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Bakterielle Pneumonien
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Organizing pneumonia is a rare subtype of interstitial lung disease that can occur following infectious alveolar insults. Imaging often demonstrates bilateral patchy opacification while biopsy reveals irregular alveolar fibrosis. Steroids are the treatment of choice, resulting in rapid clinical improvement. In this report, we describe a 69-year-old woman with a recent hospitalization for Legionella pneumonia who presented with worsening dyspnea and radiographic evidence of bilateral patchy infiltrates. Differential diagnoses included Legionella treatment failure and organizing pneumonia, therefore she was managed with both antibiotics and steroids. Her clinical status improved significantly the day after treatment initiation, making organizing pneumonia as the likely culprit for her initial decompensation. In patients with a recent history of lung injury who present with acute hypoxic respiratory failure, one must have a high index of suspicion for organizing pneumonia, for prompt treatment often results in rapid recovery.
Background:
The number of reported cases of Legionnaires' disease has increased significantly over the last decade in Switzerland and abroad. Along with the number of cases, the volume of testing has increased as well, which has been partially attributed to a change in awareness of the disease. Yet, while there are numerous guidelines and recommendations for the case management of community-acquired pneumonia, little is known about how physicians in Switzerland perceive and manage Legionnaires' disease.
Methods:
This study aimed to investigate physicians' awareness of Legionnaires' disease, their information resources and their approach to the diagnosis and treatment of pneumonia (and thus Legionnaires' disease). Using a semi-structured interview guide, we conducted in-depth interviews with physicians from different levels of care and from the German-, French- and Italian-speaking regions of Switzerland.
Results:
We conducted 46 interviews with physicians from university, cantonal and regional hospitals as well as with general practitioners (GPs) from all three language regions. Overall, the physicians working in hospitals indicated a similar level of awareness of Legionnaires' disease, and comparable diagnosis and treatment approaches. The Legionella urine antigen test (UAT) was reported to be routinely performed in inpatients. In contrast, GPs indicated lower levels of awareness, reflecting the fact that they treat pneumonia cases empirically without identification of the causative agent, in accordance with current guidelines. The value of the diagnostic tests in general and the Legionella UAT in particular was considered to be dependent on the (preferred) antibiotic treatment approach. Some physicians saw the test as redundant, as its result would not influence treatment. This was tied to concerns about the UAT's sensitivity and its limited use for the detection of Legionella pneumophila serogroup 1. Lastly, extrinsic constraints, such as financial and time considerations also affected physicians' testing and treatment preferences.
Conclusion:
Awareness of Legionnaires' disease is overall high, yet cases are mainly diagnosed and reported by hospitals. Improved diagnostic tools are needed to support physicians in reducing underestimation of Legionnaires' disease and optimise antibiotic stewardship without compromising patient health outcomes.
Introduction:
Pulmonary actinomycosis, clinically and radiologically, mimics abscess, tuberculosis, and lung malignancy, resulting in misdiagnosis or delay in diagnosis. In this study, we analyzed the clinicoradiological features of pulmonary actinomycosis, the presence of any differences between clinical prediagnosis and radiological diagnosis, and whether imaging modalities help distinguish pulmonary actinomycosis from lung cancer.
Methods:
A total of 22 patients who had a histopathological diagnosis of actinomycosis in a tertiary health center participated in this study. Of these, 14 had positron-emission tomography/computed tomography.
Results:
In all, 81.8% of the patients were males. The diagnostic procedures employed for the diagnosis of actinomycosis were surgery in 54.5% of patients, fiberoptic bronchoscopy in 36.4% of patients, and rigid bronchoscopy in 9.1% of patients. Radiological and clinical prediagnosis showed malignancy in 31.8 and 40.9% of patients, respectively. The mean of the maximum standardized uptake value was 6.33±3.6 on positron-emission tomography/computed tomography. Kappa compliance analysis revealed that clinical and radiological diagnoses were significantly compatible with each other and that radiological pre-diagnoses were not superior to clinical diagnoses (κ=0.701 and p<0.001).
