Chlamydial pneumonia - Clinicals, Diagnosis, and Management

Pulmonology

Clinicals - History

Fact Explanation
Sore throat and hoarseness This is due to pharyngitis caused by the pathogen Chlamydia pneumoniae. High affinity to the respiratory epithelium makes Chlamydophila pneumoniae a common etiological agent for pneumonia. Hoarseness occurs due to the inflammation of pharynx and larynx. These symptoms present early and there is usually a subacute onset. There is a biphasic pattern with resolution of pharyngitis prior to development of pneumonia. Sore throat and hoarseness
This is due to pharyngitis caused by the pathogen Chlamydia pneumoniae. High affinity to the respiratory epithelium makes Chlamydophila pneumoniae a common etiological agent for pneumonia. Hoarseness occurs due to the inflammation of pharynx and larynx. These symptoms present early and there is usually a subacute onset. There is a biphasic pattern with resolution of pharyngitis prior to development of pneumonia.
Cough There is often a prolonged period of cough. This is usually a cough with scanty sputum production. Cough is a defense mechanism in removing particles and pathogens. Cough
There is often a prolonged period of cough. This is usually a cough with scanty sputum production. Cough is a defense mechanism in removing particles and pathogens.
Fever The fever begins one week prior to respiratory symptoms, and disappears thereafter. This is due to the cytokines acting as endogenous pyrogens. Fever
The fever begins one week prior to respiratory symptoms, and disappears thereafter. This is due to the cytokines acting as endogenous pyrogens.
Dyspnoea This is defined as the sense of difficulty in breathing. This occurs when alveoli gets obstructed with secretions and impairs gas exchange. Usually this is a mild infection so the patient is relatively comfortable. Dyspnoea
This is defined as the sense of difficulty in breathing. This occurs when alveoli gets obstructed with secretions and impairs gas exchange. Usually this is a mild infection so the patient is relatively comfortable.
Ear ache and head ache Purulent sinusitis and otitis media with effusion can be associated with pneumonia. High affinity to the respiratory epithelium makes Chlamydophila pneumoniae a common etiological agent. Ear ache and head ache
Purulent sinusitis and otitis media with effusion can be associated with pneumonia. High affinity to the respiratory epithelium makes Chlamydophila pneumoniae a common etiological agent.
Constitutional symptoms (malaise, lethargy etc.) These are due to inflammatory mediators released during the infection.These symptoms are more marked in Chlamydia pneumoniae infections. Constitutional symptoms (malaise, lethargy etc.)
These are due to inflammatory mediators released during the infection.These symptoms are more marked in Chlamydia pneumoniae infections.
Pleuritic type chest pain This is due to the inflammation of pleura which is pain sensitive. Pleuritic type chest pain
This is due to the inflammation of pleura which is pain sensitive.
Gastrointestinal symptoms Most patients develop symptoms such as vomiting and diarrhea in comparison to other types of pneumonia. Gastrointestinal symptoms
Most patients develop symptoms such as vomiting and diarrhea in comparison to other types of pneumonia.
Past history of COPD Common among patients with chronic obstructive pulmonary disease. , Past history of COPD
Common among patients with chronic obstructive pulmonary disease. ,
Exacerbation of Asthma (dyspnoea, wheezing, nocturnal cough) There is a increased incidence of exacerbation following C.pneumoniae infections. Exacerbation of Asthma (dyspnoea, wheezing, nocturnal cough)
There is a increased incidence of exacerbation following C.pneumoniae infections.
Contact history of patients with Chlamydia pneumonia. Humans are the known reservoir and
transmission is from person to person via respiratory secretions.
Contact history of patients with Chlamydia pneumonia.
Humans are the known reservoir and
transmission is from person to person via respiratory secretions.
Extrapulmonary symptoms Erythema multiforme ( well demarcated, small round lesions with erythema and target lesions) This is mediated by the deposition of IgM in the microvasculature of the skin. Can cause an arthritis with symptoms of Joint pain,swelling and erythema. Extrapulmonary symptoms
Erythema multiforme ( well demarcated, small round lesions with erythema and target lesions) This is mediated by the deposition of IgM in the microvasculature of the skin. Can cause an arthritis with symptoms of Joint pain,swelling and erythema.
Complications of Chlamydia pneumoniae Neurological complications are: meningoencephalitis (The patient is unconscious, or can have convulsions and respiratory
arrest ), Guillain-Barre´Syndrome (limb weakness, paresthesia, respiratory muscle paralysis, dysarthria)
Cardio vascular complications: Myocarditis these patients can present with chest pain, dyspnoea, and sweating.
Complications of Chlamydia pneumoniae
Neurological complications are: meningoencephalitis (The patient is unconscious, or can have convulsions and respiratory
arrest ), Guillain-Barre´Syndrome (limb weakness, paresthesia, respiratory muscle paralysis, dysarthria)
Cardio vascular complications: Myocarditis these patients can present with chest pain, dyspnoea, and sweating.

