Pneumonia

What is Pneumonia?

Infection that inflames air sacs in one or both lungs, which may fill with fluid.

With pneumonia, the air sacs may fill with fluid or pus. The infection can be life-threatening to anyone, but particularly to infants, children and people over 65.

Epidemiology of Pneumonia.

The estimated worldwide incidence of community-acquired pneumonia varies between 1.5 to 14 cases per 1000 person-years, and this is affected by geography, season, and population characteristics. In the United States, the annual incidence is 24.8 cases per 10,000 adults with higher rates as age increases.

 What causes Pneumonia?

Common Causes of Pneumonia are viruses, bacteria, and fungi can all cause pneumonia. In the United States, common causes of viral pneumonia are influenza, respiratory syncytial virus (RSV), and SARS-CoV-2 (the virus that causes COVID-19). A common cause of bacterial pneumonia is Streptococcus pneumoniae (pneumococcus).

What are the symptoms of pneumonia?

The signs and symptoms of pneumonia may include:

• Cough, which may produce greenish, yellow or even bloody mucus.
• Fever, sweating and shaking chills.
• Shortness of breath.
• Rapid, shallow breathing.
• Sharp or stabbing chest pain that gets worse when you breathe deeply or cough.
• Loss of appetite, low energy, and fatigue.

Stages of Pneumonia

The four stages of lobar pneumonia include:

• Stage 1: Congestion
  During the congestion phase, the lungs become very heavy and congested due to infectious fluid that has accumulated in the air sacs. During this stage, your older loved one may experience early pneumonia symptoms such as:

  • Coughing
  • A feeling of heaviness in the chest
  • Loss of appetite
  • Fatigue
  • Rapid breathing
    
    

• Stage 2: Red hepatization
  Red blood cells and immune cells that enter the fluid-filled lungs to combat the infection give the lungs a red appearance. Although the body is beginning to fight the infection during this stage, your loved one may experience worsening symptoms such as:

  • Increasingly productive cough
  • Shortness of breath
  • Muscle aches
  • Headache
  • Extreme fatigue
  • Fever
  • Chills
  • Sweating
  • Blue lips or fingernails due to low levels of oxygen in the blood.
    

  Some older adults may experience confusion or delirium during this stage. If your senior loved one experiences severe symptoms such as difficulty breathing, high fever, or blue lips or fingernails, you should seek emergency treatment or dial 9-1-1.

• Stage 3: Gray hepatization
  Red blood cells will disintegrate during this stage, giving the lungs a grayish color. However, immune cells remain, and symptoms will likely persist.

• Stage 4: Resolution
  During the resolution phase, seniors may begin to feel better as immune cells rid their bodies of infection. However, they may develop a productive cough that helps to remove fluid from the lungs.

Common findings on Chest Xray.

Picture above shows the difference between a normal chest xray and a series of xrays with pneumonia.

On this picture you can see consolidation on the right mid lobe, which is a clear indication of infection. Strongly suggestive of pneumonia.

On this one its clear with consolidation on the left mid lobe and also the right show some consolidation.

How do we diagnose Pneumonia?

Normally you will start by asking about  medical history and doing a physical exam, including listening to your lungs with a stethoscope to check for abnormal bubbling or crackling sounds that suggest pneumonia.

If pneumonia is suspected, the following tests are recommended:

• Blood tests. Blood tests are used to confirm an infection and to try to identify the type of organism causing the infection. However, precise identification isn't always possible.
• Chest X-ray. This helps your doctor diagnose pneumonia and determine the extent and location of the infection. However, it can't tell your doctor what kind of germ is causing the pneumonia.
• Pulse oximetry. This measures the oxygen level in your blood. Pneumonia can prevent your lungs from moving enough oxygen into your bloodstream.
• Sputum test. A sample of fluid from your lungs (sputum) is taken after a deep cough and analyzed to help pinpoint the cause of the infection.

Golden standard investigation is a Chest xray.

Management of Pneumonia

Treatment for pneumonia involves curing the infection and preventing complications. 

People who have community-acquired pneumonia usually can be treated at home with medication. Although most symptoms ease in a few days or weeks, the feeling of tiredness can persist for a month or more.