Conclusion:
Pulmonary actinomycosis shows high metabolic uptake in positron-emission tomography/computed tomography, and this may mislead clinicians for a diagnosis of malignancy. Our results suggest that positron-emission tomography/computed tomography does not help distinguish pulmonary actinomycosis from lung malignancy and does not provide a clear diagnostic benefit to the clinician, so pathological diagnosis is necessary.
Pulmonary actinomycosis is an uncommon infectious disease. Although the gold standard for diagnosis is histological examination with bacterial culture of lung tissue, cytology samples offer a fast and low-cost alternate diagnostic procedure. The cytology literature on this topic is limited to mostly case reports. Therefore, the aim of this study was to review cytological material in a series of patients with a diagnosis of pulmonary actinomycosis to characterize the main cytomorphological findings. Different cytological respiratory samples including sputum smears, bronchoalveolar lavages (BALs), transthoracic or endobronchial fine needle aspiration cytology (FNAC) and cell block preparations were used for retrospective examination. For all cases patient age, gender, symptoms, and radiological chest findings were recorded. A total of 26 cytological respiratory samples (14 sputum smears, 9 FNAC, two BALs) including direct smears and 6 cell blocks from 9 patients were examined. In sputum smears the most remarkable findings were the presence of dark cotton ball masses with projections like spider legs and/or mouse tails (75% of the samples). Sulfur granules were observed in 4 (40%) of the sputum smears and within FNAC cases. Various respiratory cytology samples including sputum smears, FNAC and BALs can reveal cytomorphological findings diagnostic of pulmonary actinomycosis. Characteristic cytological findings compatible with a diagnosis of this infection include cotton ball masses and less frequently sulfur granules.
Nocardia species and Actinomyces species are 2 of the most commonly diagnosed filamentous bacteria in routine cytopathology practice. These genera share many overlapping cytomorphologic features, including their thin, beaded, branching, Gram-positive, GMS-positive filamentous structures that fragment at their peripheries into bacillary- and coccoid-appearing forms. Features that help distinguish between these 2 microorganisms include the width of their filamentous structures, the angles at which they branch, and their ability or lack thereof to retain a modified acid-fast stain. In addition to cytomorphologic overlap, overlap in clinical presentation is frequent with pulmonary and mucocutaneous presentations seen in both. Differentiating between Nocardia and Actinomyces is essential because patients with these infections require different approaches to medical management. Both antibiotic susceptibilities and the need for early surgical intervention as part of the treatment plan vary greatly among these 2 groups. This review focuses on the clinical presentation, cytomorphology and staining characteristics that can be useful in identifying and distinguishing between Nocardia and Actinomyces infections, as well as their mimickers.
Objective Pulmonary nocardiosis frequently develops as an opportunistic infection in patients with malignant tumor and is treated with steroids. This study was performed to clarify the clinical features of pulmonary nocardiosis in Japan.
Methods The patients definitively diagnosed with pulmonary nocardiosis at our hospital between January 1995 and December 2015 were retrospectively investigated.
Results Nineteen men and 11 women (30 in total) were diagnosed with pulmonary nocardiosis. Almost all patients were complicated by a non-pulmonary underlying disease, such as malignant tumor or collagen vascular disease, or pulmonary disease, such as chronic obstructive pulmonary disease or interstitial pneumonia, and 13 patients (43.3%) were treated with steroids or immunosuppressors. Gram staining was performed in 29 patients, and a characteristic Gram-positive rod was detected in 28 patients (96.6%). Thirty-one strains of Nocardia were isolated and identified. Seven strains of Nocardia farcinica were isolated as the most frequent species, followed by Nocardia nova isolated from 6 patients. Seventeen patients died, giving a crude morality rate of 56.7% and a 1-year survival rate of 55.4%. The 1-year survival rates in the groups with and without immunosuppressant agents were 41.7% and 59.7%, respectively, showing that the outcome of those receiving immunosuppressants tended to be poorer than those not receiving them.