Clinicals - Examination

Fact Explanation
Fever This is usually a low grade fever. This is due to endogenous pyrogens released in the inflammatory process. Fever
This is usually a low grade fever. This is due to endogenous pyrogens released in the inflammatory process.
Tachycardia This is defined as heart rate 100< beats per minutes. Only few patients has this sign due to the mild nature of the disease.
Hypoxia, Fever, release of catecholamines causes increase in the heart rate.
Tachycardia
This is defined as heart rate 100< beats per minutes. Only few patients has this sign due to the mild nature of the disease.
Hypoxia, Fever, release of catecholamines causes increase in the heart rate.
Tachypnoea Hypercarbia and Hypoxia stimulate respiratory center to increase the rate of respiration.
Only few patients has this sign due to the mild nature of the disease.
Tachypnoea
Hypercarbia and Hypoxia stimulate respiratory center to increase the rate of respiration.
Only few patients has this sign due to the mild nature of the disease.
Pharyngeal erythema This is due to the inflammation of pharynx by the C.pneumoniae.Erythema is a classic feature of acute inflammation. Pharyngeal erythema
This is due to the inflammation of pharynx by the C.pneumoniae.Erythema is a classic feature of acute inflammation.
Cervical lymphadenopathy The local lymph nodes gets inflamed when the lymph is carrying the pathogens to the draining node.This is a protective mechanism in infections. Cervical lymphadenopathy
The local lymph nodes gets inflamed when the lymph is carrying the pathogens to the draining node.This is a protective mechanism in infections.
Coarse crackles They are generated by the opening of collapsed airways. Usually these features are found in seriously ill patients. This sign can be a common finding but it doesn't prove the diagnosis. Coarse crackles
They are generated by the opening of collapsed airways. Usually these features are found in seriously ill patients. This sign can be a common finding but it doesn't prove the diagnosis.
Rhonchi These can be heard diffusely in both sides. The sound is generated by the turbulent airflow in narrowed airways. This sign can be a common finding but it doesn't prove the diagnosis. Rhonchi
These can be heard diffusely in both sides. The sound is generated by the turbulent airflow in narrowed airways. This sign can be a common finding but it doesn't prove the diagnosis.
Erythema multiforme These are polymorphous macular eruption , papules, and target lesions (central bullae or vesicle with concentric rash). The lesions in the extremities can be observed. This can sometimes be associated with Chlamydia pneumonia. Erythema multiforme
These are polymorphous macular eruption , papules, and target lesions (central bullae or vesicle with concentric rash). The lesions in the extremities can be observed. This can sometimes be associated with Chlamydia pneumonia.
Ankle swelling, tenderness and erythema This is due to a reactive arthritis that can sometimes be associated with Chlamydia pneumonia. Ankle swelling, tenderness and erythema
This is due to a reactive arthritis that can sometimes be associated with Chlamydia pneumonia.
Neck stiffness This is a feature of Meningoencephalitis-
This is due to the spasm of neck muscles in passive flexion of the neck.
Neck stiffness
This is a feature of Meningoencephalitis-
This is due to the spasm of neck muscles in passive flexion of the neck.
Low levels of GCS This is a feature of Meningoencephalitis- Low levels of GCS
This is a feature of Meningoencephalitis-
Papilloedema This is a feature of Meningoencephalitis-
It indicates raised intracranial pressure due to cerebral oedema.
Papilloedema
This is a feature of Meningoencephalitis-
It indicates raised intracranial pressure due to cerebral oedema.
Flaccid paralysis of the limbs with relative preservation of sensation This is a sign of complecated Chlamydia pneumonia (Guillain Barre Syndrome ) Flaccid paralysis of the limbs with relative preservation of sensation
This is a sign of complecated Chlamydia pneumonia (Guillain Barre Syndrome )
Mitral regurgitation Myocarditis- Features of acute heart failure. Mitral regurgitation
Myocarditis- Features of acute heart failure.
Fine basal crepitations Myocarditis- Features of acute heart failure. Fine basal crepitations
Myocarditis- Features of acute heart failure.

