ATYPICAL PNEUMONIA

Rachelle P. Mendoza MD

ATYPICAL PNEUMONIA  Once the Mycoplasma pneumoniae attaches to

the respiratory epithelium, it undergoes
COMMUNITY ACQUIRED PNEUMONIA
membrane fusion since the cell membrane of the
Pneumonia: infection that involves the alveolar sacs
M. pneumoniae closely mimics the cells
Typical Pneumonia Atypical Pneumonia
membrane of human cells.
Caused by: Caused by:  CARDS toxin (type 2)
Streptococcus pneumoniae Mycoplasma pneumoniae
 Cardiopulmonary Acute Respiratory Distress
Klebsiella pneumoniae Chlamydophila spp.
Toxin
Haemophilus influenzae Legionella pneumophila  Biofilm
Moraxella catarrhalis  Against antibiotic and immune response
Easier to gram stain Hard to gram stain  H2O2 and superoxide
Respond to Beta-lactams Does not respond to Beta-  Contributes to the destruction of host cells
antibiotics lactam antibiotics  Type 1 vs. Type 2 Mycoplasma pneumoniae***
Elevated WBC count Normal WBC count  Type 2 Strain: produces CARDS toxin and
provides a thicker biofilm
MYCOPLASMA PNEUMONIAE  TLR2
 Important for binding and activation of inflammatory
 Smallest free-living microorganism mediators
 Lacks cell wall***  It mediates the production of antibodies directed
 Spherical to filamentous against the bacteria
 Belongs to Class Mollicutes (only the Mycoplasma and  However, because Mycoplasma pneumoniae cell
Ureaplasma can cause significant human infections) membrane antigens that mimics the cell membrane
 Clinically significant Mycoplasma: antigen of humans, it leads to the production of
 Mycoplasma pneumoniae autoantibodies against human cells
 Mycoplasma hominis  Autoantibodies – brain (galactocerebroside), lung,
 Mycoplasma genitalium smooth muscles, lymphocytes, and RBC (I antigen)
 Clinically significant Ureaplasma:
 Ureaplasma urealyticum
 “Fried-egg” colonies
 Branched mycelioid structures
 Membrane has sterol, requires cholesterol (mimicking
human cell membrane) ***
 Low guanine/cytosine***

Note the “fried-egg” colonies

Mycoplasma pneumoniae exists and multiply via binary

fission as cocci but sometimes fuses together to form an
inactively dividing branched mycelioid structure
Mycoplasma pneumoniae will attach to the respiratory
Pathogenesis*** epithelium via the P1 adhesin and produce free radicals. High
 Virulence Factors: amounts of hydrogen peroxide inhibit superoxide dismutase.
 P1 adhesins High amounts of superoxide inhibit catalase. High
 Adherence and gliding motility when it attaches concentrations of free radicals will lead to the destruction of
to the ciliated columnar cells the host cell.
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Host Defense o Differentiates it from usual bacterial
 Antibody – IgM, IgG, IgA meningitis which leads to decreased glucose
 Complement concentrations
 Risk Factors: o But it closely mimics viral meningitis that
 Low IgG levels has a normal concentration of glucose.
 Smoking Increased lymphocytes and proteins
 Chest X-ray: reticulonodular pattern and/or patchy
Clinical Presentation areas of consolidation
 Pulmonary infection:  Usually affects one lobe
 Tracheobronchitis  Culture: Eaton’s agar (100% specificity) ***
 Pharyngitis  Serology
 Pneumonia – untreated severe cases of pharyngitis  PCR
or tracheobronchitis
 Symptoms: Treatment***
 Remittent fever (low grade) – the temperature  Tetracycline: doxycycline – DOC for adults
either goes up or down but never normal  Fluoroquinolones
 Cough, +/- wheezing  Macrolides – 90% resistance; DOC for children less than 8
 Headache years of age
 Malaise  Does not respond to penicillin***
 Rare: skin rash, Raynaud’s phenomenon – signifies
the production of autoantibodies which causes Prevention
agglutination of red blood cells leading to blockage  No vaccine
of end arteries; bluish black discoloration of the  No chemoprophylaxis
extremities  Cough etiquette***
 Long convalescence (4-6 weeks)  Personal protective equipment
 Complications:
 Hemolytic anemia – formation of RBC autoantibodies
CHLAMYDOPHILA SPP.
against I antigens
 Polyradiculitis – inflammation of the spinal cord and  Obligate intracellular parasite
spinal nerves  Non-motile, coccoid
 Encephalitis  Lack metabolic and biosynthetic pathways – does not
 Aseptic Meningitis produce their own ATP, relies on the host cell for energy
 Pericarditis  No peptidoglycan in cell wall***
 Myocarditis
 2 forms: ***
 Pancreatitis
Elementary Body Reticulate Body
 Hepatitis
Infectious form Intracellular form
 Skin rash
Contains rigid cell wall Has the capacity to replicate
 Otitis Media
Can exist in the environment inside the host cells
 Glomerulonephritis
Cannot replicate
 Polyarthritis
Smaller, cannot be seen Larger, can be seen in the
Epidemiology under the microscope host cells as intracytoplasmic
inclusions
 Most common cause of bacterial atypical pneumonia**
 Most common cause of atypical pneumonia is viral
 US: 2M per cases per year
 1-10 out of every 50 CAP
 Transmission: airborne droplets***
 Incubation: 2-3 weeks***
 Infection rates highest:
 School-aged children (5-15)
 Military recruits
 College students
 High during colder months

