Clinical Manifestations Of Pneumonia Research Articles

The Emergence of Linezolid-Resistant Staphylococcus Epidermidis in the COVID-19 Hospitalized Intubated Patients in North Khorasan, Iran.

The present study aimed to investigate secondary bacterial infections among patients infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Coagulase-negative Staphylococci can infect immunocompromised patients. Linezolid resistance among Staphylococcus epidermidis is one of the most critical issues. In 2019, 185 SARS-CoV-2-positive patients who were admitted to North Khorasan Province Hospital (Bojnurd, Iran), were investigated. Patients having positive SARS-CoV-2 reverse transcriptase real-time polymerase chain reaction (RT-PCR) test results, who had a history of intubation, mechanical ventilation, and were hospitalized for more than 48 hours were included. After microbiological evaluation of pulmonary samples, taken from intubated patients with clinical manifestation of pneumonia, co-infections were found in 11/185 patients (5.94%) with S. epidermidis, Staphylococcus aureus, and Acinetobacter baumani, respectively. Remarkably, seven out of nine S. epidermidis isolates were linezolid resistant. Selected isolates were characterized using antimicrobial resistance patterns and molecular methods, such as Staphylococcal cassette chromosome mec (SCCmec) typing, and gene detection for ica, methicillin resistance (mecA), vancomycin resistance (vanA), and chloramphenicol-florfenicol resistance (cfr) genes. All of the isolates were resistant to methicillin, and seven isolates were resistant to linezolid. Nine out of 11 isolated belonged to the SCCmec I, while two belonged to the SCCmec IV. It should be noted that all patients had the underlying disease, and six patients had already passed away. The increasing linezolid resistance in bacterial strains becomes a real threat to patients, and monitoring such infections, in conjunction with surveillance and infection prevention programs, is very critical for reducing the number of linezolid-resistant Staphylococcal strains. A preprint of this study was published at https://europepmc.org/article/ppr/ppr417742.

Vimentin affects inflammation and neutrophil recruitment in airway epithelium during Streptococcus suis serotype 2 infection

Streptococcus suis serotype 2 (SS2) frequently colonizes the swine upper respiratory tract and can cause Streptococcal disease in swine with clinical manifestations of pneumonia, meningitis, and septicemia. Previously, we have shown that vimentin, a kind of intermediate filament protein, is involved in the penetration of SS2 through the tracheal epithelial barrier. The initiation of invasive disease is closely related to SS2-induced excessive local inflammation; however, the role of vimentin in airway epithelial inflammation remains unclear. Here, we show that vimentin deficient mice exhibit attenuated lung injury, diminished production of proinflammatory cytokines interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and the IL-8 homolog, keratinocyte-derived chemokine (KC), and substantially reduced neutrophils in the lungs following intranasal infection with SS2. We also found that swine tracheal epithelial cells (STEC) without vimentin show decreased transcription of IL-6, TNF-α, and IL-8. SS2 infection caused reassembly of vimentin in STEC, and pharmacological disruption of vimentin filaments prevented the transcription of those proinflammatory cytokines. Furthermore, deficiency of vimentin failed to increase the transcription of nucleotide oligomerization domain protein 2 (NOD2), which is known to interact with vimentin, and the phosphorylation of NF-κB protein p65. This study provides insights into how vimentin promotes excessive airway inflammation, thereby exacerbating airway injury and SS2-induced systemic infection.