Specific treatments depend on the type and severity of your pneumonia, your age and your overall health. The options include:

• Antibiotics: These medicines are used to treat bacterial pneumonia. It may take time to identify the type of bacteria causing your pneumonia and to choose the best antibiotic to treat it. If your symptoms don't improve, your doctor may recommend a different antibiotic.
• Cough medicine:  This medicine may be used to calm your cough so that you can rest. Because coughing helps loosen and move fluid from your lungs, it's a good idea not to eliminate your cough completely. In addition, you should know that very few studies have looked at whether over-the-counter cough medicines lessen coughing caused by pneumonia. If you want to try a cough suppressant, use the lowest dose that helps you rest.
• Fever reducers/pain relievers: You may take these as needed for fever and discomfort. These include drugs such as aspirin, ibuprofen (Advil, Motrin IB, others) and acetaminophen (Tylenol, others).

Deciding on in hospital or out patient management

You can use the CURB-65.

CURB-65 SCORING

CURB-65 Management

Hospitalization

You may need to be hospitalized if:

• You are older than age 65
• You are confused about time, people or places
• Your kidney function has declined
• Your systolic blood pressure is below 90 millimeters of mercury (mm Hg) or your diastolic blood pressure is 60 mm Hg or below
• Your breathing is rapid (30 breaths or more a minute)
• You need breathing assistance
• Your temperature is below normal
• Your heart rate is below 50 or above 100

You may be admitted to the intensive care unit if you need to be placed on a breathing machine (ventilator) or if your symptoms are severe.

Children may be hospitalized if:

• They are younger than age 2 months
• They are lethargic or excessively sleepy
• They have trouble breathing
• They have low blood oxygen levels
• They appear dehydrated

Prognosis

Most pneumonia is treated successfully, especially if antibiotics are started early. Pneumonia can be fatal. The very old and frail, especially those with many other medical conditions, are most vulnerable.

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Meningitis

What is Meningitis?

Inflammation of brain and spinal cord membranes, typically caused by an infection.

Meningitis is usually caused by a viral infection but can also be bacterial or fungal. Vaccines can prevent some forms of meningitis.

Types of Meningitis

• Viral meningitis. Viral meningitis is the most common type of meningitis
• Bacterial meningitis. Bacterial meningitis is contagious and caused by infection from certain bacteria
• Fungal meningitis. Fungal meningitis is a rare type of meningitis
• Parasitic meningitis
• Non-infectious meningitis

What is viral meningitis?

Viral meningitis (when meningitis is caused by a virus) is the most common type of meningitis. Most people get better on their own without treatment. However, anyone with symptoms of meningitis should see a doctor right away because any type of meningitis can be serious. Babies younger than 1 month old and people with weakened immune systems are more likely to have severe illness from viral meningitis.

Causes

Non-polio enteroviruses are the most common cause of viral meningitis.

Other causes

• Mumps virus
• Herpesviruses, including Epstein-Barr virus, herpes simplex viruses, and varicella-zoster virus (which causes chickenpox and shingles)
• Measles virus
• Influenza virus
• Arboviruses, such as West Nile virus
• Lymphocytic choriomeningitis virus

Who is at risk?

• Children younger than 5 years old
• People with weakened immune systems caused by diseases, medications (such as chemotherapy), and recent organ or bone marrow transplantations

People of any age can get viral meningitis.

Babies younger than 1 month old and people with weakened immune systems are also more likely to have severe illness.

Symptoms

Most people with mild viral meningitis usually get better on their own within 7 to 10 days.

Initial symptoms of viral meningitis are similar to those for bacterial meningitis. However, bacterial meningitis is usually severe and can cause serious complications, such as brain damage, hearing loss, or learning disabilities. The pathogens (germs) that cause bacterial meningitis can also be associated with another serious illness, sepsis. Sepsis is the body’s extreme response to infection. Without timely treatment, sepsis can quickly lead to tissue damage, organ failure, and death.

Common symptoms in babies

• Fever
• Irritability
• Poor eating
• Sleepiness or trouble waking up from sleep
• Lethargy (a lack of energy)

Common symptoms in children and adults

• Fever
• Headache
• Stiff neck
• Photophobia (eyes being more sensitive to light)
• Sleepiness or trouble waking up from sleep
• Nausea
• Irritability
• Vomiting
• Lack of appetite
• Lethargy (a lack of energy)

Treatment

In most cases, there is no specific treatment for viral meningitis. Most people who get mild viral meningitis usually recover completely in 7 to 10 days without treatment. Antiviral medicine may help people with meningitis caused by viruses such as herpesvirus and influenza.

Antibiotics do not help viral infections, so they are not useful in the treatment of viral meningitis. However, antibiotics do fight bacteria, so they are very important when treating bacterial meningitis.

