Pulmonary Infection: An Atlas of Investigation and Management

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An Atlas of Investigation and Management

PULMONARY INFECTION

An Atlas of Investigation and Management

PULMONARY INFECTION Adam T Hill Consultant Physician Royal Infirmary of Edinburgh Scotland William AH Wallace Consultant Pathologist Royal Infirmary of Edinburgh Scotland Xavier Emmanuel Consultant Microbiologist Royal Infirmary of Edinburgh Scotland

CLINICAL PUBLISHING OXFORD Distributed worldwide by CRC Press Boca Raton London New York Washington D.C.

Clinical Publishing An imprint of Atlas Medical Publishing Ltd Oxford Centre for Innovation Mill Street, Oxford OX2 0JX, UK Tel: +44 1865 811116 Fax: +44 1865 251550 Web: http://www.clinicalpublishing.co.uk/ This edition published in the Taylor & Francis e-Library, 2006. “ To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to http://www.ebookstore.tandf.co.uk/.” Distributed by: CRC Press LLC 2000 NW Corporate Blvd Boca Raton, FL 33431, USA E-mail: [email protected] CRC Press UK 23–25 Blades Court Deodar Road London SW15 2NU, UK E-mail: [email protected] © Atlas Medical Publishing Ltd 2005 First published 2005 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Clinical Publishing or Atlas Medical Publishing Ltd. Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention. A catalogue record for this book is available from the British Library. ISBN 0-203-02493-1 Master e-book ISBN

ISBN - (Adobe eReader Format) ISBN 1 904392 19 9 (Print Edition) The publisher makes no representation, express or implied, that the dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publisher do not accept any liability for any errors in the text or for the misuse or misapplication of material in this work.

Contents Acknowledgements

vi

Foreword

vii

Abbreviations

viii

1 Community-Acquired Pneumonia

1

2 Hospital-Acquired Pneumonia

41

3 Pneumonia in the Severely Immunocompromised Patient

49

4 Tuberculosis

73

5 Chronic Obstructive Pulmonary Disease

121

6 Bronchiectasis

130

7 Miscellaneous Respiratory Infections

149

Index

175

Acknowledgements To our wives, Lucy, Amanda and Jacintha, for their continuous support and understanding without which this atlas and many other things would never have been successfully completed.

Foreword Many of us have largely visual memories. This extensively illustrated book will make an immediate impact. For clinicians at any stage of training, that impact is likely to persist. Moreover the illustrations and their explanatory texts provide complementary reality behind the heavier paragraphs of standard textbooks. To more experienced clinicians, the book will be valuable as a reference, especially when they encounter less familiar clinical problems. Conversely, trainees in microbiology, radiology, and pathology will here find a rapid insight into the potential contributions fellow disciplines can make to a diagnosis. The brief texts on clinical and therapeutic aspects are written in clear straightforward English, again summarizing the essentials. The authors and publisher have done an excellent job. I wish the book all the success it deserves, Sir John Crofton Professor Emeritus University of Edinburgh Scotland

Abbreviations AFB

acid-fast bacilli

AIDS

acquired immune deficiency syndrome

CFT

complement fixation test

CMV

cytomegalovirus

COPD

chronic obstructive pulmonary disease

CT

computed tomography

EGG

electrocardiogram

ESAT

early secretory antigenic target

FEV1

forced expiratory volume in 1 second

FiO2

inspired oxygen concentration

G-CSF

granulocyte colony stimulating factor

IFNγ

interferon gamma

i.v.

intravenous

LDH

lactate dehydrogenase

MOTT

mycobacteria other than M. tuberculosis

MRSA

methicillin-resistant Staphylococcus aureus

NIV

noninvasive ventilation

PaO2

partial pressure of arterial oxygen

PAS

periodic acid Schiff

PCP

Pneumocystis carinii pneumonia

PCR

polymerase chain reaction

SaO2

oxygen saturation

TB

tuberculosis

TNF

tumour necrosis factor

VAP

ventilator-associated pneumonia

Chapter 1 Community-Acquired Pneumonia Introduction Internationally, community-acquired pneumonia is a common problem both for community and hospital physicians. It occurs with an annual incidence of about 5–11 per 1,000 adult population and rises with age, to about 34 per 1,000 population for patients aged over 75 years. The annual incidence of patients that require hospital admission varies from approximately 1–4 per 1,000 population. The mortality rates are low (50%. It is thus a common disease and can have considerable impact on health care resources. This section on community-acquired pneumonia, with illustrative radiology, microbiology, and pathology, discusses the investigation, diagnosis, and management of community-acquired pneumonia in adults. Key areas covered include the common causative organisms, patient presentation including severity assessment, a recommended investigation strategy, and treatment options. Finally, the complications of communityacquired pneumonia are illustrated with particular emphasis on the investigation, diagnosis, and management of lung abscess and pleural infection.

Aetiology In most cases of mild community-acquired pneumonia, a microbiological cause is not determined. When sputum samples are cultured by routine bacteriological methods, the commonest pathogen isolated is Streptococcus pneumoniae. Less commonly, Haemophilus influenzae or Moraxella catarrhalis may be cultured, particularly in patients with previous airways damage. Some important respiratory pathogens cannot be cultured by routine methods, but are usually detected by immunological or molecular methods. These, the so-called ‘atypical’ causes of pneumonia, include Mycoplasma pneumoniae, Legionella pneumophila, Chlamydia pneumoniae, Chlamydia psittaci, Coxiella burnetti, and respiratory viruses such as influenza viruses, adenoviruses, and respiratory syncytial virus. Most organisms associated with mild pneumonia can also cause severe communityacquired pneumonia. Particularly severe pneumonia with septic shock may result when viral infections, such as influenza, lead to secondary lung infections with virulent pathogens such as Streptococcus pneumoniae, Staphylococcus aureus, or Streptococcus pyogenes.

Pulmonary Infection

2

Presentation • Patients may have had preceding viral upper respiratory tract symptoms. • New onset of lower respiratory tract symptoms occurs (usually cough±sputum production [sometimes haemoptysis], breathlessness, fever, and sometimes pleurisy). • Systemic features are often present (general malaise, anorexia, sweating, fevers, shivers, or aches and pains). • Extrapulmonary symptoms can be present. • New onset confusion can arise in severe cases. • New focal chest signs occur. The clinical signs in practice can be highly variable (the classical teaching in lobar pneumonia is reduced expansion, coarse inspiratory crackles, reduced percussion, bronchial breathing, and increased vocal resonance in the affected lobe). • New chest radiographic consolidation is present. • There is no other explanation for illness. Overall, the likely aetiological agent cannot be accurately predicted from clinical features. Severity score To guide placement and treatment, it is helpful to stratify patients according to illness severity. Patients with severe pneumonia have two or more of the following: • New onset mental confusion. • Blood urea >7 mmol/l. • Respiratory rate ≥30/min. • Systolic blood pressure