Conclusion Pulmonary nocardiosis developed as an opportunistic infection in most cases. The outcome was relatively poor, with a 1-year survival rate of 55.4%, and it was particularly poor in patients treated with immunosuppressant agents. Pulmonary nocardiosis should always be considered in patients presenting with an opportunistic respiratory infection, and an early diagnosis requires sample collection and Gram staining.
Severe legionella pneumonia poses a diagnostic challenge and requires early intervention. Legionnaire's disease can have several presenting signs, symptoms, and laboratory abnormalities that suggest that Legionella pneumophila is the pathogen, but none of these are sufficient to distinguish L pneumophila pneumonia from other respiratory pathogens. L pneumophila is primarily an intracellular pathogen and needs treatment with antibiotics that efficiently enter the intracellular space.
Objective:
Nocardiosis is an opportunistic infection that primarily affects the lungs. Most infected patients have deficits in cell-mediated immunity such as those with AIDS, transplant recipients, and those receiving corticosteroid therapy. We review the various CT appearances of pulmonary nocardiosis and discuss the differential diagnosis.
Conclusion:
Common CT findings include lung consolidation and nodules and masses. Cavitation may occur. Chest wall involvement develops in a small number of patients.
The pandemic coronavirus disease 2019 (COVID‐19), caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS‐CoV‐2), has affected millions of people worldwide. To date, there are no proven effective therapies for this virus. Efforts made to develop antiviral strategies for the treatment of COVID‐19 are underway. Respiratory viral infections, such as influenza, predispose patients to co‐infections and these lead to increased disease severity and mortality. Numerous types of antibiotics such as azithromycin have been employed for the prevention and treatment of bacterial co‐infection and secondary bacterial infections in patients with a viral respiratory infection (e.g., SARS‐CoV‐2). Although antibiotics do not directly affect SARS‐CoV‐2, viral respiratory infections often result in bacterial pneumonia. It is possible that some patients die from bacterial co‐infection rather than virus itself. To date, a considerable number of bacterial strains have been resistant to various antibiotics such as azithromycin, and the overuse could render those or other antibiotics even less effective. Therefore, bacterial co‐infection and secondary bacterial infection are considered critical risk factors for the severity and mortality rates of COVID‐19. Also, the antibiotic‐resistant as a result of overusing must be considered. In this review, we will summarize the bacterial co‐infection and secondary bacterial infection in some featured respiratory viral infections, especially COVID‐19.
Legionella species are environmental gram-negative bacteria able to cause a severe form of pneumonia in humans known as Legionnaires’ disease. Since the identification of Legionella pneumophila in 1977, four decades of research on Legionella biology and Legionnaires’ disease have brought important insights into the biology of the bacteria and the molecular mechanisms that these intracellular pathogens use to cause disease in humans. Nowadays, Legionella species constitute a remarkable model of bacterial adaptation, with a genus genome shaped by their close coevolution with amoebae and an ability to exploit many hosts and signaling pathways through the secretion of a myriad of effector proteins, many of which have a eukaryotic origin. This review aims to discuss current knowledge of Legionella infection mechanisms and future research directions to be taken that might answer the many remaining open questions. This research will without a doubt be a terrific scientific journey worth taking.
