratia
Hospital
marcescens, H influenzae, S
acquired
pneumoniae, Pseudomonas
(nosocomial)
aeruginosa, Acinetobacter
species, influenza A, Legionella
species, Aspergillus
Pulmonary Mycobacterium tuberculosis and

tuberculosis nontuberculous mycobacteria
Histoplasma capsulatum,
Fungal Blastomyces dermatitidis,
pneumonia Coccidioides immitis,
Subacute or chronic
Cryptococcus neoformans
Aspiration Mixed bacterial organisms.

pneumonia Anaerobes are less common than
and lung previously thought in the
abscesses absence of empyema or abscess
Increased risk of the pathogens

that cause pneumonia in
Pneumonia in immunocompetent patients; P
immunocompromised jiroveci, cytomegalovirus, atypical
patients mycobacteria, Nocardia,
Aspergillus, Phycomycetes,
Candida, Mucor
The first important distinction that the classification makes is between acute
pneumonia and subacute or chronic pneumonia. Acute pneumonia is
characterized by fairly sudden onset with progression of symptoms over a very
few days, whereas subacute or chronic pneumonia occurs in those cases in
which infection is present for weeks or months before presentation. Among the
acute pneumonias, a second important distinction is made between
community- and hospital-acquired (nosocomial) pneumonias. Hospital-
acquired pneumonias (HAPs) are classified separately because the responsible
pathogens are usually different from those that produce pneumonia in
nonhospitalized individuals.
Most of the common forms of acute community-acquired pneumonia (CAP) are

caused by pathogens transmitted from person to person. Transmission is
typically airborne over short distances or by contaminated secretions or
fomites. On encountering some pathogens—S pneumoniae, H influenzae, and S
aureus, for example—most individuals become colonized, but only a few
develop disease directly or after a variable period of colonization. Another
group of pneumonia pathogens, encountered less frequently, have animal or
environmental reservoirs. These pathogens are often not easily detected with
routine testing. In many cases of pneumonia caused by these agents, diagnosis
is difficult unless the physician seeks out the circumstances of exposure (eg,
exposure to a parrot leading to psittacosis). CAPs in infants and young children
are usually grouped separately as they have a distinctive etiological spectrum.
Several forms of subacute and chronic pneumonias can be distinguished.

These forms include tuberculosis, fungal pneumonia, and anaerobic lung
abscesses. Although this classification is based on the common clinical
patterns of disease, exceptions do occur. For example, patients with
tuberculosis, histoplasmosis, coccidioidomycosis, or lung abscesses sometimes
experience acute disease. Physicians must also be aware that
immunocompromised patients are at risk for a more severe and fulminant
presentation of both acute and subacute pneumonias. Additionally, they may
be susceptible to opportunistic pathogens that usually do not cause disease in
immunocompetent individuals.
Acute Pneumonias
Community-Acquired Pneumonia
Community-acquired pneumonia (CAP) results in about 1 million

hospitalizations per year in the United States, with about 50,000 deaths. In
elderly and chronically ill patients, CAP can be associated with prolonged
hospitalizations and high mortality. Presenting symptoms frequently include
fever and cough. Sometimes patients complain of chest pain, frequently
pleuritic (exacerbated by respiratory motion). Patients with extensive
involvement of the lungs may experience shortness of breath and exhibit rapid
respiration and cyanosis (bluish tinge to the skin indicative of hypoxemia) on
physical examination. Auscultation may reveal crackles (also called rales) and
peripherally auscultated bronchial breath sounds, which are usually indicative
of alveolar disease. Tactile fremitus and dullness to percussion over sites of
consolidation may also be present.

