Community-acquired pneumonia
KEY POINTS
• The diagnosis of CAP generally requires : an
opacity on chest imaging + a clinically
compatible syndrome (eg, fever, dyspnea,
cough, and sputum production)
Evaluation
History and physical
• Classically, CAP is characterized by acute onset fever, cough
(with or without sputum production), and shortness of
breath
• In some cases, pleuritic chest pain may also be present.
• Less common symptoms include gastrointestinal
complaints (eg, nausea, vomiting, diarrhea, abdominal
pain), loss of appetite, and mental status changes.
• In patients with advanced age or impaired immune
systems, presenting symptoms can be subtle ([Link]
may be absent in older patients and mental status changes
may be the sole presenting symptom)
History and physical
• Tachycardia, tachypnea, hypoxemia, or increased
work of breathing may be present.
• Crackles (rales) and rhonchi may be heard on chest
auscultation, along with other signs of consolidation
(eg, tactile fremitus, egophony, dullness to
percussion).
• As infection progresses, the dominant clinical
picture may be of sepsis and/or respiratory distress.
• Clinical features alone have limited diagnostic
accuracy.
Laboratory
• Routine blood tests — CBC and basic metabolic panel.
a. Leukocytosis with leftward shift is most common blood
test abnormality.
b. Leukopenia (<4000) and thrombocytopenia (<100,000) is
less common but generally connotes poorer prognosis
c. New elevations in creatinine and BUN or abnormal LFT
can be also a sign of sepsis
• Serum biomarkers —procalcitonin and CRP alone are NOT
reliably helpful in distinguishing viral vs bacterial causes of
pneumonia
Imaging
• Purpose :
1. to confirm the diagnosis,
2. assess for complications (eg, parapneumonic effusion,
empyema, abscess)
3. evaluate for alternate or concurrent diagnosis (eg, heart
failure, malignancy).
• Radiographic findings consistent with the diagnosis of CAP
include lobar consolidations, interstitial infiltrates, and/or
cavitations
• Radiographic appearance alone cannot reliably
differentiate among etiologies
Left lower lobe
consolidation of
pneumococcal
pneumonia.
Diffuse bilateral
infiltrates of
Mycoplasma
pneumoniae
Bilateral
reticulonodular
pattern of
Mycoplasma
pneumoniae.
CT of this
patient on the
next slide
At levels of main
bronchi : there is diffuse
ground glass opacity and
centrilobular nodule
(arrow)
At basal : centrilobular
nodule (arrow), branching
opacities; tree in bud
pattern (curved arrow),
small foci of
consolidations, and
thickening of interlobular
septa (arrowhead)
Imaging (cont’d)
• In some cases, chest radiographs may not be sufficiently sensitive
for the detection of pneumonia
• Case reports favoring hypothesis that volume depletion may
produce an initially negative CXR, which "blossoms" into infiltrates
following rehydration.
• In support of this hypothesis, one cohort study of suspected CAP
found that 7% of patients with negative initial radiographs
developed changes consistent with CAP on repeat chest
radiograph
• Thus, when clinical suspicion is high despite a negative chest
radiograph, we decide to either treat empirically and/or perform a
CT depending on the patient’s severity of illness, immune status,
and/or the suspected pathogen
Imaging (CT)
• CT is particularly helpful for immunocompromised patients who are
at risk for infection with broad array of pathogens.
• The enhanced sensitivity and specificity of CT can help distinguish
among causes (eg, invasive fungal infections, pneumocystis
pneumonia, bacterial pathogens)
• Immunocompromised person may not able to mount sufficient
inflammatory response to produce infiltrates on plain radiograph.
• CT is also useful for :
1. Cases in which CAP is highly suspected based on clinical features
despite a negative chest radiograph
2. There is an opacity on radiograph but not clear if due to
pneumonia versus other causes ([Link] with multiple
comorbidities)
Determining the
appropriate levels of
treatment for CAP
Differential diagnosis
• Acute bronchitis
• Influenza
• Upper respiratory tract infection (URI)
• Acute exacerbation of COPD
• Acute exacerbation of asthma
• Acute exacerbation of bronchiectasis
Differential diagnosis (non-infectious)
• Heart failure with pulmonary edema
• Pulmonary embolism
• Lung cancer
• Atelectasis
• Aspiration or chemical (including drug-
induced) pneumonitis
• Interstitial lung disease