ХАРАКТЕРИСТИКА КЛИНИКО-ГЕМАТОЛОГИЧЕСКИХ ПОКАЗАТЕЛЕЙ У ПАЦИЕНТОВ С COVID-19 АССОЦИИРОВАННОЙ ПНЕВМОНИЕЙ

Purpose of research. Assessment of the features of the clinical course of pneumonia associated with COVID-19, as well as hemogram and lymphocytic index parameters in patients with the first wave of SARS-CoV-2 coronavirus spread. Material and methods. The study included 60 patients with COVID-19 associated pneumonia (Group 1), 30 patients with bilateral community-acquired pneumonia not associated with COVID-19 (Group 2). The clinical manifestations of pneumonia and the parameters of the complete blood count were evaluated. Results. At the onset of the disease the patients of Group 1 were found to have fever (p=0.006) and dry cough (p=0.028) more often, the severity of fever being higher (p=0.019), crepitus being less frequently detected during auscultation of the lungs (p=0.03), slower regression of symptoms of pneumonia being characteristic (p=0.02) as well. Complete blood count more often determined a dysregenerative shift of the leukocyte formula to the left, manifested by an increase in the relative number of stab forms of neutrophils with a normal or reduced total number of leukocytes. As many as 45.0% patients of Group 1 showed elevated lymphocytic index (so-called excessive activation), 48.3% patients had reduced lymphocytic index, which indicates a tendency to the incompleteness of the immune responses. The inverse relationship between the lymphocytic index and the severity of pneumonia according to computed tomography (r=-0.34, p=0.0018) was established. Conclusion. Patients with COVID-19 associated pneumonia have specific clinical symptoms and hematological blood parameters as compared to those with community-acquired nonspecific pneumonia.

Karakteristik Klinik dan Pola Antibiotik pada Pasien Rawat Inap Coronavirus Disease 2019 di Rumah Sakit Wava Husada Malang

Coronavirus Disease 2019 (COVID-19) is an infection caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), which resulted in the clinical manifestation of pneumonia. A virus mainly causes pneumonia COVID-19, but bacterial co-infection plays a role in increasing mortality. This case series aimed to identify clinical characteristics and antibiotic use in treating COVID-19 patients at Wava Husada Hospital Malang. Data of a total sample of 21 patients selected from March to August 2020 showed moderate to severe infection and was further analyzed descriptively. The mean age of patients was 52±13 years, and 62% were men. Meanwhile, the most common symptoms were shortness of breath and cough with 81% and 76.2%, respectively. Several symptoms found include fever, diarrhea, nausea/vomiting, dizziness, and anorexia at 57.1%, 19%, 33.3%, 14.3%, and 4.8%. The patients had radiological features of pneumonia, where most of them had normal leukocyte and low lymphocyte counts. Additionally, 76.2% or 16 patients received antibiotic monotherapy, and 23.8% or 5 patients received the combination. Levofloxacin is the most commonly administered antibiotics, either single or combined, with a median duration of 11 days. Patients' length of stay ranged from 12 to 24 days; where 71.4% were discharged home, and 28.6% died. Procalcitonin measurement should be attempted as a stewardship strategy for using antibiotics in COVID-19 patients.

Post-Mortem Metabolomics: A Novel Approach in Clinical Biomarker Discovery and a Potential Tool in Death Investigations.

Metabolomics can be defined as the scientific field aiming at characterizing all low-weight molecules (so-called metabolites) in a biological system. At the time of death, the level and type of metabolites present will most likely reflect the events leading up to death.In this proof of concept study, we investigated the potential of post-mortem metabolomics by identifying post-mortem biomarkers, correlated these identified biomarkers with those reported in clinical metabolomics studies, and finally validated the models predictability of unknown autopsy cases. In this post-mortem metabolomics setting, ultra-high performance liquid chromatography-quadrupole time-of-flight mass spectrometry data from 404 post-mortem samples, including pneumonia cases and control cases, were processed using XCMS (R). Potential biomarkers were evaluated using principal component analysis and orthogonal partial least squares-discriminant analysis. Biomarkers were putatively annotated using an in-house database and the online databases METLIN and HMDB. The results showed that clear group separation was observed between pneumonia cases and control cases. The metabolites responsible for group separation belonged to a broad set of biological classes, such as amino acids, carnitines, lipids, nicotinamides, nucleotides, and steroids. Many of these metabolites have been reported as important in clinical manifestation of pneumonia. For the unknown autopsy cases, the sensitivity and specificity were 86 and 84%, respectively. This study successfully investigated the robustness and usability of post-mortem metabolomics in death investigations. The identified post-mortem biomarkers correlated well with biomarkers reported and identified through clinical research.