CASE
Community-Acquired Pneumonia
Thirty-six-year-old Ms. T., who has a history of smoking 20 packs of cigarettes a year,
presented to the emergency department of her local hospital after 3 days of fevers to 39.2
°C, chills, cough, and pain on her left side, which was worse with breathing. On examination,
her respiratory rate was elevated at 22 breaths per minute and her pulse oximetry was
normal at 96%. Auscultation of her lungs revealed rales in her left lower lung field. A chest
radiograph showed an infiltrate in her left lower lobe consistent with pneumonia. Her blood
work revealed an elevated white blood cell count of 16,000 per mm3. Ms. T. was diagnosed
with a CAP, prescribed a course of antibiotics, and discharged. Over the next several days,
her fevers resolved, and within 2 weeks, her symptoms had disappeared. A chest radiograph
performed at her physician's office 3 months later was normal.
1. How did the physician differentiate bronchitis from pneumonia?
2. What organisms should a physician be concerned about when treating CAP?

CASE
COVID-19
Mr. S, a 67-year-old with insulin-dependent diabetes mellitus, coronary artery disease,
hypertension, and hyperlipidemia, presented to the emergency department with
progressive shortness of breath and severe cough for the past 2 days, as well as headache,
fatigue, and myalgias that had been present for 4 days prior to the respiratory symptoms.
On interview, he indicated that he had gone to a neighborhood barbecue about a week
before his symptoms started, and that one of the other attendees had tested positive for
SARS-CoV-2 the next day. On examination, he was afebrile but tachycardic to 125, with an
elevated respiratory rate at 25 and a pulse oximetry on room air at 87% that corrected with
4 liters of oxygen via nasal cannula. He appeared in mild respiratory distress, and
auscultation revealed diffuse crackles. A chest radiograph showed faint bilateral patchy
opacities, while a CT chest demonstrated bilateral peripheral, round, ground glass opacities
(see Fig. 61-4). Laboratory studies showed a normal white blood cell count but a decreased
number of lymphocytes, as well as mild thrombocytopenia and mildly increased liver
function tests. A nasopharyngeal RT-PCR swab returned positive for SARS-CoV-2. He was
admitted to the hospital with COVID-19 pneumonia, where he developed intermittent fevers
and remained on oxygen for the next week before finally being discharged home with a
cough that resolved very slowly.

FIGURE 61-4
One section of a chest CT scan from a similar patient with early
COVID pneumonia showing nodular “ground glass” opacities in
multiple areas of both lungs.

In the full CT study, similar rounded densities were also seen in other areas not visualized

here but predominantly localized in the lung periphery (pleural based), particularly in the
posterior lungs. This CT appearance is typical but not diagnostic of COVID-19; other viral
pneumonias (eg, influenza) or organizing pneumonia associated with pulmonary drug
reactions or connective tissue diseases may look similar.
Reprinted from Bernheim A, Mei X, Huang M, et al. Chest CT findings in coronavirus disease-

19 (COVID-19): relationship to duration of infection. Radiology. 2020;295(3):685-691. Copyright
© 2020 Radiological Society of North America. (Figure 1a and 1b)
1. What extrapulmonary manifestations of COVID-19 should physicians watch for?
See Appendix for answer.
Both bacteria and viruses cause CAPs, as outlined in Tables 61-3 and 61-4,
although in approximately one-half of patients, an organism is never
identified. Traditionally, organisms have been divided into two groups, typical
and atypical, based on the belief that the clinical and radiographic features of
presentation suggest certain etiologic agents. A typical presentation is
characterized by high fever, shaking chills, chest pain, and lobar consolidation
on chest x-ray. An atypical presentation is characterized by less severe illness,
dry cough, headache, and other systemic complaints. Although studies have
shown that it is very difficult to predict an etiologic agent based on
presentation, the classification of organisms as typical and atypical persists. S
pneumoniae is the most common cause of CAP, and along with H influenzae, S
aureus, and other Gram-negative bacteria, these agents are classified as typical
organisms. M pneumoniae, C pneumoniae, and Legionella pneumophila are
among the atypical organisms.
TABLE 61-4
"
Community-Acquired Pneumonias (CAPs) Transmitted by
Animals or Environmentally
Disease Causative Organism Source
Psittacosis Chlamydia psittaci Infected birds
Q fever Coxiella burnetii Infected animals
Histoplasma
Histoplasmosis Infected soil, bats
capsulatum
Coccidioidomycosis Coccidioides immitis Soil
Cryptococcus
Cryptococcosis Soil, pigeons
neoformans
Infected animals, insect

