Radiological Diagnosis Of Pneumonia Research Articles

SARS-CoV-2 vs Streptococcus pneumoniae: a comparison of clinical features, laboratory findings, and clinical outcomes in patients hospitalized at Alessandria’s General Hospital

Aims: the aim of the present study was to compare the clinical, anamnestic, and laboratory features and outcomes of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pneumonia and pneumonia caused by Streptococcus pneumoniae in hospitalized patients at the General Hospital of Alessandria, Italy. Materials and Methods: radiological diagnosis of pneumonia by chest X-ray and/or chest Computed Tomography (CT); microbiological diagnosis of SARS-CoV-2 infection by nasopharyngeal swab Reverse Transcriptase - Polymerase Chain Reaction (RT-PCR), etiological diagnosis of S. pneumoniae pneumonia by positive urinary antigen detection and/or isolation of S. pneumoniae from respiratory and/or blood cultures. Results: 222 patients were included, 171 with SARS-CoV-2 pneumonia and 51 with S. pneumoniae. SARS-CoV-2 group most frequently treated with antiviral drugs: 139/171 (81.3%) vs 1/51 (2.1%); p<0.001; they often needed oxygen therapy: 142/171 (83%) vs 27/51 (56.3%); p<0,001; and non-invasive mechanical ventilation: 59/171 (34.5%) vs 7/51 (14.6%); p=0.004. Mortality was higher in SARS-CoV-2 pneumonia patients: 46/171 (26.9%) than in pneumococcal pneumonia patients 5/51 (9.8%); p=0.011. Conclusions: the study showed the increased prevalence of pneumonia caused by SARS-CoV-2 and S. pneumoniae in males than in females. Moreover, patients with SARS-CoV-2 pneumonia represent higher risk group for complications and death than S. pneumoniae.

Vitamin D as an adjunct to antibiotics for the treatment of acute childhood pneumonia.

Children with acute pneumonia may be vitamin D deficient. Clinical trials have found that prophylactic vitamin D supplementation decreases children's risk of developing pneumonia. Data on the therapeutic effects of vitamin D in acute childhood pneumonia are limited. This is an update of a Cochrane Review first published in 2018. To evaluate the efficacy and safety of vitamin D supplementation as an adjunct to antibiotics for the treatment of acute childhood pneumonia. We searched CENTRAL, MEDLINE, Embase, and two trial registries on 28 December 2021. We applied no language restrictions. We included randomised controlled trials (RCTs) that compared vitamin D supplementation with placebo in children (aged one month to five years) hospitalised with acute community-acquired pneumonia, as defined by the World Health Organization (WHO) acute respiratory infection guidelines. For this update, we reappraised eligible trials according to research integrity criteria, excluding RCTs published from April 2018 that were not prospectively registered in a trials registry according to WHO or Clinical Trials Registry - India (CTRI) guidelines (it was not mandatory to register clinical trials in India before April 2018). Two review authors independently assessed trials for inclusion and extracted data. For dichotomous data, we extracted the number of participants experiencing the outcome and the total number of participants in each treatment group. For continuous data, we used the arithmetic mean and standard deviation (SD) for each treatment group together with number of participants in each group. We used standard methodological procedures expected by Cochrane. In this update, we included three new trials involving 468 children, bringing the total number of trials to seven, with 1601 children (631 with pneumonia and 970 with severe or very severe pneumonia). We categorised three previously included studies and three new studies as 'awaiting classification' based on the research integrity screen. Five trials used a single bolus dose of vitamin D (300,000 IU in one trial and 100,000 IU in four trials) at the onset of illness or within 24 hours of hospital admission; one used a daily dose of oral vitamin D (1000 IU for children aged up to one year and 2000 IU for children aged over one year) for five days; and one used variable doses (on day 1, 20,000 IU in children younger than six months, 50,000 IU in children aged six to 12 months, and 100,000 IU in children aged 13 to 59 months; followed by 10,000 IU/day for four days or until discharge). Three trials performed microbiological diagnosis of pneumonia, radiological diagnosis of pneumonia, or both. Vitamin D probably has little or no effect on the time to resolution of acute illness (mean difference (MD) -1.28 hours, 95% confidence interval (CI) -5.47 to 2.91; 5 trials, 1188 children; moderate-certainty evidence). We do not know if vitamin D has an effect on the duration of hospitalisation (MD 4.96 hours, 95% CI -8.28 to 18.21; 5 trials, 1023 children; very low-certainty evidence). We do not know if vitamin D has an effect on mortality rate (risk ratio (RR) 0.69, 95% CI 0.44 to 1.07; 3 trials, 584 children; low-certainty evidence). The trials reported no major adverse events. According to GRADE criteria, the evidence was of very low-to-moderate certainty for all outcomes, owing to serious trial limitations, inconsistency, indirectness, and imprecision. Three trials received funding: one from the New Zealand Aid Corporation, one from an institutional grant, and one from multigovernment organisations (Bangladesh, Sweden, and UK). The remaining four trials were unfunded. Based on the available evidence, we are uncertain whether vitamin D supplementation has important effects on outcomes of acute pneumonia when used as an adjunct to antibiotics. The trials reported no major adverse events. Uncertainty in the evidence is due to imprecision, risk of bias, inconsistency, and indirectness.