Pleurisy in patients with chronic lymphoid leukemia

Aim . To establish the clinical and laboratory features of the pleurisy course in patients with chronic lymphocytic leukemia (CLL) living in the Amur Region. Materials and methods . We studied the case histories and outpatient records of 75 patients with CLL in stages B and C according to the J.Binet classification who were treated in the hematology department of the Amur Regional Clinical Hospital in 2012-2018. Results . Exudative pleurisy was found in 28 patients (37%). The most common cause of pleurisy in patients with CLL was lymphoid infiltration of the pleura (18 patients), less often – infectious pleurisy developed (10 patients). Based on the study of the peculiarities of the course of specific lymphoproliferative and infectious pleurisy, significant differences in the clinical course and laboratory data were established. With infectious pleurisy, “pleural” manifestations and clinical manifestations of pneumonia, the complication of which it was, prevailed; in laboratory examination of exudate, neutrophils prevailed. The prognosis of infectious pleurisy is favorable in most cases. The clinical picture of the tumor process prevailed in specific lymphoproliferative pleurisy, in the laboratory study of exudate ‒ tumor lymphocytes, the hemorrhagic nature of the fluid. Specific lymphoproliferative pleurisy occurs at the stage of malignant transformation of CLL, often being its first manifestation. Conclusion . The attachment of the specific lymphoproliferative pleurisy is an unfavorable prognostic factor for patients with CLL.

Radiology Diagnostics of a New Coronavirus Infection in Pregnant Women. Experience of O.M. Filatov Municipal Clinical Hospital No. 15, Moscow

Background. The pandemic of coronavirus pneumonia (COVID-19) is spreading globally at an accelerated rate and is a major health problem. The purpose of this study was to assess the possibility of using a combination of radiation diagnostic methods in lung lesions in pregnant women, with confirmed coronavirus infection and suspected COVID-19 pneumonia, hospitalized in O.M. Filatov Municipal Clinical Hospital No. 15, Moscow.
 Methods. Retrospectively analyzed changes in lung parenchyma and pleura detected by multispiral computed tomography of chest organs and pulmonary ultrasound in 90 pregnant patients with clinical manifestations of viral pneumonia and confirmed coronavirus infection.
 Results. Examined 90 patients with clinical manifestations of pneumonia and PCR-confirmed COVID-19. Among the clinical manifestations, coughing, fever, shortness of breath prevailed. Most changes detected by lung tomography (performed in 92% of patients), had a polysegmental and bilateral character, were more often localized in the peripheral departments, in 74 (89%) patients were involved in a pathological process of more than two lobes, in 77 (93%) of the patients were determined the centers of pulmonary tissue compaction by the type of ground glass, and the combination of the above manifestations with the presence of foci of consolidation and reticular changes was noted in 23 (28%) cases. Among the complications more common: thickening of the pleura, hydrothorax, less often pneumothorax. In 43 (48%) patients, MSCT was supplemented by ultrasound examination of the lungs and pleura, and in 21 (23%) patients, ultrasound was used in isolation as a dynamic control tool to reduce dose load and comply with the ALARA principle, while in 7 (8%) patients, ultrasound was used as the only diagnostic tool due to refusal to perform MSCT.
 Conclusion. Radiosemiotics of lung lesions in pregnant women with COVID-19, detected in MSCT of thoracic organs, does not differ from that in non-pregnant patients. The appearance of specific zones of pulmonary tissue compaction in the form of a gound glass, as a manifestation of a unilateral or bilateral, mono- or polyphocal lung lesion, is highly likely to indicate a manifestation of COVID-19. Pulmonary ultrasound also allows detecting characteristic changes in lung parenchyma and pleura in pregnant women, correlating with MSCT data, primarily in patients with medium-severe forms of pneumonia. Use of ultrasonography corresponds to the principle of ALARA in medicine, remaining a choice method with the women refusing the visualization interfaced to beam loading that can be used in the period of COVID-19 pandemic.

