Clinical variants of pneumonia

Malosymptomatic pneumonia

At the present time the symptoms of asymptomatic disease have become more frequent. According to VP Sil'vestrov (1998), three variants of low-symptom pneumonia are distinguished depending on the clinical and radiological manifestations: clinical, x-ray, 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 small bubbling rales) and extrapulmonary manifestations (fever, intoxication syndrome, small leukocytosis, increased ESR). At the same time, a pulmonary inflammatory infiltrate is not detected with the help of a conventional radiographic examination of the lungs. This is due to the fact that the foci of pulmonary infiltration, despite the prevalence, are small and exudation to the alveolar tissue is rather weakly expressed. 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 the usual radiography of the lungs does not reveal pneumonia. However, computed tomography allows detecting focal inflammatory infiltration of the lungs.

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

X-ray variant

This variant of low-symptom pneumonia is characterized by mild clinical manifestations or even their absence, but a clear radiographic picture of inflammatory infiltration in the lungs. The main complaints of patients are: severe general weakness, malaise, decreased efficiency, sweating, headache. These complaints are nonspecific and sometimes come to light only after a purposeful questioning. Significantly more important are complaints of cough with separation of sputum, pain in the chest during breathing, some difficulty in breathing. However, these symptoms are mild and often absent. The physical signs of pulmonary inflammation (crepitus, blunting of percussion sound, sonorous wheezing as a manifestation of concomitant local bronchitis), of course, are of great diagnostic significance, but can also be expressed indistinctly. Sometimes with this variant of pneumonia, its auscultatory symptomatology is better revealed by listening to the lung in the patient's position on the diseased side. In addition, it is possible to increase the lung root from the corresponding side. However, the main method of diagnosing this variant of low-symptom pneumonia is lung radiography.

Mixed variant

Mixed variant of low-symptom pneumonia is characterized by a low degree of clinical and laboratory signs of inflammation, as well as radiographic manifestations of it. Diagnosis of this type of pneumonia is very difficult. A very thorough analysis of clinical, laboratory and radiographic data is needed to diagnose pneumonia. Sometimes the diagnosis of a 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 make it difficult to diagnose the disease. As a rule, the course of upper lobe pneumonia is severe, often the nervous system is affected, resembling meningitis in its manifestations, a prolonged febrile period is possible. Pain in the chest is usually absent. When palpation of the chest, the tension (sometimes slight soreness) of the trapezius muscle on the side of the lesion is determined. The physical symptoms of upper lobe pneumonia (crepitatio indux in the first day, bronchial respiration on the second or third day of the disease) can sometimes be determined only deep in the armpit, especially when lying on the alleged side of the lesion. X-ray examination reveals inflammatory infiltration in the upper lobe.

Central pneumonia

With this clinical form, the inflammatory infiltrate is located in the root zone in the region of the lung root and does not extend to the periphery. Typical 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;
• absence of pain in the chest;
• low severity of auscultatory signs of inflammation;
• a significant increase in percussion of the root of the lung from the corresponding side.

To determine the value of the roots of the lungs, one should use a quiet percussion according to VP Obraztsov. Normally, the roots of the lungs blunt the percussion sound from III to VI of the thoracic vertebrae, 8-9 cm in length, and laterally to the right and left, the blunting extends 6-8 cm to each side, forming a horizontally located ellipse in the interblade area. You can percutate not the whole root of the lungs, but only from below and upwards medially along the line connecting the lower corner of the right or left scapula with the III thoracic vertebra (ie, determine the location of the lower border of the lung root). Normally dulling begins on both sides at the same level 8-10 cm above the lower angle of the scapula, and with the increase in the root - before;

• X-ray also determines the increase in the root of the lung from the corresponding side, as well as radical inflammatory infiltration.

Massive pneumonia

This variant of pneumonia develops when the lumen of the large leading bronchus is closed by thick dense exudate. In this case, the physical picture resembles atelectasis of the lung (above the affected part with percussion - a dull sound, with auscultation - vesicular and bronchial breathing is not heard, there is also no crepitation, vesicular breathing, bronchophony, voice tremor is not determined). This option is more often observed with pneumococcal lobar pneumonia (croupous) and requires differential diagnosis with exudative pleurisy and lung cancer. In contrast to lobar pneumonia, the upper border of blackout in exudative pleurisy on the roentgenogram has an oblique level, the mediastinum is biased to the healthy side, the character of dimming is intense, homogeneous. The presence of effusion in the pleural cavity also helps to recognize the ultrasound. In contrast to lung cancer, with massive pneumonia after vigorous expectoration of the sputum and clearing the lumen of the bronchus in the lesion, bronchial breathing appears and bronchophasia is determined. With lung cancer in the lesion, no auscultatory phenomena after sputum discharge does not appear ("no answer, no greetings" according to the figurative expression of Professor FG Yanovsky).

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 acute onset, high body temperature, cough and abdominal pain of various localization (in the right hypochondrium, right iliac region). This may strain the muscles of the anterior abdominal wall. This symptomatology is 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 cavity. About pneumonia, a significant shortening of percussion sound in the lower parts of the right side of the thorax, 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 elderly people is extremely urgent due to its great medical and social significance. Almost 50% of cases of pneumonia in elderly patients result in a fatal outcome (usually pneumonia with an extended zone of inflammatory infiltration in the lungs).

The main clinical features of pneumonia in elderly people are:

• insufficient severity of physical symptoms and radiographic manifestations of pneumonia;
• frequent absence of acute onset and pain syndrome;
• significant shortness of breath;
• frequent violations of the functional state of the central nervous system (confusion, inhibition, disorientation in time, persons, place); often these signs are regarded as acute disorders of cerebral circulation;
• significant deterioration in the general condition and reduced physical activity of the patient;
• exacerbation and decompensation of various concomitant diseases, especially diabetes, circulatory insufficiency of any genesis, etc .;
• prolonged course of pneumonia, prolonged resolution of inflammatory infiltrate in the lungs;
• long subfebrile body temperature against the background of a mild clinical symptomatology of pneumonia.

Arepatic pneumonia

This clinical variant is observed in old age, as well as in people with severe diseases of the cardiovascular system, liver, kidneys, with severe exhaustion. Arepatic pneumonia is characterized by a mild, gradual onset, a slight increase in temperature, pronounced general weakness, anorexia, shortness of breath, low blood pressure. The physical signs of pneumonia and the laboratory manifestations of the inflammatory process are expressed indistinctly. Finally, the diagnosis is refined using an X-ray study that identifies the focus of inflammatory infiltration in the lung tissue.

Aspiration pneumonia

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

[1], [2], [3], [4], [5], [6], [7], [8]