Expected final online publication date for the Annual Review of Pathology: Mechanisms of Disease, Volume 15 is January 24, 2020. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
Background: Pulmonary nocardiosis (PN) is an uncommon but potentially life-threatening infection. Most of our knowledge on PN is derived from case reports and small case series. Increasing incidence rates of PN have been reported recently. The aim of this study was to describe the clinical course of and risk factors for PN in four Western European countries and to estimate population-based annual hospitalization rates. Methods: This was a retrospective evaluation (1995–2011) of the clinical course of and risk factors for PN in patients at 11 hospitals in four European countries (Germany, Austria, Switzerland, and the Netherlands). Population-based estimates of hospitalization rates for PN in Germany (2005 to 2011) were calculated using official German nationwide diagnosis-related groups (DRG) hospital statistics. Results: Forty-three patients fulfilled stringent criteria for proven (n = 8) and probable (n = 35) PN; seven had extrapulmonary dissemination. For these 43 patients, the major risk factors for PN were immunocompromising (83.7%) and/or pulmonary (58.1%; as only comorbidity in 27.9%) comorbidities. The median duration of PN targeted therapy was 12 weeks. Distinctive patterns of resistance were observed (imipenem susceptibility: Nocardia farcinica 33.3%; Nocardia asteroides 66.7%). The overall mortality rate was 18.9% (50% in disseminated PN). Over time, annual PN hospitalization rates remained unchanged at around 0.04/100 000, with the highest rate among men aged 75–84 years (0.24/100 000). Conclusions: PN is a rare, but potentially life-threatening disease, and mainly affects immunocompromised elderly males. Overall, annual hospitalization rates remained stable between 2005 and 2011.
With its award-winning, innovative approach, the new edition of Practical Pulmonary Pathology, by Kevin O. Leslie, MD and Mark R. Wick, MD, provides comprehensive, practical guidance in the accurate identification and interpretation of neoplastic and non-neoplastic diseases of the lungs. Lavishly illustrated in full color throughout, this "one-stop" resource captures key morphologic patterns for a full range of common and rare conditions and assists in the interpretation of complex diagnostic puzzles. An easily accessible format with a unique "visual index" places in-depth diagnostic guidance quickly at your fingertips-in print or online at www.expertconsult.com.
Before 1945, Streptococcus pneumoniae caused more than 90% of cases of pneumonia in adults. After 1950, the proportion of pneumonia caused by pneumococcus began to decline. Pneumococcus has continued to decline; at present, this organism is identified in fewer than fewer10%-15% of cases. This proportion is higher in Europe, a finding likely related to differences in vaccination practices and smoking. Gram-negative bacilli, Staphylococcus aureus, Chlamydia, Mycoplasma, and Legionella are each identified in 2%-5% of patients with pneumonia who require hospitalization. Viruses are found in 25% of patients, up to one-third of these have bacterial coinfection. Recent studies fail to identify a causative organism in more than 50% of cases, which remains the most important challenge to understanding lower respiratory infection. Our findings have important implications for antibiotic stewardship and should be considered as new policies for empiric pneumonia management are developed.
Imaging examinations are often performed in patients with Legionnaires’ disease. The literature to date has documented that the imaging findings in this disorder are relatively nonspecific, and it is therefore difficult to prospectively differentiate legionella pneumonia from other forms of pneumonia, and from other noninfectious thoracic processes. Through a review of clinical cases and the literature, our objective is for the reader to gain a better understanding of the spectrum of radiographic manifestations of Legionnaires’ disease.
Dail and Hammar's Pulmonary Pathology has established itself as the definitive reference in the field. This third edition is now a two-volume, full color text and has been thoroughly updated to cover newly recognized entities and the latest advances in molecular diagnostic techniques. It is abundantly illustrated with more than 2,000 illustrations in total, 1,900 of which are in full color. This outstanding contribution to pathology literature is a must-have for the library of every surgical and pulmonary pathologist. It has set the standard for which all other pathology texts strive to achieve. This first volume focuses on Non-neoplastic lung diseases, and Volume II covers Neoplastic Lung Diseases. New chapters include information on the pathology of small airways disease; forensic lung pathology; molecular genetics of lung and pleural neoplasms and pre-invasive disease. This new edition also includes two chapters devoted to molecular pathology that are a compendium of information on the molecular pathology of lung tumors as well as a primer on basic molecular pathology. © 2008 Springer Science+Business Media, LLC. All rights reserved.