Investigations - Diagnosis

Fact Explanation
Full blood count Can indicate granulocytosis but this is nonspecific. Full blood count
Can indicate granulocytosis but this is nonspecific.
C-Reactive protein This is a acute response proteins and in is elevated in infections. C-Reactive protein
This is a acute response proteins and in is elevated in infections.
Blood cultures, gram staining and antibiatogram This is done as a basic test to exclude other bacterial pathogens., Blood cultures, gram staining and antibiatogram
This is done as a basic test to exclude other bacterial pathogens.,
chest X-ray This is done as a basic test to support clinical suspicion. There are irregular segmented inflammatory infiltrates . The commonest site is the middle or lower lobes chest X-ray
This is done as a basic test to support clinical suspicion. There are irregular segmented inflammatory infiltrates . The commonest site is the middle or lower lobes
Antigen detection The test is done with TWAR antigen specific for C. pneumoniae. It can distinguish between antibodies in the IgM and IgG serum fractions,which helps in identifying recent from past infection and reinfection from primary infection. Antigen detection
The test is done with TWAR antigen specific for C. pneumoniae. It can distinguish between antibodies in the IgM and IgG serum fractions,which helps in identifying recent from past infection and reinfection from primary infection.
Serology C. pneumoniae specific MAbs have been useful in cell cultures. However, they are insensitive for detection in direct smears.Antigen detection by ELISA, has a poor sensitivity. Serology
C. pneumoniae specific MAbs have been useful in cell cultures. However, they are insensitive for detection in direct smears.Antigen detection by ELISA, has a poor sensitivity.
PCR Several C. pneumoniae-specific primers have been used in PCR detection of organisms. PCR
Several C. pneumoniae-specific primers have been used in PCR detection of organisms.
Culture Cell lines for isolation are HL and HEp-2 . TWAR specific M Ab conjugated with fluorescein has greatly enhanced identification. An oropharyngial swab is used instead of sputum sample. Culture
Cell lines for isolation are HL and HEp-2 . TWAR specific M Ab conjugated with fluorescein has greatly enhanced identification. An oropharyngial swab is used instead of sputum sample.

Investigations - Management

Fact Explanation
Chest X ray Done after 6 weeks to assess the state of resolving of the pneumonia. Chest X ray
Done after 6 weeks to assess the state of resolving of the pneumonia.
Plasma urea level Levels less than 7mmol/L indicate increased severity. Plasma urea level
Levels less than 7mmol/L indicate increased severity.
Arterial blood gas Done if oxygen saturation is <94%
Pa O2 of <8kPa is a marker of severity of community acquired pneumonia.
Arterial blood gas
Done if oxygen saturation is <94%
Pa O2 of <8kPa is a marker of severity of community acquired pneumonia.
Albumin level Albumin level less than <35g/l is a marker of severity of community acquired pneumonia. Albumin level
Albumin level less than <35g/l is a marker of severity of community acquired pneumonia.