People who develop severe illness, or are at risk for developing severe illness, may need care in a hospital.

What is  bacterial meningitis?

Bacterial meningitis is serious. Some people with the infection die and death can occur in as little as a few hours. However, most people recover from bacterial meningitis. Those who do recover can have permanent disabilities, such as brain damage, hearing loss, and learning disabilities.

Causes

Mainly the causes of meningitis are:

• Streptococcus pneumoniae
• Group B Streptococcus
• Neisseria meningitidis
• Haemophilus influenzae
• Listeria monocytogenes
• Escherichia coli

Some causes of bacterial meningitis are more likely to affect certain age groups:

• Newborns: Group B Streptococcus, S. pneumoniae, L. monocytogenes, E. coli
• Babies and young children: S. pneumoniae, N. meningitidis, H. influenzae, group B Streptococcus, M. tuberculosis
• Teens and young adults: N. meningitidis, S. pneumoniae
• Older adults: S. pneumoniae, N. meningitidis, H. influenzae, group B Streptococcus, L. monocytogenes

Mycobacterium tuberculosis, which causes tuberculosis or TB, is a less common cause of bacterial meningitis (called TB meningitis).

Symptoms

Meningitis symptoms include sudden onset of

• Fever
• Headache
• Stiff neck

There are often other symptoms, such as

• Nausea
• Vomiting
• Photophobia (eyes being more sensitive to light)
• Altered mental status (confusion)

Newborns and babies may not have, or it may be difficult to notice the classic symptoms listed above. Instead, babies may

• Be slow or inactive
• Be irritable
• Vomit
• Feed poorly
• Have a bulging fontanelle (the “soft spot” on a baby’s head)
• Have abnormal reflexes

 

Diagnosis

For a definitive diagnosis of meningitis, you'll need a spinal tap to collect cerebrospinal fluid (CSF). In people with meningitis, the CSF often shows a low sugar (glucose) level along with an increased white blood cell count and increased protein.

Treatment

In most cases of bacterial meningitis a broad spectrum cephalosporin (cefotaxime or ceftriaxone) is the most appropriate empirical choice in children over 3 months old. These cover Neisseria meningitides, Streptococcus pneumoniae, and Haemophilus influenzae, and penetrate CSF well.

What is Cryptococcus meningitis?

Cryptococcal meningitis is a type of meningitis caused by a fungus called Cryptococcus. This type of meningitis mainly affects people with weakened immune systems due to another illness. If not treated, cryptococcal meningitis can have lasting consequences and can even be fatal.

In most cases, cryptococcal meningitis is caused by the fungus Cryptococcus neoformans. This fungus is found in soil around the world. Cryptococcus gattii can also cause meningitis, but this form can cause disease in patients with a normal immune system as well.

Is Cryptococcus meniningitis contagious?

Cryptococcosis is not contagious, meaning it cannot spread from person-to-person. Cryptococcal meningitis specifically occurs after Cryptococcus has spread from the lungs to the brain. Meningitis can also be caused by a variety of other organisms, including bacteria, viruses, and other fungi.

Symptoms

Symptoms of cryptococcal meningitis often develop gradually, within a few days to weeks of exposure to the fungus.

A person with cryptococcal meningitis may develop the following symptoms:

• headache
• nausea and vomiting
• fatigue
• confusion or hallucinations
• personality changes
• sensitivity to light
• fever
• stiff neck
• blurred vision

It may be difficult for someone to tell if they have symptoms of cryptococcal meningitis. Many of the symptoms may be similar to the side effects of a medication they may be taking to treat an underlying condition.

If left untreated, cryptococcal meningitis can lead to more serious symptoms, including:

• fluid on the brain
• coma
• hearing loss

Cryptococcal meningitis can be fatal if not treated quickly, especially in people with HIV or AIDS.

Diagnosis

The definitive diagnosis of cryptococcal meningitis is made by culture from the CSF. The opening pressure should be measured along with India ink evaluation, cryptococcal antigen testing, fungal culture, and routine spinal fluid studie.

Management of Cryptococcus meningitis.

Cryptococcal meningitis is treated with antifungal drugs such as amphotericin, fluconazole, and flucytosine (induction therapy); recurrence of the infection is prevented by taking fluconazole daily for life or until the immune system recovers.

Current guidelines recommend 2 weeks of amphotericin B (0.7–1.0 mg/kg per day) intravenously in combination with flucytosine 100mg/kg/day as first line therapy for treatment of cryptococcal meningitis.

