PNEUMONIA
Definition
Acute infection of lung parenchyma including alveolar spaces and/or interstitial tissue. Causative
agent may be bacterial, viral, mycoplasmal, or fungal.
Symptoms
Pneumococcal: often preceded by URI, onset sudden with single shaking shill, followed by fever,
pain with breathing on affected side, cough, dyspnea, and sputum production. Pain mb referred.
Temp rises rapidly to 100.4-105 F, pulse 100-140/min, respirations 20 to 45/min. Also common
are nausea, vomiting, malaise, myalgias. Cough dry mb initially, but usually becomes productive
with purulent, blood streaked or "rusty" sputum. In patients at age extremes, symptoms may not
be as obvious.
Pneumocystis: progressive dyspnea, tachypnea, cyanosis; dry, nonproductive cough evolving in
subacute fashion over several weeks or acutely over several days. Nearly all patients have
immunologic deficiencies.
Viral: Headache, low fever, myalgia, cough producing mucopurulent sputum
Mycoplasmal: initially resembles influenza, with malaise, sore throat and dry cough. Sx increase in
severity, mb paroxysm of coughing with production of sputum that is mucoid, mucopurulent, or
blood-streaked. Progression gradual (unlike pneumococcal). Acute sx persist 1-2 wks followed by
gradual recovery. Maculopapular rashes (erythema multiforme) occur in 10-20%.
Coccidiomycosis (San Joaquin Valley Fever): ssx mild to severe- moderate fever, cough, pleural
pain, headache, weakness, erythema nodosum or multiforme. Secondary forms can occur weeks
or months after primary infx and can lead to abscess, meningitis, or bone infection
Histoplasmosis: as in Coccidiomycosis, or may present like influenza. A progressive form can be
chronic and look like TB. Mb hepatomegaly, splenomegaly, lymphadenopathy, uveitis, retinitis.
DDx
Etiology/Epidemiology
Pneumococcus (Strep pneumoniae) causes 60-80% of bacterial pneumonias, others caused by
Hemophilus influenza, Klebsiella, group A beta Strep, Legionella, Pneumocystis carinii
Predisposing factors: respiratory viral infection, alcoholism, age extremes, debility,
immunosuppressive disorders and therapy, compromised consciousness, dysphagia, exposure to
transmissible agents.
Mechanism: inhalation of droplets small enough to reach alveoli, aspiration of secretions from
upper airways, hematogenous dissemination via lympatics, directly from contiguous infections
Pathophysiology (RF)
mycoplasma pneumoniae is a frequent cause of atypical pneumonia; it behaves as a extracellular
human parasite and incites epithelial damage of the airways
-interstitial inflammation resembling viral inflammation of intra cellular septa
-no severe exudate as in bronchial bacterial pneumonia
-Pneumonia Infections
Klebsiella & Enterobacteria
-Klebsiella produces severe pneumonia
-more resistant to antibiotics than E. Coli
-bronchiopneumonia ,in chronic alcoholics without homes, which produces pus and exudate that
plugs airway and prevents air escape
PNEUMONIA
Pneumocystis carinii (Protozoa)
-no life cyle outside human
-lives as a commensal grazing on epith. lining of the alveolar cells (I &II)
-fairly common, only appears: long term corticosteriods, immune suppressed, children in
Somalia(protein and calorie def.)
-principal reasons for activation: not held at bay by macrophages because no T cell support;
AAlso long term malignancies: ie. Hodgkins-pneumocytis secondary to it.
Pneumococcus (Strep pneumoniae)
-classified under strep as s. pneumoniae
-present in 60 % of individuals in the winter time in nasal secretions; sensitive to pencillin
-a gram positive diplococcus; 80 serotypes based on different cell capsules; normally colonize the
pharynx
-carbohydrate capsule around cell wall is slippery, so neutrophils have difficulty phagocytotizing it.