Management - Supportive

Fact Explanation
Decide the treatment setting Depends on severity-of-illness scores, assessed by the CURB-65 criteria ( includes confusion, uremia, respiratory rate, low blood pressure and age 65 years or greater; each component carries one point). Decide the treatment setting
Depends on severity-of-illness scores, assessed by the CURB-65 criteria ( includes confusion, uremia, respiratory rate, low blood pressure and age 65 years or greater; each component carries one point).
Oxygen This is to improve oxygen saturation of the blood.
In a patient with COPD should be given between 88%-92% because the hypoxic drive should not be abolished.
Oxygen
This is to improve oxygen saturation of the blood.
In a patient with COPD should be given between 88%-92% because the hypoxic drive should not be abolished.
Intravenous fluids Is given in hypotensive patients to replace volume depletion. Intravenous fluids
Is given in hypotensive patients to replace volume depletion.
Analgesia and antipyretics This improves well being of the patient.It helps to reduce pleuritic pain and improve breathing and sputum clearance. Analgesia and antipyretics
This improves well being of the patient.It helps to reduce pleuritic pain and improve breathing and sputum clearance.
Physiotherapy This is needed only if there is sputum retention Physiotherapy
This is needed only if there is sputum retention
Thromboprophylaxis with subcutaneous heparin and TED stockings This can be considered in patients hospitalized for more than 12hs. Thromboprophylaxis with subcutaneous heparin and TED stockings
This can be considered in patients hospitalized for more than 12hs.

Management - Specific

Fact Explanation
Tetracycline These are broad-spectrum antibiotics that inhibit protein synthesis of the pathogens.
It is given 500 mg four times daily for 14 days
Tetracycline
These are broad-spectrum antibiotics that inhibit protein synthesis of the pathogens.
It is given 500 mg four times daily for 14 days
Doxycycline These are broad-spectrum antibiotics that inhibit protein synthesis of the bacteria.It is given at a dose of 100 mg twice daily for 14 days Doxycycline
These are broad-spectrum antibiotics that inhibit protein synthesis of the bacteria.It is given at a dose of 100 mg twice daily for 14 days
Erythromycin This is a bactericidal drug.It is used as 500 mg four times daily for 14 days. Erythromycin
This is a bactericidal drug.It is used as 500 mg four times daily for 14 days.
Management of a patient with high mortality ( example: hospitalized patient with CURB 65 score over 3) This is empirical therapy.The rout of admission is by intravenous line. Intravenous antibiotics can be given to hospitalized patients( CURB 65 score of 2 ) who can't take oral medications. Alternatively: IV Ceftriaxone and IV Clarythromycin or Benzylpenicillin and Levofloxacin. Co-amoxiclav acts againsts gram positive organisms and gram negative cocci. It is resistant to beta lactamases. Clarythromycin has a bactericidal action. Ceftriaxone is a third generation cephalosporin and it they are broad-spectrum antibiotics with bactericidal action. Benzylpenicillin acts againsts gram positive organisms and gram negative cocci. Levofloxacin is a fluoroquinolone and it inhibits bacterial DNA synthesis.It is Baceristatis. It has a more gram negative coverage. Management of a patient with high mortality ( example: hospitalized patient with CURB 65 score over 3)
This is empirical therapy.The rout of admission is by intravenous line. Intravenous antibiotics can be given to hospitalized patients( CURB 65 score of 2 ) who can't take oral medications. Alternatively: IV Ceftriaxone and IV Clarythromycin or Benzylpenicillin and Levofloxacin. Co-amoxiclav acts againsts gram positive organisms and gram negative cocci. It is resistant to beta lactamases. Clarythromycin has a bactericidal action. Ceftriaxone is a third generation cephalosporin and it they are broad-spectrum antibiotics with bactericidal action. Benzylpenicillin acts againsts gram positive organisms and gram negative cocci. Levofloxacin is a fluoroquinolone and it inhibits bacterial DNA synthesis.It is Baceristatis. It has a more gram negative coverage.

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