The report of two cases infection with novel coronavirus (2019-ncov) after kidney transplantation and the association literature analyzation/ 中华器官移植杂志

Objective To investigate the clinical experience of patients with novel coronavirus (2019-ncov) infection after kidney transplantation. Method Clinical data of two patients with 2019-nCoV infection after renal transplantationin Jan 2020 Renmin Hospital of Wuhan Universiyt were retrospectively analyzed.Case 1 was a 48-year-old male with CMV pneumonia secondary to 2019-nCoV infection at 4 months after transplantation. CT imaging showed multiple patchy ground-glass images of both lungs. Case 2 was a 59-year-old male, who was screened positive for 2019-nCoV nucleic acid due to fever at 9 days after renal transplantation and showed no clinical manifestations of pneumonia. After diagnosis, case 1 was transferred to a designated hospital for isolation. Treatment regimens: cefoperazone sulbactam sodium + linezolid to resist infection, gamma globulin to enhance immunity function, methylprednisolone to control inflammatory response, antiviral regimens including arbidol tablets + lopina-velitonavir tablets. Case 2 was treated with isolated treatment in a single room. The treatment plan included anti-infection (cefoperazone sulbactam sodium), enhancing immunity function (gamma globulin), antivirus therapy with arbidol and other symptomatic treatment. Result Follow up with 3 weeks, case 1 recovered with renal dysfunction, nucleic acid test with nasopharyngeal swabs turned negative, and pulmonary imaging improved. Case 2 showed no obvious clinical symptoms, and the nucleic acid test of nasopharyngeal swabs turned negative for 3 times. Conclusion Renal transplant recipients should receive fine protection to avoid exposure to high-risk environments. Diagnosis should be defined with combination of clinical manifestations, nucleic acid test and pulmonary imaging. At present, there are no antiviral drugs and symptomatic treatment is the main choice. Key words: 2019-nCov; NCP; Kidney transplant; Level III Protection

1464. The Clinical Features of Pneumonia Caused by Legionella pneumophila vs. Streptococcus pneumoniae: A Retrospective Study

BackgroundLegionnaires’ disease (LD) is a serious and often lethal pneumonia caused by Legionella bacteria. From 2001 to 2016, the incidence of Legionnaires’ disease has tripled in the United States. The clinical manifestations of pneumonia caused by L. pneumophilia (LP) may be similar to those caused by Streptococcus pneumoniae (SP). As mortality from Legionella pneumonia is high (15–50%), an investigation of factors that differentiate these two types of pneumonia is required.Methods(1) To determine the clinical features that differentiate community-acquired pneumonia (CAP) caused by LP SG 1 vs. SP; and (2) to assess outcomes associated with CAP caused by LP serogroup 1 vs. SP. W conducted a retrospective chart review of adult patients admitted between January 1, 2013 and October 31, 2017 for confirmed LP or SP pneumonia. Data were collected on demographic and clinical characteristics, comorbidities, month of admission, laboratory values, vital signs, and outcomes. Data were analyzed using Student’s t-test, the chi-squared test and logistic regression with the forward likelihood ratio algorithm.ResultsOf 106 patients, 48.1% had LP, 64.4% were male, 56.6% were black and the mean age was 59.1 ± 15.3 years. The incidence of LP peaked in the summer. Results of univariable analysis are shown in the table.FactorLPSP P-ValueMean Temp. (°F)102.3 ± 1.799.0 ± 9.00.009Diarrhea50%20.4%0.002Male gender78.4%43.6%<0.0001Median CWIC score0.0 (1–4)1.0 (0–13)0.02Mean Na (mEq/L)130.2 ± 4.6132.1 ± 18.90.5From multivariable analysis, predictors of LP were male gender (OR=18.2, P < 0.0001), diarrhea (OR = 3.7, P = 0.05), BMI (OR = 1.2, P = 0.05) and CWIC score (OR = 0.57, P = 0.004). Patients with SP were more likely to require intubation (P = 0.04), an ICU stay (P = 0.004) and to die (P = 0.002).ConclusionOur data suggest that high temperature and diarrhea may be used to help differentiate LP and SP pneumonia. The higher incidence among men requires further investigation. LP demonstrated a higher morbidity and mortality than SP.Disclosures All authors: No reported disclosures.