Assessment of Hyponatremia in Pneumonia in Children

Introduction: Pneumonia has been the leading cause of mortality in children. Among the various complications of pneumonia, hyponatremia has often been overlooked which incidentally happens to be the commonest and life threatening as well. There are several reports on high prevalence of hyponatremia in the western countries as an indicator of severity of pneumonia. These researches have been lacking in Nepal.
 Objectives: The objectives of this study was to determine the prevalence of hyponatremia in children between 2 months to 5 years of children with radiologically or clinically proven pneumonia admitted at Birat Medical College & Teaching Hospital (BMCTH) and also to investigate the relationship between serum sodium level and other laboratory parameters.
 Methodology: A descriptive cross-sectional study was carried out at BMCTH on children aged 2 months to 5 years admitted with pneumonia. Those who met the inclusion criteria were included. History and physical examination was done to confirm diagnosis and classify the severity of pneumonia on the basis of WHO classification. A 2ml blood sample was then withdrawn from the patient and taken to the laboratory for serum sodium as well as other relevant parameters.
 Results: A total of 50 children of age ranging from 2 months to 5 years who were admitted with clinical or radiological diagnosis of pneumonia were enrolled in the study. Cough was present in 76% of studied children while fever was present in 92%. Clinical diagnosis revealed majority of children with severe pneumonia (40%).Leukocytosis was seen in 70% of children while acute phase reactants CRP was positive in 86% of the children. Hyponatremia was revealed in 80% of the children with pneumonia. Among children between 2 months to 12 months 20% had severe hyponatremia while children in age group between 1 to 3 years 6% had severe hyponatremia and between 3 to 5 yrs of children 8% had severe hyponatremia. The relation was statistically not significant. Leukocytosis was demonstrated in 58% of children with hyponatremia . The relation however was not statistically significant. CRP was found positive in 76% of children with hyponatremia. This was statistically significant. There were 18% of the children who had very severe pneumonia along with severe hyponatremia. While 14% with severe hyponatremia had severe pneumonia and only 2% of the children with severe hyponatremia had pneumonia. In children with moderate hyponatremia 16% of them suffered from moderate pneumonia and 10% had very severe pneumonia and 4% had pneumonia. Among children with pneumonia 12% had pneumonia only while 2% had severe pneumonia and 6% had very severe pneumonia.
 Conclusion: Children admitted with clinical or radiological diagnosis of pneumonia and were assessed for sodium level. Hyponatremia was detected in children with pneumonia which was statistically significant. Hence along with management of pneumonia, hyponatremia should also be cautiously addressed in these patients.

Diabetes Mellitus Prevalence and Burden among Community Acquired Pneumonia Patients

<strong></strong>This work aimed at measuring the prevalence of Diabetes Mellitus among community acquired pneumonia (CAP) patients and declaring its effect on CAP patient's outcome. Both community acquired pneumonia and diabetes mellitus are common in Egypt, and patients with associated CAP and DM need special care and supervision. This prospective study was carried out on 108 CAP patients admitted to Abassia Chest Hospital during the period from January 2016 to December 2016. Clinical and radiological diagnosis of pneumonia and DM diagnosis were performed. DM recorded a prevalence of 39.8% among community acquired pneumonia patients. Disturbed level of consciousness is more frequent among diabetic patients than non diabetics. Diabetic patients recorded higher rate of hospital admission, longer duration of hospital stay, higher rate of ICU admission and more sever pneumonia than among non diabetic patients. CURB-65 score showed significant positive correlation with HbA1c of the patients. Associated community-acquired pneumonia and diabetes mellitus is frequent in our locality and labor a double burden on the affected patients leading to poorer prognosis, higher rate of hospitalization with longer duration of hospital stay and ICU admission. So CAP patients with DM need intimate care.

