Pneumonia - adults (community acquired)

Bronchopneumonia; Community-acquired pneumonia; CAP

Last reviewed: May 29, 2012.

Pneumonia is a breathing (respiratory) condition in which there is an infection of the lung. This article covers pneumonia in people who have not recently been in the hospital or another health care facility (nursing home or rehab facility). This type of pneumonia is called community-acquired pneumonia, or CAP. See also: Hospital-acquired pneumonia

Causes, incidence, and risk factors

Pneumonia is a common illness that affects millions of people each year in the United States. Germs called bacteria, viruses, and fungi may cause pneumonia. Ways you can get pneumonia include: Bacteria and viruses living in your nose, sinuses, or mouth may spread to your lungs. You may breathe some of these germs directly into your lungs. You breathe in (inhale) food, liquids, vomit, or fluids from the mouth into your lungs (aspiration pneumonia)

Pneumonia caused by bacteria tends to be the most serious kind. In adults, bacteria are the most common cause of pneumonia. The most common pneumonia-causing germ in adults is Streptococcus pneumoniae (pneumococcus). Atypical pneumonia, often called walking pneumonia, is caused by certain other bacteria. Pneumocystis jiroveci pneumonia is sometimes seen in people whose immune system is not working well.

Many other bacteria can also cause pneumonia. Viruses are also a common cause of pneumonia, especially in infants and young children. Risk factors that increase your chances of getting pneumonia include: Chronic lung disease (COPD, bronchiectasis, cystic fibrosis) Cigarette smoking Dementia, stroke, brain injury, cerebral palsy, or other brain disorders Immune system problem (during cancer treatment or due to HIV/AIDS or organ transplant) Other serious illnesses, such as heart disease, liver cirrhosis, or diabetes mellitus Recent surgery or trauma Surgery to treat cancer of the mouth, throat, or neck

Symptoms
The most common symptoms of pneumonia are: Cough (with some pneumonias you may cough up greenish or yellow mucus, or even bloody mucus) Fever, which may be mild or high Shaking chills Shortness of breath (may only occur when you climb stairs)

Other symptoms include: Confusion, especially in older people

Excess sweating and clammy skin Headache Loss of appetite, low energy, and fatigue Sharp or stabbing chest pain that gets worse when you breathe deeply or cough

Signs and tests

If you have pneumonia, you may be working hard to breathe, or breathing fast. The health care provider will hear crackles or abnormal breath sounds when listening to your chest with a stethoscope. Other abnormal breathing sounds may also be heard through the stethoscope or by tapping on your chest wall (percussion). The health care provider will likely order a chest x-ray if pneumonia is suspected. You may need other tests, including: Arterial blood gases to see if enough oxygen is getting into your blood from the lungs CBC to check white blood cell count CT scan of the chest Culture of your sputum to look for the bacteria or virus that is causing your symptoms Pleural fluid culture if there is fluid in the space around the lungs

Less often patients may need: Bronchoscopy--a flexible tube with a lighted camera on the end passed down to your lungs Thoracentesis--removing fluid from the space between the outside lining of the lungs and the chest wall

Treatment
Your doctor must first decide whether you need to be in the hospital. If you are treated in the hospital, you will receive: Fluids and antibiotics in your veins Oxygen therapy Breathing treatments (possibly)

It is very important that you are started on antibiotics very soon after you are admitted (unless you have viral pneumonia). You are more likely to be admitted to the hospital if you: Have another serious medical problem Have severe symptoms Are unable to care for yourself at home, or are unable to eat or drink Are older than 65 or a young child Have been taking antibiotics at home and are not getting better

However, many people can be treated at home. Your doctor may tell you to take antibiotics. Antibiotics help some people with pneumonia get better. Don't miss any doses. Take the medicine until it is gone, even if you start to feel better. Do NOT take cough medicine or cold medicine unless your doctor says it is okay. Coughing helps your body get rid of mucus from your lungs.

Breathing warm, moist (wet) air helps loosen the sticky mucus that may make you feel like you are choking. These things may help: Place a warm, wet washcloth loosely over your nose and mouth. Fill a humidifier with warm water and breathe in the warm mist.

Take a couple of deep breaths two or three times every hour. Deep breaths will help open up your lungs. Tap your chest gently a few times a day and lie with your head lower than your chest. This can help bring up mucus from the lungs.

Drink plenty of liquids (as long as your health care provider says it is okay): Drink water, juice, or weak tea Drink at least 6 to 10 cups a day Do NOT drink alcohol

Get plenty of rest when you go home. If you have trouble sleeping at night, take naps during the day.

Expectations (prognosis)
With treatment, most patients will improve within 2 weeks. Elderly or very sick patients may need longer treatment. Those who may be more likely to have complicated pneumonia include: Older adults or very young children People whose immune system does not work well People with other, serious medical problems such as diabetes or cirrhosis of the liver

In rare cases, more severe problems may develop, including: Life-threatening changes in the lungs that require a breathing machine Fluid around the lung (pleural effusion) Lung abscesses

Your doctor may want to make sure your chest x-ray becomes normal again after you are treated. However, it may take many weeks for your x-ray to clear up.