STUDY OF EXPRESSION OF HBD-1 AND HBD-2 GENES IN EPITHELIAL CELLS OF MUCOUS UPPER AIRWAY IN NEWBORNS WITH PNEUMONIA DEPENDING ON THE CAUSATIVE AGENT

Β-defensins play an important role in protecting the fetus from infection, so the expression of these antimicrobial peptides in the respiratory tract in newborns is really important. In this regard, we set a task of studying the expression of the HBD-1 and HBD-2 genes in the epithelial cells of the mucous of the upper airway in newborns with pneumonia and in healthy newborns, depending on the causative agent. Also, the polymorphic marker G(-20) A in the DEFB1 gene was associated with infectious pathology of newborns (in particular pneumonia). Methods: The microflora and the factors of congenital immunity on the mucous membranes of the upper airway have been studied in two groups: newborns with ventilator-associated and congenital pneumonia. The biological material was scrapings of epithelial cells of the mucous membrane of the upper airway of newborns and puerperas and blood. Results: It was found that the expression of the HBD-2 gene increases 2.3-fold in children who have an infectious agent, but there are no clinical manifestations of pneumonia. A significant decrease in HBD-2 (3.2 times) in patients with pneumonia caused by K. pneumonia was shown. The frequencies of alleles of the DEFB1 gene in the fetal infection group and in the comparison group: allele G - 0.66, 0.79, allele A - 0.34, 0.21, respectively. The frequencies of the genotypes of the test marker in mothers in the ventilator-associated, congenital pneumonia and the comparison group were as follows: GG - 0.78, 0.58, 0.58; AA is 0, 0.25, 0; AG - 0.22, 0.17, 0.42, respectively. In newborns allele G dominated among alleles (frequency was higher than 0.73 in all groups) and genotype GG (frequency exceeded 0.52). Conclusion: In the course of the study, it was confirmed that β-defensins protect the mucous from infectious agents. The results indicate that the genetic marker G (-20) A of the DEFB1 gene is associated with the risk of developing the child's UTI.

Two confirmed cases of severe fever with thrombocytopenia syndrome with pneumonia: implication for a family cluster in East China

BackgroundSevere fever with thrombocytopenia syndrome (SFTS) was first reported in China in 2011. Human-to-human transmission of the virus occurred occasionally in family clusters. However, pneumonia as an onset syndrome was not common in most SFTS cases. Our aim is to report a family cluster of SFTS with clinical manifestation of pneumonia in Shanghai.MethodsEpidemiologic investigations were conducted when a family cluster of severe fever with thrombocytopenia syndrome virus (SFTSV) infection was identified in Shanghai in June 2016. Samples were collected from two secondary cases and two close contacts with fever. SFTSV was detected by Real-Time reverse transcription polymerase chain reaction (RT-PCR).ResultsThere were two confirmed STFS cases and one potential index case. The potential index case became ill on 21 May and died on 31 May. Case A had onset from 4 to 23 June and case B from 8 June to 25 June. All the three cases experienced pneumonia at the early stage of SFTSV infection. Three (3) out of thirty two (32) close contacts had symptoms of fever or cough but were detected STFSV negative by real-time RT-PCR. According to epidemiologic investigations, the potential index case had outdoor activities on a nearby hill. A tick bite could have been the reason for the SFTSV infection in the potential index case as ticks were found both in grassland or shrubs on the hill and also found on mice caught in her house. Both cases A and B had provided bedside care for the potential index case without any protection and had contacted with blood and other body fluids.ConclusionIt was a family cluster of SFTSV infection imported from Jiangsu province located in the east of China. We suggested to become alert to atypical SFTSV infected cases.

