Lung infections in smokers

By: Ayman Fatima

 Objectives
• Introduction to smoking and listing the various disease caused
• Pathological changes
• Lung diseases seen in smokers:
1.Pneumonia
2. Influenza
3. Tuberculosis
4. Covid 19
• Conclusion
• Things to remember
• Bibliography
 Introduction to smoking
• Approximately, 120 million smokers in world.
• India accounts for 12 % (Ac. to WHO)
• Around 1 million deaths occur due to tobacco
consumption.
• Some infectious diseases which are associated with
smoking are in the following slide:
• Pneumonia, pneumococcal and
meningococcal infections
• Tuberculosis
• Influenza
• HIV and its complications
• Periodontitis
• Reproductive tract infections
• surgical infections
• Corona virus and SARS
How does smoking predispose to infections

• Mechanisms are multifactorial and interactive

in their effects.
• Structural mechanisms
• peribronchiolar inflammation and fibrosis
• increased mucosal permeability
• impairment of the mucociliary clearance
• changes in pathogen adherence
• disruption of the respiratory epithelium
Immunological changes:
• elevated peripheral white blood cell count (30%)
• increase in band cell counts, higher levels of L-
selectin, and increased myeloperoxidase content.
• Decreased CD+4 and increased CD+8
• higher % of macrophages in BAL
• depressed migration and chemotaxis of PMN
• decreased IL-1, IL-6 and TNF alpha
• Decreased NK cell activity
• Antigen mediated signaling of T cells
• lower serum Ig (A,G,M) levels (10 -30%)
• IgG content 2 times higher
• resolve in 6 weeks after cessation.
• A chemically diverse mixture of pro-
inflammatory, oxidative and carcinogenic factors
found in tobacco smoke has a number of
different, sometimes contradictory effects.
• And lastly, the microbe biome was found to lose
its diversity with increase in duration of smoking
exposure, which in turn lead to increase in the
growth of pathobionts.
 Pneumonia and Smoking

• substantial risk factor for pneumococcal pneumonia,

especially in COPD patients
• nearly 2-fold risk of community-acquired pneumonia
• strongest independent risk factor for invasive
pneumococcal disease among immunocompetent adults.
• risk of pneumococcal disease declined to nonsmoker
levels 10 years after cessation
• In vitro adherence of Streptococcus pneumoniae to
buccal epithelial cells has been shown to be increased in
cigarette smokers. May persist for up to 3 years after
smoking cessation.
 Legionnaires disease
• Independent risk factor
• Seen  1% to 3% of CAP
• risk of legionnaires disease was increased
121% per cigarette pack consumed daily in
smokers
 Meningococcal disease
• Associated with meningococcal colonization of the
nasopharynx.
• 55% of active smokers were carriers compared with 36% of
nonsmokers and 76% of those exposed to secondhand tobacco
smoke.
• tobacco smoke is a risk factor for meningococcal
nasopharyngeal carriage,
• preceding viral infection, which is more frequent in smokers,
can act as a cofactor for meningococcal disease
• ineffective humoral immunity against the Neisseria
meningitidis polysaccharide capsule is a well-recognized risk
factor for invasive meningococcal disease.
 Severity in case of pneumonia with smoking
history
• The incidence of COPD and therapy with inhaled corticosteroids was higher,
whereas the incidence of neurological disease was lower in smokers than in
non smokers
• At admission smokers had more frequently pleuritic pain,. During
hospitalization smokers were more often treated with corticosteroids .
• Although the two CAP groups showed no differences in complications, a
greater percentage of smokers were admitted to the ICU under mechanical
ventilation and had a longer hospital stay (12 days vs. 10 as average).
• In subanalysis, ex- smokers were men mostly> 65, with diabetes and COPD,
but the course of the disease did not differ to smokers.
• In multivariate analysis the presence of COPD, male gender, treatment with
intravenous corticosteroids and the absence of neurological disease make
the profile of a smoker with CAP.
 Influenza
• Ex-smokers, second-hand smokers and non-smokers who
were inoculated with an attenuated influenza virus in the
nasal mucosa found not only suppression of the response
to the virus but also a higher viral load in people exposed to
smoking.
• It also found greater disease severity and persistence of
the effect of smoking in ex-smokers.
• Enhanced bacterial adherence (superinfection)
• decreased antibody production and rapid waning of the
antibodies
 Severity of influenza in smokers
• A history of smoking may increase the
risk of hospitalization in smokers and ex-
smokers.
• More severe, with more cough, acute
and chronic phlegm production,
breathlessness, and wheezing in smokers
 
• Influenza was more severe among
smokers, with a dose-related increase in
rate: 30% in nonsmokers, 43% in light
smokers, and 54% in heavy smokers
 Tuberculosis
• Smoking is a risk factor for tuberculin skin test
reactivity, skin test conversion, and the development
of active tuberculosis.
• Smokers of 20 years’ or greater duration had 2.6
times the risk of nonsmokers for tuberculosis.
• Duration of smoking was more important than the
number of cigarettes smoked daily.
• Decrease in immune response, mechanical disruption
of cilia function, defects in macrophage immune
responses, and/or CD4+ lymphopenia, increasing the
susceptibility to pulmonary tuberculosis.
 Severity of tuberculosis in smokers
• Smoking increases the risk of contracting
tuberculosis (TB), increases the risk of
recurrent TB and impairs the response to
treatment of the disease
 Covid 19 Pandemic
• Higher affinity was observed between
modified S protein of SARS-CoV-2 and ACE2,
almost 10 to 20 folds compared with S protein
of the previous SARS-CoV
• Action of macrophages and Cytokine storm
• Formation of Neutrophil Extracellular Traps
and neutrophil trafficking
• ARDS
• higher risk of mortality than the non-smokers.
 Severity in covid 19 infection in smokers

• 10.7% of nonsmokers, COVID-19 disease was severe,

while in active smokers, it was severe in 21.2%
• approximate 1.5-fold increased risk of ICU admission,
symptom, severity, and mortality in smokers
  CONCLUSION
• smokers incur a 2- to 4-fold increased risk of invasive
pneumococcal disease
• Influenza risk is severalfold higher and much more
severe in smokers compared with nonsmokers.
• smoking contributes substantially to the worldwide
disease burden of tuberculosis.
 IMPORTANT THINGS TO REMEMBER!!!

• Smoking cessation should be part of the therapeutic plan

for people with any serious infectious disease,
periodontitis, or positive results of tuberculin skin tests.
• Secondhand smoke exposure should be controlled in
children to reduce the risks of meningococcal disease and
otitis media and in adults to reduce the risks of influenza
and meningococcal disease.
• Pneumococcal and influenza vaccine in all smokers
• Acyclovir treatment for varicella in smokers
• Yearly Papanicolaou smears in women who smoke.
 Bibliography
• Tobacco Smoke Induces and Alters Immune
Responses in the Lung Triggering Inflammation,
Allergy, Asthma and Other Lung Diseases: A
Mechanistic Review Agnieszka Strzelak ID ,
Aleksandra Ratajczak, Aleksander Adamiec and
Wojciech Feleszko
• Cigarette Smoking and Infection Lidia Arcavi,
Neal L. Benowitz
• WIKIPEDIA AND GOOGLE