Diagnosis***
 Laboratory Abnormalities
 Positive Coomb’s test
 Elevated reticulocyte count
 Elevated cold agglutinin titers
 Detects autoantibodies directed against the I
antigens of RBCs
 Non-specific for Mycoplasma pneumoniae
Reticulate body (RB), Elementary body (EB)
 Normal WBC count***
 CSF (For the detection of meningitis) ***:
 Increased lymphocytes  3 species:
 Increased proteins  Chlamydia trachomatis
 Normal glucose***  Chlamydophila psittaci
 Chlamydophila pneumoniae

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Life Cycle Diagnosis
 Tissue scrapings
 Culture with iodine staining***
 It will only stain Chlamydia trachomatis (no other
Chlamydia or Chlamydophila spp.)
 Antigen detection
 Serology
 Nucleic acid probes
 Chest X-ray: diffused interstitial infiltrates

CHLAMYDOPHILA PSITTACI

 Psittacosis (a.k.a. parrot fever, ornithosis)

 Humans are accidental hosts
 Inhalation via bird droppings (tissues, feathers, urine,
 0 hours: an elementary body attaches and enters the
feces) ***
cytoplasm of a susceptible host cell
 Dried microorganism becomes airborne and viable for
 12 hours: the elementary body reorganizes to form a
months – can be used as a bioterrorism agent
reticulate body
 Other reservoir: cats, cattle
 20 hours: the reticulate body then undergoes several
 Person to person transmission is rare
binary fissions
 50-100 cases annually
 30 hours: reticulate bodies reorganize into elementary
body
 48 hours: lysis of cells to release the new elementary
bodies

Pathogenesis***
 Virulence Factors:
 Hemagglutinin – attachment to host cells
 Endotoxin-like toxin
 Major outer membrane proteins
 Immunity is short-lived
 Transmission:  Incubation period: 5-14 days***
 Direct contact (ocular, genital)  Symptoms:
 Inhalation (respiratory)  Fever
 Tissue damage by:  Chills
 Direct cytotoxic effect  Non-productive cough
 Induction of inflammation: IL-1α, IL-1β, TNFα  Pneumonitis
 Severe headache – most common symptom
 Photophobia – most common symptom
CHLAMYDIA TRACHOMATIS
 Diarrhea
Clinical Presentation  Complications:
 Pulmonary: failure
 Renal: oliguria, ATN
 Hematologic: thrombocytopenia
 Hepatitis, granuloma
 Hepatomegaly
 CNS: encephalitis, transverse myelitis, GBS
 Musculoskeletal: reactive arthritis, rhabdomyolysis
 CVS: endocarditis, myocarditis, pericarditis
 Skin: erythema nodosum, Horder spots – red spots
confined on the facial area

 Inclusion conjunctivitis
 Mucopurulent discharge
 Corneal infiltrates
 Corneal vascularization
 5-12 days after passage thru infected birth canal
 +/- ear infected and rhinitis
 Infant pneumonia***
 Preceded by conjunctivitis
 Wheezing and cough (staccato), +/- fever
 Coughing interspersed with inhalation
 Sexually Transmitted Infection Erythema nodosum in Psittacosis
 Males – 75% asymptomatic Diagnosis
 Females – 80% asymptomatic  Clinical history
 3-5x increased risk of HIV  Serology: 4-fold rise
 MAB techniques (sputum, swab)

