Clinical variants of the course of pneumonias

Low-symptom pneumonia

At present, low-symptom forms of the disease are increasingly encountered. According to V. P. Silvestrov (1998), three variants of low-symptom pneumonia are distinguished depending on clinical and radiological manifestations: clinical, radiological, mixed.

Clinical variant

This variant of low-symptom pneumonia is characterized by the presence of pulmonary (cough, chest pain when breathing, a focus of crepitus and fine bubbling rales) and extrapulmonary manifestations (fever, intoxication syndrome, slight leukocytosis, increased ESR). At the same time, pulmonary inflammatory infiltrate is not detected by a conventional X-ray examination of the lungs. This is due to the fact that the foci of pulmonary infiltration, despite their prevalence, are small and exudation into the alveolar tissue is expressed quite weakly. Along with this, compensatory increased airiness of the remaining alveoli not involved in the inflammatory process is possible. All of the above leads to the fact that conventional chest X-ray does not reveal pneumonia. However, computed tomography allows you to register focal inflammatory infiltration of the lungs.

This clinical variant of low-symptom pneumonia can also be called radio-negative.

X-ray variant

This variant of low-symptom pneumonia is characterized by weakly expressed clinical manifestations or even their absence, but a clear radiographic picture of inflammatory infiltration in the lungs. The main complaints of patients are: pronounced general weakness, malaise, decreased performance, sweating, headache. These complaints are non-specific and are sometimes revealed only after targeted questioning. Much more important are complaints of cough with sputum, chest pain when breathing, some difficulty in breathing. However, these symptoms are weakly expressed and may often be absent. Physical signs of pulmonary inflammation (crepitus, dullness of percussion sound, sonorous fine-bubble wheezing as a manifestation of concomitant local bronchitis), of course, have great diagnostic value, but they can also be expressed indistinctly. Sometimes, with this type of pneumonia, its auscultatory symptoms are better revealed by listening to the lung with the patient on the affected side. In addition, the root of the lung on the corresponding side may be enlarged. However, the main diagnostic method for this type of low-symptom pneumonia is chest X-ray.

Mixed variant

The mixed variant of low-symptom pneumonia is characterized by low clinical and laboratory signs of inflammation, as well as its radiological manifestations. Diagnosis of this type of pneumonia is very difficult. A very thorough analysis of clinical, laboratory and radiological data is necessary to diagnose pneumonia. Sometimes, diagnosis of the mixed variant of low-symptom pneumonia is possible only with the help of computed tomography.

Upper lobe pneumonia

This localization of pneumonia is characterized by a number of features that can complicate the diagnosis of the disease. As a rule, the course of upper lobe pneumonia is severe, often there is damage to the nervous system, resembling meningitis in its manifestations, a long febrile period is possible. Chest pain is usually absent. Palpation of the chest reveals tension (sometimes slight soreness) of the trapezius muscle on the affected side. Physical symptoms of upper lobe pneumonia (crepitatio indux on the first day, bronchial breathing - on the second or third day of the disease) can sometimes be determined only deep in the armpit, especially in the supine position on the presumed affected side. X-ray examination reveals inflammatory infiltration in the upper lobe.

Central pneumonia

In this clinical form, the inflammatory infiltrate is located in the root zone in the area of the lung root and does not spread to the periphery. Characteristic features of such pneumonia:

• significant severity of intoxication syndrome (high body temperature, headache, general weakness, sweating) and laboratory signs of inflammation;
• severe shortness of breath;
• no chest pain;
• low severity of auscultatory signs of inflammation;
• significant increase on percussion of the root of the lung on the corresponding side.

To determine the size of the lung roots, one should use quiet percussion according to V. P. Obraztsov. Normally, the lung roots give a dullness of percussion sound from the III to the VI thoracic vertebrae of 8-9 cm, and laterally to the right and left, the dullness extends by 6-8 cm in each direction, forming a horizontal ellipse in the interscapular region. It is possible to percuss not the entire root of the lung, but only from below and upward medially along the line connecting the lower angle of the right or left scapula with the III thoracic vertebra (i.e. determine the location of the lower border of the lung root). Normally, dullness begins on both sides at the same level 8-10 cm above the lower angle of the scapula, and earlier if the root increases;

• X-ray also reveals an enlarged lung root on the corresponding side, as well as periradicular inflammatory infiltration.