Plague Yersinia pestis
vectors
Pseudomonas
Melioidosis Soil
pseudomallei
Tularemia Francisella tularensis Infected animals, ticks
Legionnaires Legionella
Contaminated water
disease pneumophila
Although considerable overlap exists in the clinical manifestations of

pneumonia, certain pathogens tend to be associated with characteristic
presentations or to affect certain patient populations. For instance, M
pneumoniae and C pneumoniae are seen with higher frequency in patients with
less severe presentations of pneumonia. Pneumococcal pneumonia can occur
at any age, but it has a predilection for the very young and the elderly,
particularly those with COPD. It usually has an acute onset and a rapid course.
Patients with a history of COPD also have an increased risk for infection with H
influenzae and M catarrhalis. Compared to the general population, patients
with alcohol use disorder are more susceptible to S pneumoniae, Klebsiella
pneumonia, S aureus, and anaerobic pathogens (by aspiration). Nursing home
residents, immunocompromised patients, and people with underlying
structural lung disease are at higher risk for pneumonia due to Pseudomonas
aeruginosa, Gram-negative enteric bacteria (derived from the gut), and S
aureus.
Several pneumonias result from agents found in animals or in the environment

(see Table 61-4). Infection by these agents is usually associated with a unique
exposure. For example, Chlamydia psittaci, a common cause of disease in birds,
can lead to psittacosis (parrot fever) in humans and may be acquired by
inhalation (see Chapter 27). This illness is difficult to diagnose unless the
physician obtains the history of contact with birds. Another example is Q fever,
caused by the rickettsia Coxiella burnetii and usually acquired from sheep,
goats, or cattle. The organism is stable in the environment, and infection can
occur after exposure to contaminated material from infected animals. As with
psittacosis, diagnosis of Q fever is difficult unless the physician elicits the
history of exposure to animals or their environment. Another agent of CAP, L
pneumophila, is associated with contaminated environmental water sources
that produce aerosols, such as showers, fountains, sprayers, air conditioners,
and water-cooling towers.
Viruses such as influenza, rhinovirus, RSV, coronavirus, parainfluenza,

metapneumovirus, and adenoviruses can also cause pneumonia. The clinical
course is usually milder, with spontaneous recovery. However, some viral
pneumonias can lead to severe respiratory illness in certain cases. Severe
acute respiratory syndrome virus and influenza, as well as SARS-CoV-2 (see
Chapter 34), have been associated with acute respiratory distress syndrome.
Additionally, bacterial and viral coinfection can occur, causing a more severe
clinical picture. Bacterial infection can also classically follow viral infection,
especially influenza, leading to a delayed worsening. RSV can cause severe lung
disease in young children, especially premature infants, sometimes with long-
term sequelae such as wheezing and asthma. In children under 2 years of age,
the agents of acute pneumonias are more often viruses than bacteria. While
viral pneumonia was previously thought to be infrequent in adults, recent
research suggests that viruses are common CAP etiologic agents. In many
cases, a specific pathogen is never identified.
SARS-CoV-2, the etiologic agent causing COVID-19, is a recently emerged

pathogen that can cause respiratory illness with a wide range of severity. Some
individuals remain asymptomatic through the entire course of infection. Others
develop symptoms ranging from a mild flulike illness to a severe, life-
threatening viral pneumonia. In the most severe cases, SARS-CoV-2 can cause
multiorgan system failure and death. While our understanding of this pathogen
is still evolving, it is clear that this virus can manifest outside of the respiratory
tract in other tissues that express the ACE2 receptor (see Chapter 34). Frequent
extrapulmonary manifestations include myocardial infarction, venous
thromboembolism and coagulopathy, hematologic disturbances (ie,
lymphopenia and thrombocytopenia), gastrointestinal symptoms like vomiting
and diarrhea, mild liver injury, myalgias and myopathy, nervous system effects
from headaches to encephalitis and stroke, kidney injury, and multiple rashes
and cutaneous findings. The symptom of anosmia or hyposmia is thought to be
particularly specific to COVID-19. In children, the disease is often milder,
although severe cases do occur.
Chest radiographs may be normal or show mild interstitial changes, especially