The radiological diagnosis of pneumonia in children.

Despite the importance of paediatric pneumonia as a cause of short and long-term morbidity and mortality worldwide, a reliable gold standard for its diagnosis remains elusive. The utility of clinical, microbiological and radiological diagnostic approaches varies widely within and between populations and is heavily dependent on the expertise and resources available in various settings. Here we review the role of radiology in the diagnosis of paediatric pneumonia. Chest radiographs (CXRs) are the most widely employed test, however, they are not indicated in ambulatory settings, cannot distinguish between viral and bacterial infections and have a limited role in the ongoing management of disease. A standardised definition of alveolar pneumonia on a CXR exists for epidemiological studies targeting bacterial pneumonias but it should not be extrapolated to clinical settings. Radiography, computed tomography and to a lesser extent ultrasonography and magnetic resonance imaging play an important role in complicated pneumonias but there are limitations that preclude their use as routine diagnostic tools. Large population-based studies are needed in different populations to address many of the knowledge gaps in the radiological diagnosis of pneumonia in children, however, the feasibility of such studies is an important barrier.

<b>Socioeconomic profile of children hospitalized by community acquired pneumonia</b> - doi: 10.4025/actascihealthsci.v35i2.18746

Acute respiratory infections are frequent and are the leading cause of infant morbidity and mortality. This study aimed to verify the socioeconomic profile of children hospitalized with community-acquired pneumonia. We realized a prospective study where social data were collected by direct interview conducted with parents and guardians and supplemented by information from medical records of children under five years of age hospitalized in wards at Hospital Infantil Pequeno Príncipe in the city of Curitiba. All children had clinical and radiological diagnosis of pneumonia. Twenty-two children were included in the study so. Eighteen children (82%) had family incomes below three minimum wages. In 36% (n = 8) of cases the mother worked outside the home. Living with household smokers was also observed in 36% of cases. Elementary education was found in 82% of mothers. Seventeen children (77%) were breastfed for less than six months. Nine children attended day care. Less than 14% (n = 3) of the children were daughters of teenage mothers. This study underscored the importance of socioeconomic factors on the morbidity of community pneumonia in childhood, being family income, maternal education and early weaning the factors most frequently rated among the internees.

Multidetector CT investigation of the mummy of Rosalia Lombardo (1918–1920)

Whole-body multidetector computed tomography (CT) was performed on the mummified corpse of two-year-old Rosalia Lombardo, an anthropogenic mummy displayed in the Capuchin Catacombs of Palermo, Sicily, Italy. Rosalia Lombardo reportedly died of bronchopneumonia in 1920 and was preserved by the embalmer and taxidermist Alfredo Salafia with a formaldehyde-based fluid. Rosalia Lombardo's body is still exhibited in the Capuchin Catacombs inside the original glass-topped coffin in which she was placed. Only her head is visible: the rest of her body is covered by a sheet. CT images of Rosalia's body within her coffin were of reduced quality because of distinct metal artifacts caused by the coffin itself. Nevertheless, a detailed radiological analysis was possible for most of the body. Analysis of the data from the CT examination revealed indicators for the historically-reported endovasal and intracavity treatment. Rosalia's entire body was preserved in a remarkable state. The exceptional preservation of her internal organs made it possible to consider a radiological diagnosis of pneumonia. For this study, CT was determined to be the ultimate method for investigation, since Rosalia's body had to be kept untouched in her sealed coffin for conservation purposes. The CT examination offered new insights into the current preservation status of the body, and the superior contrast of CT allowed detailed assessment of different tissues. Post-processing methods provided reconstructions on any desired plane, as well as three-dimensional reconstruction, for the best possible visualization and interpretation of the body.