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Treatment***  2 clinical syndromes:
 Tetracyclines: doxycycline, minocycline – DOC for adults  Legionnaire’s disease
 Macrolides: erythromycin, azithromycin – DOC for  Pontiac fever
children less than 8 years of age  Causes:
 Chloramphenicol  Pneumonia
 Rifampin  Thermotolerance***
 Ofloxacin  Habitat: natural surface waters (amoebae, ciliated
protozoa) – Legionella pneumophila exists in the
Prevention environment by inhabiting amoebae or a ciliated
 Treatment of birds protozoon
 Proper cleaning of aviaries  Requires iron for replication***
 PPE  Medium: BCYE agar***
 2 growth phases:
CHLAMYDOPHILA PNEUMONIAE  Multiplicative
 Active Infective
 Single strain, TWAR  Sources: air-conditioning system, cooling tower, hot
 Transmission: Respiratory droplets*** water system, whirlpool spas***
 Young adults (military bases, college campus)
 200K – 300K annually (not seasonal) Pathogenesis
 Incubation: 3-4 weeks***  Virulence Factor:
 Causes:  Flagella
 Asymptomatic - mostly  Pili
 URTI: rhinitis, laryngitis, pharyngitis, sinusitis  DOT-ICM gene***
 Bronchitis***  Defective Organelle Transport Intracellular
 Lobar pneumonia*** Multiplication gene
 Symptoms:  Inhibits phagolysosome fusion
 Cough with scant cytoplasm  Found in virulent Legionella spp.
st
 Fever (1 week)  Exotoxin:
 Hoarseness  Hemolysin
 Headache  Cytotoxin
 Sinus tenderness  Deoxyribonuclease
 Complications (immune-mediated):  Ribonuclease
 Guillain-Barre Syndrome: Ascending paralysis  Proteases
characterized by aminocytologic dissociation in CSF  Endotoxin (weak) – active classical complement
 Meningoencephalitis  Transmission: inhaled aerosolized water containing
 Reactive arthritis bacteria, aspiration of drinking water***
 Myocarditis  Attachment: flagella, pili
 Associated with:  Phagocytosis: monocyte complement receptors, C3,
 Increased risk of atherosclerosis (Journal of the MOMP (major outer membrane protein), and Mip
American College of Cardiology), 74%) (monocyte infectivity potentiator)
 Multiple sclerosis  Inhibits phagolysosome fusion (DOT-ICM)
 Macular degeneration  Alters endosome to attract mitochondria and rough
 Alzheimer’s disease endoplasmic reticulum
 Chronic fatigue syndrome
 Asthma Host Defense
 Sarcoidosis  Primary
 Cell-mediated Immunity
Diagnosis  Secondary
 Culture (swab)  Humoral Immunity
 Serology  IgM, IgG
 Antigen Detection – DFA/EIA  Do not promote complement-mediated killing
 PCR
Clinical Presentation
Treatment***  Incubation period: 2-10 days***
 Macrolides: for empiric treatment - DOC for children less  Symptoms:
than 8 years of age  Cough
 Tetracycline: doxycycline – DOC for adults  High fever
 Fluoroquinolones  Chills
 Telithromycin  Dyspnea
 Nausea, vomiting
 Neurologic abnormalities
LEGIONELLA PNEUMOPHILA  Chest pain
 General information  Host Risk Factors:
 1976 – American Legion Convention, Philadelphia  Cigarette smoking
 50 species, 70 serogroups  Chronic lung disease
 Humans: 17 species; serogroups 1,4,6  Immunosuppression
 Thin, aerobic, facultative intracellular, flagellated (polar),  Elderly
gram negative bacilli  Receipt of biological therapies

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 END OF TRANSCRIPTION

Laban2019
Bakbakan na! Patumbahin natin ang Evals 4.

Transcription Team 2019

Transcribed by: Don Edward Dela Rosa
Danielle Delas Alas
Edited by:
References: Doctor’s PPT
Diagnosis Recordings
 Indications for Testing (IDSA, ATS): Lecture Notes
 Patients who have failed outpatient antibiotic Remarks: Malapit na JFT  Kaya
therapy for community-acquired pneumonia natin to guys!
 Patients with severe pneumonia, those requiring #PASSION #Laban2019
intensive care
 Immunocompromised patients with pneumonia
 Patients with pneumonia I the setting of a
legionellosis outbreak
 Patients with a travel history (patients that have
traveled away from their home within two weeks
before the onset of illness
 Health-care associated pneumonia
 Tests:
 Urine antigen test: serogroup 1***
 Culture
 Serology
 Antigen test (DFA)
 PCR

Treatment***
 Legionnaire’s:
 Fluoroquinolones: levofloxacin, moxifloxacin - DOC
 Azithromycin
 Doxycycline
 Tigecycline
 Co-trimoxazole
 Rifampin
 Clindamycin, Imipenem
 Pontiac:
 No antibiotic
 1 week recovery

Prevention
 Minimize Legionella growth in water systems:
 Disinfection of water supply (copper-silver
ionization)
 Superheat and flush
 Chlorine dioxide
 Monochloramine
 Timely identification and reporting

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