Since first identified in early 1977, bacteria of the genus Legionella are recognised as a common cause of community-acquired pneumonia and a rare cause of hospital-acquired pneumonia. Legionella bacteria multisystem manifestations mainly affect susceptible patients as a result of age, underlying debilitating conditions, or immunosuppression. Water is the major natural reservoir for Legionella, and the pathogen is found in many different natural and artificial aquatic environments such as cooling towers or water systems in buildings, including hospitals. The term given to the severe pneumonia and systemic infection caused by Legionella bacteria is Legionnaires' disease. Over time, the prevalence of legionellosis or Legionnaires' disease has risen, which might indicate a greater awareness and reporting of the disease. Advances in microbiology have led to a better understanding of the ecological niches and pathogenesis of the condition. Legionnaires' disease is not always suspected because of its non-specific symptoms, and the diagnostic tests routinely available do not offer the desired sensitivity. However, effective antibiotics are available. Disease notification systems provide the basis for initiating investigations and limiting the scale and recurrence of outbreaks. This report reviews our current understanding of this disease.
Copyright © 2015 Elsevier Ltd. All rights reserved.
Wir berichten über zwei Patienten, die uns unter dem Verdacht auf einen malignen Prozess zugewiesen wurden. In beiden Fällen wurde eine thorakale Aktinomykose diagnostiziert. Ein 76-jähriger Patient wies eine endobronchiale und pulmonale Aktinomykose auf, vergesellschaftet mit einer Broncholithiasis. Die Diagnose wurde bronchoskopisch gestellt. Unter einer antimikrobiellen Therapie mit Ampicillin und Sulbactam kam es zur Ausheilung. Im Falle des zweiten 36-jährigen Patienten lag eine ausgedehnte perikardiale, mediastinale und pulmonale Aktinomykose mit Pleuraergüssen beidseits, Perikarditis konstriktiva und oberer Einflussstauung vor. Die Diagnose wurde operativ im Rahmen einer kardiochirurgischen Perikardektomie gestellt. Der Heilungsprozess verlief protrahiert mit zufriedenstellendem Ergebnis.
Wir diskutieren die Notwendigkeit des Einschlusses der Aktinomykose in die Differenzialdiagnose pulmonaler Verschattungen und mediastinaler Raumforderungen, um diagnostische Irrwege zu vermeiden und invasive Eingriffe auf das notwendige Minimum zu reduzieren und illustrieren die Notwendigkeit einer individualisierten Therapie.
Actinomyces and Nocardia species are frequently overlooked pulmonary pathogens until their presence is histologically proved. These infections often are not considered in the differential diagnosis of lung disease because of the spectrum of their presentation, the similarity of their appearance to other granulomatous or neoplastic diseases, and coexistence of these infections with other pulmonary conditions. Pulmonary actinomycosis is characterized by pulmonary consolidation, frequently with cavitation and spread to contiguous tissues without regard for normal anatomic barriers. The appearance often is confused with that of bronchogenic carcinoma or other granulomatous infections, especially tuberculosis. Pulmonary nocardiosis most frequently develops in immunocompromised patients, and the incidence of this infection is increasing. The radiographic manifestations of nocardiosis are pleomorphic, but early recognition is essential to initiate appropriate therapy.