Contribution of viruses to severe pneumonia in children

ObjectiveCommunity acquired pneumonia (CAP) accounts for more than two million deaths per year in children less than 5years of age, mostly in developing countries. Viruses causing CAP have been identified in up to 50% of patients in studies using the real-time polymerase chain reaction (PCR). This study aimed at screening of viral etiology among hospitalized children with severe pneumonia. MethodsIn this prospective study conducted at Cairo University Children’s Hospital from 31st March 2010 to 1st April 2011 on 733 children admitted with a clinical and radiological diagnosis of pneumonia, nasopharyngeal or throat swabs were analyzed for common respiratory viruses, including respiratory syncytial virus (RSV), human metapneumovirus (hMPV), influenza B (Flu B), human parainfluenza virus (hPIV), influenza A (H1N1) and adenovirus (ADV) using the real time PCR technique. ResultsOne or more respiratory viruses were detected in 311 patients. RSV was the most commonly detected virus isolated in 197(63.3%) followed by hPIV in 38(12.2%), hMPV in 34(10.9%) and ADV in 26(8.4%) patients. Six cases were positive for H1N1 making the virus the second least common, after Flu B, identified in a single patient in our study. Mixed infection with more than one respiratory virus was detected in 156(45%) cases. ConclusionRSV was the most predominantly isolated virus from all patients in addition to being the most common single virus to cause pneumonia in children with chronic diseases. Although the most commonly isolated virus in our study, RSV came third in causing complications following hPIV & H1N1, but this observation cannot be applied to the community.

P17 The Accuracy of a Diagnosis of Pneumonia in a UK Teaching Hospital

Background Obtaining an accurate diagnosis of pneumonia is an essential part of optimal patient care. Analysis of patients’ hospital records allows clinical coding (ICD-10) of admission events which assist development of clinical decision algorithms, assessment of quality of care and public health evaluation. We sought to evaluate the reliability of applied clinical codes and the accuracy of a diagnosis of pneumonia in our institution. Methods A retrospective case note review of all patients admitted to University Hospital Llandough in 2011 with a final clinical code diagnosis of pneumonia. Pneumonia was defined as the presence of new radiographic infiltrate in patients with symptoms consistent with an acute lower respiratory tract infection.1 The chest radiographs of each patient were reviewed by a respiratory physician (KP, HED) and the formal radiology report was independently scrutinised (IM). Results 710 patient episodes of ICD-10 coded pneumonia were identified in a 1 year period at our hospital. Ten patients had no chest x-ray performed and one x-ray had no report. Radiological confirmation of pneumonia (by radiology reporting) occurred in 69.8% (488/699); a radiological diagnosis of pneumonia was made by a respiratory physician (KP, HED) in 71.8% (502/699) of patients. There was 85% agreement between the Respiratory and Radiology reports (592/699 cases) with a kappa of 0.66 (95% CI 0.57 to 0.69). The accuracy of a pneumonia diagnosis differed little between patients cared for by a respiratory physician (72.3% agreement with radiology report) and those admitted to a non-respiratory ward (68.1%). In 27.0% and 31.9% of patients respectively there was no radiological evidence of pneumonia. Conclusions A clinical coding diagnosis of pneumonia is unreliable with 30.2% of patients not having compatible radiograph change. This has implications for the validity of any research performed on data selected on the basis of clinically coded information. Misdiagnosis by clinicians is the most likely reason for this discrepancy. Reference BTS Guidelines for the Management of Community Acquired Pneumonia in Adults Update 2009.

Usefulness of consecutive biomarkers measurement in the management of community-acquired pneumonia

The aim of this study was to investigate whether procalcitonin (PCT), neopterin, C-reactive protein (CRP), and mid regional pro-atrial natriuretic peptide (MR-proANP) levels at admission and during the clinical course can be useful for the management of patients with pneumonia. The study population consisted of 75 patients with clinical and radiological diagnosis of pneumonia. Serum samples were collected at admission and during hospitalization. Complications were defined as intensive care unit (ICU) admission or death. The levels of PCT were significantly higher in pneumonia of definite bacterial origin in comparison to probable bacterial or unknown origin. The PCT levels were higher in pneumococcal pneumonia. The PCT and MR-proANP levels increased significantly according to the Pneumonia Severity Index (PSI). All biomarkers levels are higher in patients developing complications and who were dying. The serial levels of MR-proANP remain significantly elevated in patients developing complications and in patients classified in PSI and CURB-65 risk groups. In patients not developing complications, there is a significant decrease in the PCT levels. PCT can be useful for identifying pneumonia etiology. PCT and MR-proANP levels correlate with pneumonia severity rules. PCT and MR-proANP serial measurements can be useful for predicting short-term prognosis. Systemic biomarkers can provide additional information regarding clinical evolution, because these are dynamic and can be measured daily.