Clinical Characteristics of Invasive Pneumococcal Disease of the Mucoid Phenotype：A Case Series

Streptococcus pneumoniae is a gram-positive coccus that causes invasive and non-invasive pneumococcal diseases. Invasive pneumococcal disease (IPD) is defined as an infection confirmed by the isolation of S. pneumoniae from a normally sterile site. IPD has a high mortality rate of around 20% in adults. Colonies of S. pneumoniae show various morphological features which include a mucoid appearance. The production of large amounts of capsular polysaccharide gives colonies of S. pneumoniae their mucoid appearance. This is thought to be a mechanism of microbial escape from phagocyte killing, leading to strong pathogenicity despite their high susceptibility to antibiotics. To our knowledge, the clinical characteristics of patients with mucoid IPD are unknown. We retrospectively analyzed the records of adult patients with IPD of the mucoid phenotype at Teine Keijinkai Hospital, Hokkaido, Japan, between 2009 and 2015. Seven patients (six males) with age range between 62 and 80 years were diagnosed as having mucoid IPD during the study period. Two patients had a history of malignancy and diabetes mellitus respectively, and six patients were living independently. No patients were previously vaccinated with pneumococcal vaccine. Six patients had clinical manifestations of pneumonia; one patient had multiple concomitant complications of mastoiditis, meningitis, and prosthetic joint infection. All isolates were isolated from blood. All isolates were susceptible to beta-lactam antibiotics, while six isolates were resistant to macrolides and chloramphenicol. Based on the Quellung reaction and real-time polymerase chain reaction (PCR) results, one isolate of mucoid phenotype was confirmed as serotype 3 with the penicillin binding protein gene of pbp2x and the macrolide resistant gene of ermB. Although all patients received appropriate antibiotics based on susceptibility testing, four patients required mechanical ventilation and vasopressors. One patient had neurological sequelae (hypacusis) and two patients died during the course of hospitalization. This case series suggests that mucoid IPD can occur in immunocompetent hosts and can cause high mortality. Since most of the mucoid phenotype of S. pneumoniae are serotype 3, widespread use of pneumococcal vaccine is important to prevent morbidity and mortality associated with IPD.

The Role of Genetic Polymorphism of IL-4 (C-589T) and TNfa (G-308A) and Regular Passive Smoking in Clinical Manifestations of Pneumonia in Infants

Objective: This study set out to investigate the relationship between molecular-genetic mechanisms that modulate cytokine in infants whose parents expose them to cigarette smoke and those that do not expose their infants to cigarette smoke with the possible effects on the severity of pneumonia at presentation to hospital. Methods: This cross sectional study recruited infants and parents from a regional Children’s Hospital. The infants where classified into three groups: 1. Where the infant was exposed to cigarette smoke through the mother directly (N = 50).2. The mother did not smoke but the infant was exposed to tobacco smoke from the relatives in the family (N = 50). 3. The infant was in a family in which no one smoked. Analysis of genetic polymorphisms (regional frequencies) and determination of CRP and IgE concentrations were performed to investigate if exposure to cigarette smoke could be linked to the severity of pneumonia. Results: Exposure to cigarette smoke in infants changed the likelihood of the severity of pneumonia. The results suggest a possible link between the duration of clinical manifestation of pneumonia within infants that are exposed to cigarette smoke. Infants who are exposed to cigarette smoke had higher plasma concentrates in both IgE and CRP. Among infants with the mutant variant of the TNF-α (G-308A) gene, infants from households where both parents smoked or had a father who smoked had longer duration of clinical signs of pneumonia than did infants with no exposure to tobacco smoke. The plasma concentration of IgE in infants in families where one or both parents smoke was significantly higher than in infants with no smoke exposure. Conclusion: The study begins to develop evidence that if the newborn infant is exposed to tobacco smoke either directly from their mother or from others in the household including automobiles, the severity of pneumonia is increased. Both nurses and pediatricians should reinforce the consequences of smoke around the baby to all parents at every opportunity.

