Atypical Pneumonia

Maricruz Pajares, MS III

 Introduction
• Atypical agents are classified as such
because they lack a cell wall and do not
respond to β-Lactam Antibiotics

• Classic Etiologic Species:

– Mycoplasma pneumoniae
– Legionella Species
– Chlamydia pneumoniae
 Mycoplasma pneumoniae
• Most common cause of Atypical Pneumonia
• Affects only humans
• Transmitted through respiratory droplets
• Increased incidence during the winter months
• Mostly affects young adults
• Outbreaks in
– Groups with close contact
• Families
• Military
• College students

• Pathogenesis:
– Respiratory mucosa is not invaded, instead the ciliary motion is
inhibited and necrosis of the epithelium occurs.
• Signs & Symptoms:
– Gradual symptoms
– Nonproductive cough
– Sore throat
– Earache
– Sputum:
• Small amounts of whitish, non-bloody sputum
– Along with:
• Fever
• Headache
• Malaise
• Myalgias

• Labs:
– Sputum is cultured…Grows really slow and requires at least 1 week to
form a visible colony
– Cold – agglutinin titer of 1:128 or higher is indicative of recent infection
– CXR:
• Infiltrates are visible
• Complications:
– M. pneumoniae infection causes auto-antibodies to be produced
which can attack:
• Red blood cells
• Brain
• Lungs
• Liver Cells
– Can cause:
• Bronchitis
• Arthalgias
• Guillian-Barre Syndrome

• Treatment:
– Disease resolves spontaneously in 10-14 days
– The following will only help to shorten the symptoms:
• Macrolide
– Erythromycin
– Azithromycin
• Tetracycline
– Doxycline
 Legionella
• Commonly found in :
– Immunocompromised patients
– Smokers
– Chronic Lung Disease
• Caused by:
– Legionella pneumophila
• Transmitted through:
– Contaminated water sources, i.e.
• Showerheads
• Faucets
• Air conditioning cooling towers
• Symptoms & Signs:
– High fevers
– A toxic patient
– Pleurisy
– Grossly purulent sputum
• Lab Findings:
– Hyponatremia
– Elevated Liver Enzymes
– Elevated Creatine Kinase
– CXR:
• Patchy infiltrate with occasional appearance of hilar
adenopathy and pleural effusions
– Culture:
• Charcoal-Yeast Extract Agar
• Dieterle Silver Staining
• Complications:
– GI symptoms i.e. abdominal pain, vomiting, and diarrhea
– Can affect other organ systems, and cause:
• Sinusitis
• Pancreatitis
• Mycarditis
• Pyelonephritis

• Treatment:
– Azithromycin: 500 mg Oral Daily
– Clarithromycin 500 mg oral BID
– Fluoroquinolones
– Levofloxacin 500 mg oral once daily
** Given for 10-14 days to general population
*** Immunocompromised patients a 21 day therapy is
recommended.
 Chlamydia pneumoniae
• Infection is common but often asymptomatic
• 80% of adults are seropositive for C.pneumoniae
• Common in:
– Teens
– Young adults
• Transmission:
– Human to human via respiratory route
– Outbreaks are more common in enclosed
populations:
• Military
• Household members
• Pathogenesis:
– Obligate intracellular organism
– Grows in macrophages, smooth muscle cells, and endothelial
cells
– Inhibits ciliary action = persistent cough
• Complications:
– Chronic cough and wheeze may linger
– Anti – C. pneumoniae IgE may be responsible for inducing:
• Asthma
• Labs:
– WBC: very high <15,000 cells/mm3
– CXR:
• non specific
• Unilateral subsegmental or segmental infiltrate
• Signs & Symptoms:
– Non specific
– Many times asymptomatic
• Treatment:
– Slow recovery (weeks to months)
– Erythromycin: 500mg oral 4x daily
– Doxycycline: 100mg oral 2x daily
– Azithromycin: standard 5 day course
– If symptoms don’t improve a 2nd antibiotic may
be tried
 Question:
20 year old college student comes into your office with
fever, headache, malaise, non -productive cough, sore
throat and a earache. He states he has been feeling this
way for the last 8 days. His CXR shows some infiltrates.
You recommend he gets plenty of rest and lots of fluids
and don’t prescribe any antibiotics. Why?

a. He is going to die soon.

b. It will resolve on its own.
c. His insurance won’t cover it.
d. It is a viral infection and it would be pointless.
 Resources
• Lee Kathryn A, Chan Edward D, "Chapter 37. Viral & Atypical
Pneumonia" (Chapter). Hanley ME, Welsh CH: CURRENT
Diagnosis & Treatment in Pulmonary Medicine:
http://www.accessmedicine.com/content.aspx?aID=578283.

• Levinson W, "Chapter 23. Mycoplasmas" (Chapter). Levinson W:

Review of Medical Microbiology and Immunology, 10e:
http://www.accessmedicine.com/content.aspx?aID=3328827.

• Moffa, Jr. Donald A, Emerman Charles L, "Chapter 63. Bronchitis,

Pneumonia, and Pleural Empyema" (Chapter). Tintinalli JE, Kelen
GD, Stapczynski JS, Ma OJ, Cline DM: Tintinalli's Emergency
Medicine: A Comprehensive Study Guide, 6e:
http://www.accessmedicine.com/content.aspx?aID=591464.