early in a patient's course, with peripheral ground glass opacities being
characteristic on chest CT. Appropriate treatment of COVID-19 is still under
investigation. While SARS-CoV-2 initially emerged from a zoonotic source,
specifically bats (see Table 72-4), transmission is now overwhelmingly person-
to-person and may occur even with asymptomatic infection.
Diagnosis of CAP is generally based on appropriate clinical history and chest

radiographs. The most important diagnostic finding is a chest radiograph that
reveals a shadow, or infiltrate. Although CT scan is considered more sensitive, it
is not considered necessary in most cases. While certain radiographic patterns,
such as consolidations and interstitial infiltrates, previously were thought to
suggest particular pathogens, this has not been borne out in practice. However,
organisms that tend to cavitate include S aureus, aerobic Gram-negative
bacteria, and Mycobacterium tuberculosis. Skilled interpretation is important
because other processes, tumors, pulmonary edema, or pulmonary
hemorrhage can produce radiographic changes very similar to those of
pneumonia.
The decision to admit a patient to the hospital for CAP treatment rather than to
administer outpatient therapy can be a difficult one, but factors such as
severity of illness and medical comorbidities are used as general guidelines.
Several prediction rules have been proposed to identify patients at increased
risk of a complicated course. These are generally based on identifying host
factors associated with more virulent organisms or an impaired response to
infection.
In most cases, the choice of antibiotic therapy is empiric based on the patient's
risk factors for certain organisms and the severity of illness. A patient with
relatively mild illness managed outside the hospital usually does not undergo
sputum Gram stain and culture tests, whereas these tests are often performed
for patients admitted to hospitals. However, in at least half of cases of
pneumonia, a microbiologic cause is not identified. Opinion-based
recommendations by multispecialty experts have been published to provide
guidance for empiric antimicrobial therapy based on clinical scenarios and
host factors. Increasing antimicrobial resistance among respiratory pathogens,
especially S pneumoniae, has altered initial antimicrobial therapy
recommendations. Beyond local resistance rates, risk factors for drug-resistant
S pneumoniae (DRSP) include recent respiratory infection; recent antimicrobial
use; advanced age; medical comorbidities, including being
immunocompromised; and frequenting a high-risk setting (eg, a residential
institution, a day-care center). Patients at risk for DRSP should be treated with
antibiotics with expanded activity against S pneumoniae.
Hospital-Acquired Pneumonia
Hospital-acquired pneumonia (HAP) is defined as a new parenchymal lung

infection appearing 48 or more hours after admission to the hospital. It is the
most common hospital-acquired infection, with a high mortality rate. Similar to
CAP, symptoms suggesting a diagnosis of HAP include fever, cough, purulent
sputum production, shortness of breath, and pleuritic chest pain. Physical
examination may reveal fever, tachycardia (elevated heart rate), and tachypnea
(elevated respiratory rate). Signs of consolidation on physical examination
include crackles, bronchial breath sounds, tactile fremitus, and dullness to
percussion.
Microaspiration of bacteria from the oropharynx is considered the most

common route of infection. Factors influencing the risk of pneumonia are the
types of bacteria colonizing the pharynx and prior exposure to antibiotics. The
oropharynx of hospitalized patients can become colonized with Gram-negative
bacteria within several days of admission. Furthermore, illness and
medications can disrupt the gastric pH, leading to colonization of the stomach
with bacteria. Aspiration of bacteria-contaminated gastric contents can
increase oropharyngeal colonization and heighten the risk of HAP. Patients with
advanced age; poor nutrition; history of smoking, alcohol use disorder, or
intravenous drug use; or other underlying chronic illnesses are also at
increased risk for developing nosocomial pneumonia.
One important type of HAP is ventilator-associated pneumonia (VAP), which is