Review on the Antimicrobial Resistance of Pathogens from Tracheal and Endotracheal Aspirates of Patients with Clinical Manifestations of Pneumonia in Bacolod City in 2013.

Microbiological content specifically bacterial and fungal etiologies from tracheal aspirates in a tertiary hospital in Bacolod City was reviewed for baseline information. A total of 130 tracheal aspirates were subjected for culture to isolate and identify the pathogen and determine their susceptibilities to various antibiotics. Productions of certain enzymes responsible for antibiotic resistance like ESBL (Extended Spectrum Beta-Lactamase), metallo-β-lactamase, and carbapenemase were also studied. Out of 130 specimens, 69.23% were found to be positive for the presence of microorganisms. Most infections were from male patients aging 60 years and above, confined at the Intensive Care Units (ICU). Pseudomonas aeruginosa and Klebsiella pneumoniae were found to be the most frequent bacterial isolates and non-Candida albicans for fungal isolates, respectively. Among the various antibiotics tested, most isolates were found to be resistant to third generation cephalosporins and penicillins, but susceptible to aminoglycoside Amikacin. On the other hand, production of ESBL and carbapenemase was found to be common among members of Enterobacteriaceae especially K. pneumoniae.

Early identification of severe community-onset pneumonia in “frail elderly patient”

The article from Pieralli et al. [1], published in this issue of Internal and Emergency Medicine, underscores the importance of delirium, for the high prevalence and association with mortality, in elderly patients with communityacquired pneumonia (CAP). Despite advances in diagnosis, antimicrobial therapy and medical technologies, CAP remains an important cause of morbidity and mortality, especially in patients who require hospitalization. Approximately 1 in 20 persons over 85 years of age will present a new episode of pneumonia every year, and the incidence is likely to increase in relation to the progressive aging of the general population. In the past decade, the number of hospitalizations due to pneumonia has increased by 34 %, and this increase is primarily seen in people over the age of 75 years, who represent the population of patients with the highest risk of death. Particular attention has recently been directed at the concept of the ‘‘frail elderly patient’’ [2]. Although frailty has been considered synonymous with disability, comorbidity or advanced old age, it has only recently been recognized as a biological syndrome of decreased reserve and resistance to stressors resulting from a cumulative decline across multiple physiologic systems, and causing increased vulnerability to an adverse outcome. Fried et al. [3] developed and validated a phenotype of frailty analyzing a population of 5,317 patients aged 65 years and older. They define frailty as a clinical condition characterized by three or more of the following criteria: unintentional weight loss (10 lbs in the past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. Elderly patients with poor functional status are characterized by a higher risk of developing severe CAP, due to the frequent presence of underlying respiratory and cardiac diseases, alteration of mental status, and immunosuppression; the contemporary presence of renal impairment or hepatic failure. They usually require specific dose adjustment of antibiotic therapy, which may be toxic in this specific patient population. Moreover, older frail patients have a high frequency of aspiration pneumonia and pneumonia due to gram-negative bacilli and other multi-drug resistant (MDR) pathogens. Data are lacking on the prognostic significance of conditions unique to older patients, such as delirium and the coexistence of multiple comorbidities. Hence, the article of Pieralli and coworkers represents an important step forward in the assessment of the importance of delirium as a predictor of in-hospital mortality in elderly patients with CAP. In this study, delirium was highly prevalent (25 % of patients with CAP) during hospitalization and occurred more frequently in patients with an adverse outcome: the occurrence of at least one episode of delirium during the stay increased by 5.7 times the risk of in-hospital death. As reported in Table 1, pneumonia in the elderly patients tends to occur more often with extrapulmonary manifestations than with pulmonary findings: nausea, vomiting, altered sensorium or diarrhea are often present. As reported by Pieralli et al., clinical manifestations of pneumonia, such as fever, cough and self-reporting dyspnea, may frequently be absent. These diagnostic difficulties are further burdened by the fact that the white blood cell count may be within normal limits, and often fever may be absent in this group of patients due to a The commentary refers to the article available at doi:10.1007/s11739-013-0991-1

Round Pneumonia Mimicking Pulmonary Malignancy on F-18 FDG PET/CT

Round pneumonia is well known in the pediatric population; however, it is relatively uncommon in adults. The appearance of round pneumonia may be difficult to distinguish from lung carcinoma on anatomic images. This case illustrates a round pneumonia mimicking a pulmonary malignancy on PET/CT. In patients found to have rapid development of a round pulmonary lesion and clinical manifestations of pneumonia, it may be prudent to treat with empiric antibiotics before invasive diagnostic procedures for malignancy.