-damage of mucociliary escalator can predispose to pathogenesis
-most common cause of lobar pneumonia but can also produce bronchopneumonia, upper
respiratory infections, sinusitis, middle ear infections(major cause of infection in children), and
mastoid infections
-severe consequences are meninigitis or brain abscess when it spreads through the blood
-pneumococcal pneumonia has a high mortality if untreated; seen among the aged, debilitated,
and immunosuppressed
-disseminate to pneumococcemia, a serious consequence which can lead to meningitis (40%
mortality rate even when treated)
Key PE
EXAM
Pneumococcal: mb pleural rub, increased fremitus, local fine crackles, dullness, bronchial breath
sounds, pectoriloquy, egophony
Pneumocystis: minimal auscultatory signs except perhaps diffuse crackles
Viral: diffuse fine crackles and wheezes or WNL
Mycoplasma: as in bacterial or WNL
Fungal: physical signs mb absent, or occasional rales and areas of dullness to percussion mb
present
X-RAY
Pneumococcal: dense consolidation usually unilateral, confined to single lobe
Pneumocystis: diffuse bilateral interstitial infiltrates
Viral: interstitial pneumonia or peribronchial thickening, or WNL
Mycoplasmal: variable, but most commonly show patchy bronchopneumonia in lower lobes
Key Lab
CBC, sputum gram stain/culture
Pneumococcal: leukocytosis w/ shift to left, gram stain shows gram + lancet-shaped diplococci in short chains,
>=10 typical morphotypes per oil immersion
Pneumocystis: organism identified on stained slide of lung material derived from bronchial
brushing, open lung biopsy; aspirates of tracheobronchial mucous mb positive as well
Viral: peripheral WBC count often low, but mb normal or moderately elevated
Mycoplasmal: Gram stain shows sparse bacteria, mixture of PMNs and macrophages, and
clumps of desquamated respiratory epithelial cells.
Fungal: skin test 10-20 days after infection; organism found in sputum; eos mb high
Strategy
Evaluate carefully: fulminant cases in the compromised patient must receive aggressive therapy in
hospital setting.
Skilled Dx based on history, palpation and auscultation obviates the need for X-Ray (RB)
Very responsive to drugless therapy in appropriately selected cases (2)
PNEUMONIA
TX PROTOCOLS
Nutrient Considerations
Vit A 25,000-100,000 IU/day (2,10); dose varies w/ viscosity of mucous (BB)
Vit C 500-1000 mg/hr (2,10)
Vit E, B-complex, Zn & Se(2,10); Bioflavonoids (EM,10)
Adequate protein (10) and water (2)
Glandulars: Thymus, lymph, spleen (2)
Eliminate dairy and known allergens (2)
Calcium: 1000 mg qd (viral/mycoplasma)
Magnesium: 500 mg qd
Zinc: 50 mg qd
B complex
Vit D 4000 qd
Dietary Considerations
Pneumococcal pneumonia: papaya, pineapple, sprouts
Botanicals
Tnct: Phytolacca(4)-Glycyrrhiza fl.ext.(4)-Echinacea(4)-Grindelia(2)-Lobelia(2)
sig: 30 gtt qid (RB)
Glycyrrhiza powdered extract (EM) Anti-inflammatory.
Eucalyptus oil: Steam inhalation (EM, 5) Anti-bacterial.
Bryonia alba tnct: 1-5 bid. (11,5) With sharp chest pain.
Allium sativa (12)
Aconite tnct: 1/2-2 minim (5)
Ipecac, Turpentine, or Strophanthus (5)
Symphytum, Veratrum, Quebracho, or Asclepias (6)
Sanguinaria
Viral pneumonia: Lomatium isolate, Thymic fractions (SSL)
Pneumococcal pneumonia: Valerian fluid ext: 10 gtt qid, Echinacea tinct: 30 gtt 5x/day
Hydrastis tinct: 20 gtt qid, Leptandra tinct: 10 gtt tid, Bee propolis
Homeopathy
Prescribe constitutionally
Physical Medicine
Diathermy to chest (BB,RB)
Postural drainage, rest (2)
Mustard plaster to chest (BB,5)
Color therapy: green light, potentized oil to chest (13)
Hydrotherapy: Cold compresses (RC), Revulsive poultices: hot moist to back, cold to front
Castor oil poultice
Sine wave to spleen, liver, thymus
Thoracic adjustment (T9)
Colonic--lung reflex
Oriental Medicine
Acupuncture: LU7, K3,24-27, ST 13-16, BL 42-44, 36-37, LI 3-4, SP21, LV14 (14)
Other
Bed rest important
Postural drainage and percussion -- AM and at bedtime (4)