Massive pneumonia

This variant of pneumonia develops when the lumen of a large afferent bronchus is closed by thick dense exudate. In this case, the physical picture resembles pulmonary atelectasis (a dull sound is heard over the affected lobe during percussion, vesicular and bronchial breathing is not heard during auscultation, crepitation, vesicular breathing, bronchophony are also absent, vocal fremitus is not determined). This variant is more often observed in pneumococcal lobar pneumonia (croupous) and requires differential diagnosis with exudative pleurisy and lung cancer. Unlike lobar pneumonia, the upper border of the darkening in exudative pleurisy on the radiograph has an oblique level, the mediastinum is shifted to the healthy side, the nature of the darkening is intense, homogeneous. The presence of effusion in the pleural cavity can also be recognized by ultrasound. Unlike lung cancer, with massive pneumonia, after vigorous expectoration of sputum and clearing of the bronchial lumen, bronchial breathing appears in the affected area and bronchophony is determined. With lung cancer, no auscultatory phenomena appear in the affected area after expectoration of sputum (“neither answer nor greeting,” as Professor F. G. Yanovsky figuratively put it).

Abdominal form of pneumonia

This form of pneumonia is more common in children. The inflammatory process is localized in the lower lobe of the right lung. The clinical picture is characterized by an acute onset, high body temperature, cough and abdominal pain of various localizations (in the right hypochondrium, in the right iliac region). In this case, tension of the muscles of the anterior abdominal wall is possible. The above symptoms are due to the involvement of the diaphragmatic pleura and lower intercostal nerves in the inflammatory process. The abdominal form of pneumonia must be differentiated from acute appendicitis, acute cholecystitis and other acute inflammatory diseases of the abdominal organs. Pneumonia is indicated by a significant shortening of the percussion sound in the lower parts of the right half of the chest, auscultatory and radiographic manifestations of the inflammatory process in the lower lobe of the right lung.

Pneumonia in the elderly

The problem of pneumonia in elderly and senile people is extremely relevant due to its great medical and social significance. Almost 50% of cases of pneumonia in elderly patients end in death (as a rule, these are pneumonias with an extended zone of inflammatory infiltration in the lungs).

The main clinical features of pneumonia in the elderly are:

• insufficient expression of physical symptoms and radiological manifestations of pneumonia;
• frequent absence of acute onset and pain syndrome;
• significant shortness of breath;
• frequent disturbances of the functional state of the central nervous system (confusion, lethargy, disorientation in time, persons, place); often these symptoms are regarded as acute cerebrovascular accidents;
• significant deterioration in the general condition and decrease in the patient’s physical activity;
• exacerbation and decompensation of various concomitant diseases, primarily diabetes mellitus, circulatory failure of any genesis, etc.;
• protracted course of pneumonia, prolonged resorption of inflammatory infiltrate in the lungs;
• prolonged subfebrile body temperature against the background of mild clinical symptoms of pneumonia.

Areactive pneumonia

This clinical variant is observed in old age, as well as in people with severe diseases of the cardiovascular system, liver, kidneys, and severe exhaustion. Areactive pneumonia is characterized by a non-acute, gradual onset, a slight increase in temperature, pronounced general weakness, anorexia, shortness of breath, and low blood pressure. Physical signs of pneumonia and laboratory manifestations of the inflammatory process are not clearly expressed. The diagnosis is finally clarified using an X-ray examination that reveals a focus of inflammatory infiltration in the lung tissue.

Aspiration pneumonia

Aspiration pneumonia occurs in people who are unconscious (alcohol intoxication, coma, stroke, anesthesia). In this case, food particles, vomit, foreign bodies, and nasopharyngeal microflora enter the lower respiratory tract. The disease begins with a reflex bronchospasm, a very strong, hacking cough, during which the patient's face turns blue, then within 24 hours, symptoms of bronchopneumonia and severe intoxication appear. Aspiration pneumonia is often complicated by a lung abscess.

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