defined as pneumonia developing more than 48 hours after intubation. In
patients requiring mechanical ventilation, the endotracheal tube can provide a
conduit from the outside environment to the lower airway by circumventing
the defenses of the upper airway and allowing direct passage of oropharyngeal
secretions, gastric contents, and associated bacteria down the course of the
tube itself into the lower respiratory tract.
The bacteria that most commonly cause HAP are enteric Gram-negative rods
and S aureus. Common Gram-negative rods include members of the
Enterobacteriaceae family, K pneumonia, Proteus species, and Escherichia coli.
Other organisms reported include H influenzae, Serratia marcescens, and S
pneumoniae. In patients who have more severe infections, who have been
exposed to broad-spectrum antimicrobial agents, or have had more prolonged
hospitalizations, P aeruginosa and Acinetobacter species are more common.
Rare etiologic agents include influenza A, RSV, Legionella species, and
Aspergillus species.
Diagnosis of HAP in clinical practice can be difficult. Fever, elevated white

blood cell count, and purulent sputum are suggestive but not definitive. Chest
radiograph showing a new infiltrate is sensitive but not specific because other
conditions (eg, congestive heart failure and pulmonary embolus) can cause
similar radiographic abnormalities. Sputum Gram stain and culture are
frequently obtained, but, unfortunately, the microscopic examination of
sputum has limitations. Some patients cannot produce sputum, or they
produce sputum contaminated by oropharyngeal microbiota. The presence of
squamous epithelial cells in large numbers indicates contamination by
oropharyngeal contents, and a culture of such a specimen can yield misleading
information. Finding a predominant organism in the Gram stain may point
toward the etiological agent; however, if an organism is cultured, it can be
difficult to differentiate a colonizing organism from one causing active disease.
Bronchoscopic sampling of the lower airways by bronchoalveolar lavage may

be more helpful in establishing an etiologic agent but is an invasive procedure
generally reserved for immunocompromised patients, individuals with severe
disease, and those with illness not resolving with standard therapy.
As with CAP, the choices in initial antibiotic therapy for HAP are generally
empiric, based on severity of illness and patient risk factors. Antibiotic therapy
is based on the likelihood of infection with multidrug-resistant (MDR)
pathogens. Risk factors for infection with MDR pathogens include antimicrobial
therapy in the preceding 90 days, current hospitalization of 5 days or more,
high frequency of MDR organisms in the community or hospital unit,
immunosuppressive disease and/or therapy, and the presence of risk factors
for health care–associated pneumonia such as chronic dialysis, home infusion
therapy, or a family member with an MDR pathogen. If risk factors for infection
by MDR pathogens are present, broad-spectrum agents are generally used; if
not, more limited-spectrum therapy is generally recommended. With
appropriate therapy, many patients display improvement 48-72 hours after
treatment is initiated. However, many patients with severe infections may
develop complications and require mechanical ventilation, sometimes for
prolonged periods. Patients with pleural effusion associated with pneumonia
(parapneumonic effusion) should have the fluid evaluated for evidence of
infection of the pleural space. Pus in the pleural space is called an empyema
and requires surgical drainage. This can occur in CAP as well as HAP.

CASE
Hospital-Acquired Pneumonia
At 52 years of age, Mr. L., who had a history of alcohol use disorder, was admitted to the
hospital for an emergent appendectomy. The procedure went well, but on postoperative day
3, he was noted to have a fever of 38.5 °C, an elevated heart rate of 115 beats per minute,
pulse oximetry of 89%, a cough productive of green sputum, and increased shortness of
breath. Examination revealed an ill-appearing patient in moderate respiratory distress. In
his left lung base, he had bronchial breath sounds on auscultation. Chest radiograph
revealed a large left-sided infiltrate (Fig. 61-5). The patient was started on supplemental
oxygen therapy by nasal cannula. Gram stain and sputum culture were performed. Broad-
spectrum antibiotic therapy was begun. The sputum culture eventually showed heavy
growth of K pneumoniae, one of the Enterobacteriaceae. Mr. L.'s 3-week hospital course was
stormy, and he required mechanical ventilation for 4 days. He was discharged to a chronic
care hospital and eventually recovered.
FIGURE 61-5
Pneumonia caused by Klebsiella pneumoniae.