Does a Parent-Reported History of Pneumonia Increase the Likelihood of Respiratory Symptoms Needing Therapy in Asthmatic Children and Adolescents?

Background. Asthmatic children and adolescents attending outpatient clinics often have a history of pneumonia. Whether respiratory symptoms, lung function, and airway inflammation differ in asthmatic patients with and without a history of pneumonia remains controversial. Aims. To compare clinical, lung functional, and inflammatory variables in asthmatic outpatients with and without a history of pneumonia. Methods. In 190 asthmatic outpatients, aged 6–18 years, we assessed respiratory symptoms, lung function (flows, volumes, and pulmonary diffusion capacity, DLCO/VA), and atopic-airway inflammation as measured by the fractional concentration of exhaled nitric oxide (FENO). A previous medical and radiological diagnosis of pneumonia was defined as “recurrent pneumonia” if subjects had at least three pneumonia episodes or two episodes within a year. Results. Of the 190 outpatients studied, 38 (20%) had a history of pneumonia. These patients had more frequent upper-respiratory symptoms, nighttime awakenings in the past 4 weeks, daily use of inhaled corticosteroids, and lower FENO than the 152 asthmatic children without previous pneumonia (FENO: 20.6 ppb, 95% CI: 15.2–28.0 vs. 31.1 ppb, 95% CI: 27.0–35.8; p < .05). Of the 38 patients with previous pneumonia, 14 had recurrent pneumonia. Despite comparable lung volumes and flows, they also had lower DLCO/VA than asthmatic children with no recurrent pneumonia and asthmatic children without previous pneumonia (DLCO/VA%: 91.2 ± 11.3 vs. 108.5 ± 14.7 vs. 97.9 ± 18.6, p < .05). Conclusion. Respiratory assessment in asthmatic children and adolescents with a history of pneumonia, especially recurrent pneumonia, often discloses symptoms needing corticosteroid therapy, and despite normal lung volumes and flows, mild reductions in the variables reflecting gas diffusion and atopic-airway inflammation (DLCO/VA and FENO). Whether these respiratory abnormalities persist in adulthood remains an open question.

Comparative study of etiological diagnosis of nosocomial pneumonia

Nosocomial pneumonia is a common complication in patients on mechanical ventilation and results in significant mortality. Diagnosis of pneumonia in patients who are intubated and under mechanical ventilation is difficult, even with the aid of clinical, laboratory, and endoscopic tests. The objective of this study was to compare three methods of tracheal sputum collection in patients with a clinical and radiological diagnosis of pneumonia. Twenty-two patients with a clinical diagnosis of liver disease were enrolled, 18 years of age or older, 13 males and nine females, who had been mechanically ventilated over an intubation period of 5.86 +/- 4.62 days. These patients were being treated in intensive care unit (ICU) of the Liver Transplant department. Secretion collection was carried out according to a protocol with three distinct methods: endotracheal aspiration with a closed aspiration system, Bal cath and bronchoalveolar lavage. Of the 22 patients analyzed, 21 (95.4%) showed one or more infectious agent when the closed aspiration system was used. With the Bal cathâ collection, 19 patients (86.3%) had one or more infectious agents; in the collection by bronchoalveolar lavage, 10 patients (45.4%) presented one or more infectious agent. According to the laboratory analysis, 14 different microorganisms were isolated, the most frequent of which were Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pneumoniae. We concluded that aspiration with the closed system produced the most effective results in comparison with those of bronchoalveolar lavage and the Bal cathâ, and may be an acceptable method for diagnosing hospital-acquired pneumonia when no fiberoptic technique is available.