A comprehensive and authoritative review of the clinical, epidemiologic, pathologic and microbiologic features of legionellosis is presented. Clinically, the non-pneumonic, self-limited, non-fatal Pontiac fever is distinguished from the more severe Legionnaires' disease, which is characteristically an acute pneumonic illness that can have prominent multisystem manifestations and has a case-fatality ratio of 15-20%. The diagnosis of legionellosis is usually confirmed by the demonstration of a 4 fold rise in indirect fluorescent antibody titer to ≥128, by demonstration of the organism by direct immunofluorescence in lung tissue, pleural fluid, respiratory secretions, or by its isolation from these specimens and blood. Treatment with erythromycin for at least 3 weeks is recommended. When rifampicin, which is highly effective in experimental animals, is used it should not be used alone because of the potential for development of resistant strains. Factors predictive of an unfavourable outcome of Legionnaires' disease include age, and immunosuppression, while initial clinical features associated with a poor prognosis include tachypnea (≥30/min) tachycardia (≥110/min), elevated serum urea nitrogen and creatinine concentrations, total white cell counts and percentage of segmented white blood cells, hypoxemia, hyponatremia, hematurea, and bilateral abnormalities on chest radiograph. Nineteen epidemics have been investigated by the Center for Disease Control, while sporadic cases occur frequently. The incubation period for Pontiac fever is 20 to 48 hours and for Legionnaires' disease 2 to 10 days. In some outbreaks cooling towers have been established as the source and the transmission in these cases has been airborne. L. pneumophila can cause both lobar pneumonia and more commonly nodular bronchopneumonia that tends to become confluent. The histopathologic features characterised by an acute fibrino-purulent exudate are similar to certain other bacterial pneumonias, particularly those caused by Klebsiella and Streptococcus pneumoniae. Pathologic sequelae include interstitial and intra-alveolar fibrosis, interstititial inflammation, desquamation of alveolar lining, obliteration of respiratory bronchioles and alveolar ducts, chronic vasculitis and chronic organizing pleuritis. The Organisms may be demonstrated in the tissues by the Dieterle stain, or the Wolbach modification of the Giemsa stain. With regard to the direct fluorescent antibody staining procedure, polyvalent as well as monovalent conjugates may be used to include L. pneumophila serogroups 1, 2, 3, 4, 5 and 6, L. bozemanii, L. micdadei, etc. For antigen detection direct immuno-fluorescence, enzyme-linked immuno-specific assay and a simple slide agglutination test have been used successfully. (J.R. Murray, Johannesburg, S. Africa).
Chest radiography is the imaging technique of choice in evaluating patients with suspected pneumonia because of its low radiation dose, low cost, and wide accessibility. In daily practice, radiographs are used to confirm the clinical diagnosis of pneumonia, characterize the extent and severity of disease, search for complications such as empyema, monitor the response to therapy, and examine for possible alternative or additional diagnoses. Although CT scan has no defined role in the routine assessment of patients with either community-acquired or nosocomial pneumonias, its advantages of superior contrast resolution and cross-sectional display can often be helpful in the analysis of complex cases, particularly when radiographic evidence of associated central obstruction, cavitation, lymphadenopathy, or empyema is equivocal. In the immunocompromised patient population, high-resolution CT has been shown to be more sensitive than plain film radiography in the early detection of pulmonary infections.
Pulmonary nocardiosis (PN) is an infrequent but severe infection caused by Nocardia spp., which can behave either as opportunistic or primary pathogens. The present study identifies the risk factors for PN, clinical symptoms and radiographic features and the factors that affect its prognosis.
An observational study of all the patients diagnosed with PN over a 13-year period at the authors' institution.
Thirty-one adult patients were identified with PN, 11 of whom had disseminated nocardiosis. The predisposing conditions were COPD (23%), transplantation (29%), HIV infection (19%), alcoholism (6.5%) and treatment with steroids (64.5%). Respiratory tract sampling using non-invasive techniques had a diagnostic yield of 77%, while specimens from invasive methods had a yield of 47%. Mean time to diagnosis was 42 days. Dissemination to the central nervous system was related to alcoholism. The mortality rates were 41% for PN and 64% for disseminated nocardiosis; when Nocardia disseminated to the central nervous system, the mortality was 100%.
Specific risk factors were found in 94% of patients, with the most common being corticosteroid treatment and immunosuppressive therapy. The time to reach diagnosis and to prescribe specific treatment was considerable and mandatory assessment for nocardia in high-risk patients is required. The mortality rate of PN is high and early diagnosis and treatment are needed. Medications other than co-trimoxazole may be required.
Diagnostic atlas of non-neoplastic lung disease
- A-L Katzenstein
Specialty imaging - HRCT of the lung
- J W Gurney
Non-neoplastic pathology
- S Mukhopadhyay
Postviral complications: bacterial pneumonia
- J E Prasso
- J C Deng
- JE Prasso
Biopsy interpretation of the lung
- D I Suster
- S Suster