Chest radiograph shows extensive consolidation of the left lower lobe. Cavity formation is

apparent within the involved area (arrow).
1. How do most patients in the hospital contract pneumonia?
2. Which patients are at increased risk for developing HAP?
Subacute Pneumonias
A common cause of subacute pneumonia is the lung abscess, often a

consequence of gross aspiration of oropharyngeal or gastric contents. The
typical lung abscess represents a polymicrobial infection with multiple species
of bacteria that are normal flora of the mouth. Lung abscesses can also result
from infection with other organisms that destroy lung tissue, including S
aureus, K pneumoniae, mycobacteria, and others. The resulting infection has a
number of distinguishing features. The clinical course tends to be less acute
than that of most other forms of bacterial pneumonia. Patients may be ill for
several weeks or even months before seeking medical attention. Definitive
diagnosis is usually made on the basis of a chest radiograph. Prolonged
antibiotic therapy is generally required. If not treated promptly, lung abscess
can spread to involve the pleural space, resulting in empyema.
Other causes of infectious subacute pulmonary diseases are fungi and

mycobacteria. Fungi that affect the lungs include Histoplasma capsulatum,
Blastomyces dermatitidis, Coccidioides immitis, Paracoccidiodes species, and
Cryptococcus neoformans (see Chapters 46 and 47). H capsulatum and B
dermatitidis are dimorphic fungi found in the soil and are endemic to the
midwestern and south-central United States, although B dermatitidis extends
farther north. C immitis is found in the deserts of the southwestern United
States, while Paracoccidiodes species are found in Central and South America.
C neoformans can be seen in areas frequented by pigeons. The latter is
frequently but not exclusively found in individuals who are
immunocompromised. Other causes of subacute pneumonias include
infections with M tuberculosis (see Chapter 23), nontuberculous mycobacteria
such as M avium intracellulare, actinomycosis, and nocardiosis.
Pneumonia in the Immunocompromised Patient
Pneumonia is a common occurrence in immunocompromised individuals,

including individuals who undergo cancer chemotherapy, have HIV, are taking
immunosuppressive medications, or have congenital immunodeficiencies (see
Chapter 69). In addition to being at higher risk for contracting the same kinds
of infections to which individuals with fully functioning immune systems are
susceptible, immunocompromised patients can become infected with
opportunistic pathogens that rarely cause infections in individuals without
immune compromise. Examples include Pneumocystis jiroveci (previously
Pneumocystis carinii), which is typically seen in patients with HIV whose CD4
lymphocyte count is <200 cells/mm3, the fungus Aspergillus fumigatus, and
cytomegalovirus, which can be seen in patients receiving immunosuppressive
therapy after organ transplantation. The etiologic agent in patients who
develop pneumonia in the setting of an immunosuppressed status depends, in
part, on the basis of the defect in the host immune system. Some of these
infections can be diagnosed only by carrying out invasive procedures such as
bronchoscopy or lung biopsy.

CASE
Lung abscess
Mr. A., who is 46 years old with a poorly controlled seizure disorder, was brought to a
physician after 2 weeks of coughing, fever, and weight loss. Physical examination revealed
an ill-appearing man with a temperature of 38.3 °C and foul-smelling breath. He had
amphoric breath sounds (resembling those produced by blowing across the mouth of a
bottle), suggestive of a lung cavity. A chest radiograph showed a large cavity in the left
midlung with extensive surrounding inflammation (Fig. 61-6). Mr. A. was admitted to the
hospital and treated with high-dose intravenous penicillin. He began to feel better almost
immediately, his fever disappeared over the course of a week, and he was then discharged.
He was then treated for 3 months with oral penicillin before his infection was deemed fully
resolved.

FIGURE 61-6
Lung abscess.
Chest radiograph showing a cavitary lesion (arrow) with surrounding infiltrate.