Oral fluconazole, 200 mg/d, is the most effective maintenance therapy for AIDS-associated cryptococcal meningitis [17, 24] (AI). A randomized comparative trial demonstrated the superiority of fluconazole (200 mg/d) over amphotericin B (1 mg/kg/w) as maintenance therapy.

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Food for thoughts.

Amphotericin B is toxic, because mammalian and fungal membranes are similar in structure and composition, this is one mechanism by which amphotericin B causes cellular toxicity. Amphotericin B molecules can form pores in the host membrane as well as the fungal membrane. This impairment in membrane barrier function can have lethal effects.

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Diabetes Mellitus

Diabetes Mellitus Type 1

Sometimes called juvenile diabetes due to the frequency of childhood diagnoses, type 1 diabetes can affect anyone, regardless of age, race, or weight. This form of the disease prevents the body from producing insulin, which is responsible for regulating blood glucose or blood sugar.

Causes

Type 1 diabetes is an autoimmune disease, and its exact origin is unknown. Autoimmune diseases are those that cause the immune system to attack the body mistakenly. In the case of type 1 diabetes, the body attacks and destroys islet cells in the pancreas. Once enough of those cells are gone, the body ceases the production of insulin. Because insulin lowers the amount of sugar in the bloodstream, lack of it can cause these sugars to build up, leading to life-threatening complications.

Symptoms

Symptoms of type 1 diabetes can appear quickly and often without warning. Some of the more common symptoms include dehydration, frequent urination, weight loss, and tingling or numbness in the legs. Less common but possible symptoms such as blurry vision, heart palpitations, and fatigue affect some people. Additionally, a drop in blood sugar can cause sudden mood changes and irritability.

Risk Factors and Prevention

Because doctors do not know how to prevent type 1 diabetes, scientists research certain risk factors, which include family history and genetics, geography, age, and, in some cases, ethnicity. Those with a parent or sibling who has the disease is at a slightly higher risk of developing it than those who don't. Although type 1 diabetes can affect anyone of any age, it is more commonly diagnosed in children under the age of 15.

Diagnosis and Treatment

A glycated hemoglobin test is the best and most common blood test for diagnosing type 1 diabetes. This test measures how much blood sugar is attached to the oxygen-carrying red blood cells or hemoglobin. The higher one's blood sugar, the more sugar-coated hemoglobin. After the diagnosis, a person with diabetes will have to visit their doctor to have their blood sugar monitored regularly. Treatments for type 1 diabetes include insulin injections, diet and nutrition, and exercise.

Type 2 Diabetes

Type 2 diabetes used to be known as adult-onset diabetes, but doctors are diagnosing more and more children. This is the type of diabetes most commonly associated with obesity, unhealthy eating habits, and the modern sedentary lifestyle.

Causes

Type 2 diabetes is another chronic condition -- the body either begins to resist insulin or stops producing enough of it to maintain normal blood glucose levels. Several factors can cause type 2 diabetes, but the most common and important of those are lifestyle and genetics. Approximately 90% of people with diabetes have type 2, and six in ten show few to no symptoms, which can delay diagnosis.

Symptoms

If the body isn't producing the correct amount of insulin to absorb glucose, a person might experience fatigue. Other common symptoms of type 2 diabetes include an increased need to urinate, thirst, and increased susceptibility to yeast infections. Unfortunately, most people consider these symptoms parts of everyday life and do not see a doctor. If type 2 diabetes goes undiagnosed for too long, high blood sugar levels can damage the heart, kidneys, eyes, and feet.

Risk Factors and Prevention

The factors that increase the risk of getting type 1 or type 2 diabetes differ widely. A person's lifestyle greatly affects their likelihood of developing type 2 diabetes. Related factors include being overweight, inactivity, age, and some preexisting conditions. For example, polycystic ovarian syndrome can lead to type 2 diabetes.

Diagnosis and Treatment

Unlike type 1, healthy lifestyle changes can help people prevent type 2 diabetes. Even those with a family history of diabetes can reduce their risk by maintaining a healthy lifestyle that includes a good diet and exercise. Lifestyle changes can also slow the progression of prediabetes. Healthy changes include choosing lower-fat foods, undertaking 30 to 60 minutes of exercise a day, losing weight, and avoiding being sedentary for long periods. Doctors will often prescribe similar treatments to people diagnosed with the condition: weight loss, healthy eating, and exercise, in addition to regular blood sugar monitoring.

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Pathophysiology