Comparison of the clinical and radiographic diagnosis of paediatric pneumonia

Pneumonia causes 3 · 2 million deaths per year in children under 5 years old according to the World Health Organization. In spite of the number of deaths, no single clinical or radiological definition for the diagnosis of pneumonia is widely accepted. To determine the extent of agreement between clinical and radiographic diagnoses of pneumonia, we compared the clinical diagnoses made by an experienced paediatrician with diagnoses based on a paediatric radiologist's interpretation of chest radiographs. In 226 children with respiratory illness brought to a hospital outpatient department in Lesotho, pneumonia was the clinical diagnosis for 39 and the radiographic diagnosis for 40; however, for only 19 children did the 2 diagnoses concur. Children with a radiographic diagnosis of pneumonia tended to have been ill longer, to be older, and to be more likely to have a technically adequate radiograph than children with negative radiographs, independent of the clinical diagnosis. In this comparison, radiographic and clinical diagnoses for pneumonia differed substantially. Some of this discrepancy may be explained by misinterpretation of suboptimal films and different rates of evolution of radiographic and clinical manifestations of pneumonia. Radiographic studies and clinical evaluations produced complementary data in this evaluation: of the 60 children with clinical or radiographic evidence of pneumonia, 14 would not have been treated with an antimicrobial drug without radiography. Wider availability of radiography is needed to supplement clinical examination for the diagnosis of pneumonia, and may be particularly valuable in children more than 18 months old, those who have been ill for more than 6 d, and those with fever.

DIAGNOSIS OF VENTILATOR-ASSOCIATED PNEUMONIA

Ventilator-associated pneumonia is a frequent complication of mechanical ventilation, and it carries a significant added mortality. Proper recognition and treatment of pneumonia are associated with improved outcome. Clinical manifestations of pneumonia, chest radiograph findings, and routine analysis of the tracheal aspirate are inadequate, alone or in combination, in diagnosing pneumonia. This article discusses the methodologies that are presently available for diagnosing pneumonia in ventilated patients. Correct use of these techniques helps the clinician to establish a diagnosis with a high degree of reliability and facilitates the rational use of antibiotic treatment.

Acute life-threatening asthma

Although adrenergic therapy may be lifesaving in patients with severe acute asthma, attention must also be directed toward reversing underlying inflammation with corticosteroids. Other therapy for acute severe bronchospasm is controversial, although inhalant anticholinergic therapy may have adjunctive benefit. Aminophylline or magnesium sulfate may be indicated in those patients with life-threatening asthma who do not respond to conventional therapy. Chest radiographs are needed in patients who (1) present in extreme distress, (2) need to be hospitalized, or (3) have clinical manifestations of pneumonia or pneumothorax. Antibiotics are not used for acute asthma in the absence of pneumonia.

Pneumonia in pediatric outpatients: Cause and clinical manifestations

The cause and clinical manifestations of pneumonia were studied in 98 pediatric outpatients. A viral diagnosis was established in 38 (39%) of the 98 patients, and a bacterial diagnosis in 19 (19%). Ten (53%) of the 19 patients with bacterial pneumonia had a concurrent viral infection. No clinical, laboratory, or radiographic findings that would reliably differentiate viral from bacterial infection were identified. This study suggests that bacterial pneumonia is more common in pediatric outpatients than previously reported, and that the clinical, laboratory, and radiographic findings in patients with bacterial infection may be indistinguishable from findings in patients with viral infection.