1. Which organisms can cause cavitary lung lesions?

CASE
Pneumonia in a Compromised Host

Mrs. S., who is 53 years old and has HIV but is not on antiviral therapy, presented to her
internist with a 1-month history of low-grade fevers, cough, and fatigue. On examination,
her temperature was 37.7 °C without respiratory distress. Her pulse oximetry was 94% on
room air but dropped with exertion to 88%. Auscultation and percussion of the chest were
normal. Chest radiograph revealed a diffuse, bilateral interstitial infiltrate. Sputum was
induced by inhalation of nebulized hypertonic saline. PCR of the sputum confirmed the
diagnosis of P jiroveci. Mrs. S. underwent a 3-week course of trimethoprim and
sulfamethoxazole, and antiviral drugs were started. Repeat chest radiograph 2 months later
showed no infiltrate, and Mrs. S.'s energy level returned to normal.
1. Which patients are at increased risk for developing P jiroveci pneumonia?
CONCLUSION
The respiratory tract is in continuous exposure with the external environment
and is therefore at high risk for infection. However, most microorganisms do
not cause infection unless other factors impair host defenses. Respiratory tract
infections can become very serious if they affect the patency of a patient's
airway or the ability of the lungs to exchange oxygen and carbon dioxide.
Familiarity with the spectrum of pathogens that affect each part of the
respiratory tree and knowledge of pathogenic predilections for certain patient
populations can help physicians make rapid, rational decisions regarding
treatment of infections of the respiratory system. Awareness of the natural
course of infections and their potential complications will help the physician
identify patients needing immediate attention and treatment.
Suggested Readings
Alcaide ML, Bisno AL. Pharyngitis and epiglottitis. Infect Dis Clin North Am. 2007;21(2):449-469.
doi:10.1016/j.idc.2007.03.001
Bisno AL. Acute pharyngitis: etiology and diagnosis. Pediatrics. 1996;97:949-954.
Burk M, El-Kersh K, Saad M, Wiemken T, Ramirez J, Cavallazzi R. Viral infection in community-acquired

pneumonia: a systematic review and meta-analysis. Eur Respir Rev. 2016;25(140):178-188.
doi:10.1183/16000617.0076-2015
Chakinala MM, Trulock EP. Pneumonia in the solid organ transplant patient. Clin Chest Med. 2005;26:113-
121. doi:10.1016/j.ccm.2004.10.010
Denny FW, Clyde WA Jr. Acute lower respiratory infections in non-hospitalized children. J Pediatr.
1986;108:635. doi:10.1016/s0022-3476(86)81034-4
Dick EC, Jennings LC, Mink KA, et al. Aerosol transmission of rhinovirus colds. J Infect Dis. 1987;156:442-448.
doi:10.1093/infdis/156.3.442
Harris AM, Hicks LA, QAseem A, et al. Appropriate antibiotic use for acute respiratory tract infection in
adults: advice for high-value care from the American College of Physicians and the Centers for Disease
Control and Prevention. Ann Intern Med. 2016;164(66):425-434. doi:10.7326/M15-1840
Huxley EJ, Viroslav J, Gray WR, et al. Pharyngeal aspiration in normal adults and patients with depressed
consciousness. Am J Med. 1978;64:564-568. doi:10.1016/0002-9343(78)90574-0
Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-
associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and
the American Thoracic Society. Clin Infect Dis. 2016;63(5):e61-e111. doi:10.1093/cid/ciw353
Marrie TJ, Poulin-Costello M, Beecroft MD, et al. Etiology of community-acquired pneumonia treated in an
ambulatory setting. Respir Med. 2005;99:60-65. doi:10.1016/j.rmed.2004.05.010
Marston BJ, Plouffe JF, File TM Jr, et al. Incidence of community acquired pneumonia requiring
hospitalization. Arch Intern Med. 1997;157:1709-1718.
Marti C, Gavin N, Grosgurin O. Prediction of severe community-acquired pneumonia: a systematic review