COMPARISON OF SPIRAMYCIN AND CLARITHROMYCIN FOR COMMUNITY‐ACQUIRED LOWER RESPIRATORY TRACT INFECTIONS

SUMMARYThis open multicentre study compared the efficacy and tolerability of clarithromycin and spiramycin in the treatment of lower respiratory tract infections in Brazil and Colombia. A total of 125 patients with a clinical and radiological diagnosis of pneumonia, acute bronchitis or exacerbation of chronic bronchitis were randomised to receive oral doses of either clarithromycin (500 mg) or spiramycin (3 MIL)) every 12 hours for courses of 5‐10 days. Patients were assessed before the start of treatment, and at days 3‐4 and days 9‐17. Twenty‐six (26) patients (16 in the spiramycin group and 10 in the clarithromycin group) reported adverse events, seven of whom withdrew from the trial. Statistical analysis detected no significant differences between efficacy (p=0.768) or tolerability (p=0.236) for the two treatment groups. Spiramycin therefore has similar efficacy to clarithromycin in the treatment of community‐acquired lower respiratory tract infections.

Factors related to child care increase the risk of pneumonia among children living in a poor community in northeast Brazil.

A case-control study in a Brazilian city looked at the increased risk of pneumonia faced by children under age 2 who stayed in day care centers while their mothers were employed. The 650 cases received a radiological diagnosis of pneumonia from the main pediatric hospitals and the 650 controls were of the same age and neighborhood as the cases. It was found that mothers paid employment outside of the house independently increased the occurrence of pneumonia. Risk increased 1.8 times for children whose mothers worked 75% more of the time since the birth than other mothers and attendance at a day care center increased risk more than five times. This may be caused by stress experienced by the child as well as by inappropriate child care practices and increased exposure to pathogens. Since the number of children attending day care centers is increasing it is urgent to devise ways to design and manage day care centers to minimize the risk of pneumonia.

Attendance at day care centers increases the risk of childhood pneumonia among the urban poor in Fortaleza, Brazil.

We carried out a case-control study to investigate risk factors for childhood pneumonia in two groups of 650 children aged under two years in the city of Fortaleza, Ceará, Brazil. The cases were children recruited at the main pediatric hospital with a radiological diagnosis of pneumonia, and controls were children of the same age group recruited from the neighbourhood of the cases. In this paper we focus on variables related to childcare practices. Working mothers, proportion of time the mother had worked since the child was born, and use of day care centers emerged as important risk factors with estimated relative risks of 1.58, 1.76 and 5.22, respectively. Also important were the number of children living in the house and presence of grandparents. However, the presence of siblings under two years and the birth order were not associated with pneumonia. All analysis included adjustment for confounding by income, parents' education, and other risk factors as appropriate. This is the first study from a developing country to identify attendance at day care centers as a risk factor for increased childhood morbidity, in this case pneumonia. This finding is of significant public health importance for countries such as Brazil with growing urban populations and an increasing need by mothers to find work outside the home.

Radiological diagnosis of pneumonia in children.

During 12 months in 1981-82, 201 children were hospitalized due to radiologically verified definite or probable pneumonia. In 1985, 194 chest radiographs (anteroposterior views) were re-evaluated jointly by two radiologists, and classified into three categories: alveolar, interstitial and probable pneumonia. In 127 cases definite pneumonia was diagnosed on both occasions, alveolar in 48 cases and interstitial in 79 cases. Variation between the two evaluations 3 years apart was observed in 46 (24%) of the 194 cases; the adjusted kappa (0.47) was in the modest region. Factors contributing to this variation were young age, less than 12 months, and the presence of interstitial infiltration, bronchial obstruction and low C-reactive protein. Factors associated with less marked variation were the presence of alveolar infiltration, auscultatory fine rates and elevated C-reactive protein. The microbial aetiology of infection, assessed by viral and bacterial antigen and antibody assays, showed no association with diagnostic variation. A lateral view of the chest radiograph was obtained from 158 patients; it was positive in 99 (91%) of the 109 cases with definite pneumonia. In only three cases the diagnosis was based on the lateral view alone. Our results show that the radiological diagnosis of pneumonia is difficult in children, especially in young children with interstitial pneumonia.

The radiological diagnosis of pneumonia in the adult: A commentary

Almost ten years ago, an issue of Seminars in Roentgenology (Vol. 15, No 1) reviewed the radiological aspects of the pneumonias in depth. This article is an effort to update that material and to provide some personal opinions and prejudices. The broad topic of opportunistic lung infection will not be discussed