and meta-analysis. Crit Care. 2012;16(4):R141.
Mason CM, Nelson S. Pulmonary host defenses and factors predisposing to lung infection. Clin Chest Med.
2005;26:11-17. doi:10.1016/j.ccm.2004.10.018
Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired
pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious
Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e62. doi:10.1164/rccm.201908-
1581ST
Shulman ST, Bisno AL, Clegg HW. Clinical practice guideline for the diagnosis and management of group A
streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis.
2012:55(10):e86-e102. doi:10.1093/cid/cis629
Wedzicha JA, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory
Society/American Thoracic Society Guideline. Eur Respir J. 2017;49:1600791. doi:10.1183/13993003.00791-2016

Respiratory System Infections - Schaechter's Mechanisms of Microbial Disease, 6e - Medical Education - Health Library

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Respiratory System Infections - Schaechter's Mechanisms of Microbial Disease, 6e - Medical Education - Health Library

Uploaded by

Copyright:

Available Formats

Respiratory System Infections | Schaechter's Mechanisms of Microbial Disease, 6e | Medical Education | Health Library 8/29/23, 7:47 AM

CHAPTER 61: Respiratory System Infections

Clinical syndromes associated with infection at different locations

within the respiratory tract.

ENTRY AND SPREAD

Defense mechanisms of the respiratory tract.

The respiratory epithelium itself has specialized defenses against infection.

Group A Streptococcal Pharyngitis

This case raises two questions:

1. What organisms commonly cause pharyngitis?

See Appendix for answers.

INFECTIONS OF THE NOSE AND THROAT

Group A streptococcal pharyngitis is most frequently seen in school-aged

Location Common Pathogens

Rhinovirus, coronaviruses, other respiratory viruses,

Group A streptococcus (Streptococcus pyogenes),

Middle ear Streptococcus pneumoniae, Haemophilus influenzae,

Haemophilus influenzae, Streptococcus pneumoniae,

S pneumoniae, H influenzae, Mycoplasma pneumoniae,

Bronchioles Respiratory syncytial virus (RSV)

Lungs See Table 61-3

Various respiratory viruses frequently cause pharyngitis, including

Agent Relative Importance

Streptococcus pyogenes (group A β-hemolytic) ++++

Herpes simplex virus +

Mixed anaerobic bacteria +

Often in patients with pharyngitis, a pathogen is not identified. Non–group A β-

Radiograph of the neck taken in a lateral projection reveals

marked swelling of the epiglottis (arrow).

This case raises a two-part question:

1. Why is H influenzae type b currently a relatively rare cause of epiglottitis?

2. Why was P. at risk?

See Appendix for answers.

This case raises one question:

1. Why did the pediatrician suspect a viral pathogen?

See Appendix for answers.

INFECTIONS OF THE EPIGLOTTIS

If a child presents with the characteristic manifestations of epiglottitis as

INFECTIONS OF THE LARYNX AND TRACHEA

Laryngotracheitis in small children, commonly referred to as “croup,” is

In adults, the major clinical manifestation of infection of the larynx is

This case raises one question:

See Appendix for answers.

INFECTIONS OF THE LARGE BRONCHI

In general, acute tracheobronchitis tends to run a short, self-limited course

A critical distinction should be made between bronchitis in otherwise healthy

INFECTIONS OF THE BRONCHIOLES

Bronchiolitis is a common clinical syndrome in the first 2 years of life and is

INFECTIONS OF THE LUNGS

Pulmonary Mycobacterium tuberculosis and

Aspiration Mixed bacterial organisms.

Increased risk of the pathogens

Most of the common forms of acute community-acquired pneumonia (CAP) are

Several forms of subacute and chronic pneumonias can be distinguished.

Community-acquired pneumonia (CAP) results in about 1 million

This case raises two questions:

1. How did the physician differentiate bronchitis from pneumonia?

See Appendix for answers.

One section of a chest CT scan from a similar patient with early

COVID pneumonia showing nodular “ground glass” opacities in

multiple areas of both lungs.

This case raises one question:

1. What extrapulmonary manifestations of COVID-19 should physicians watch for?