Calling your health care provider

Call your doctor if you have: A cough that brings up bloody or rust-colored mucus Breathing (respiratory) symptoms that get worse Chest pain that gets worse when you cough or breathe in Fast or painful breathing Night sweats or unexplained weight loss Shortness of breath, shaking chills, or persistent fevers Signs of pneumonia and a weak immune system (for example such as with HIV or chemotherapy)

Prevention
Wash your hands often, especially after: Blowing your nose Going to the bathroom Diapering

Also wash your hands before eating or preparing foods.

Don't smoke. Tobacco damages your lung's ability to ward off infection. Vaccines may help prevent some types of pneumonia. They are even more important for the elderly and people with diabetes, asthma, emphysema, HIV, cancer, or other long-term conditions: Flu vaccine prevents pneumonia and other problems caused by the influenza virus. It must be given each year to protect against new virus strains. Pneumococcal vaccine (Pneumovax, Prevnar) lowers your chances of getting pneumonia from Streptococcus pneumoniae.

If you have cancer or HIV, talk to your doctor about ways to prevent pneumonia and other infections.

References
1. 2. 3. 4. Centers for Disease Control and Prevention. Recommended adult immunization schedule--United States, 2012. MMWR. 2012;61(4) Limper AH. Overview of pneumonia. In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier;2011:chap 97. Niederman M. In the clinic. Community-acquired pneumonia. Ann Intern Med. 2009;151(7). Torres A, Menandez R, Wunderink R. Pyogenic bacterial pneumonia and lung abscess. In: Mason RJ, Broaddus VC, Martin TR, et al. Murray & Nadel's Textbook of Respiratory Medicine. 5th ed. Philadelphia, Pa: Saunders Elsevier; 2010:chap 32.
Review Date: 5/29/2012. Reviewed by: Denis Hadjiliadis, MD, Assistant Professor of Medicine, Division of Pulmonary, Allergy and Critical Care. University of Pennsylvania, Philadelphia, PA. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.

A.D.A.M., Disclaimer PARA AORTIC LYMPHADENOPATHY The Para-aortic lymph nodes also known as Para-aortic, and Peri-aortic, are a group of lymph nodes that lie in front of the lumbar vertebral bodies near the aorta. Theselymph nodes receive drainage from the lower gastrointestinal tract and the pelvicorgans. Para-aortic Lymphadenopathy is an enlargement in the size of the lymph nodes which are near the aorta. The aorta is defined as the largest blood vessel. Its main function is to transports blood out of the heart to the rest of the body. There are many causes for Para-aortic lymphadenopathy. Para-aortic lymphadenopathy is a condition which can either be caused by inflammation of the aorta, infection in the aorta or cancer in the aorta cells. Generally cancers in the aorta are benign and the simplest way of treating them is surgery, which may include a heart transplant, as well as chemotherapy. Chemotherapy is the treatment of cancer with an anti-neoplastic drug or with a combination of such drugs into a standardized treatment regimen. Most commonly, chemotherapy acts by killing cells that divide rapidly, which is one of the main properties of most cancer cells. This means that it also harms cells that divide rapidly under normal circumstances such as cells in the bone marrow, digestive tract and hair follicles; this results in the most common side effects of chemotherapy: Myelosuppression, decreased production of blood cells, hence also immunosuppressant, mucositis, inflammation of the lining of the digestive tract, and alopecia hair loss. Inflammation of the aorta can be caused by an aortic aneurysm and is one of the conditions that gets a lot of media attention because they are asymptomatic until they burst. The treatment for this depends on the inflammation of the aorta. If it is bigger than a size of 5.5cm this typically requires surgery, dependent on other conditions. While below this point, treatment tends to be to simply monitor it as aortic aneurysms smaller than 5.5cm have a low incidence rate of rupture. Finally a person with Para-aortic lymphadenopathy should have no problem what so ever with conceiving, though it is advised that you discuss it with your doctor as in the long term it could have an effect on your condition.

What is ascites?
Ascites is the accumulation of fluid (usually serous fluid which is a pale yellow and clear fluid) in the abdominal (peritoneal) cavity. The abdominal cavity is located below the chest cavity, separated from it by the diaphragm. Ascitic fluid can have many sources such as liver disease, cancers,congestive heart failure, or kidney failure.

What causes ascites?

The most common cause of ascites is advanced liver disease or cirrhosis. Approximately 80% of the ascites cases are thought to be due to cirrhosis. Although the exact mechanism of ascites development is not completely understood, most theories suggest portal hypertension (increased pressure in the liver blood flow) as the main contributor. The basic principle is similar to the formation of edema elsewhere in the body due to an imbalance of pressure between inside the circulation (high pressure system) and outside, in this case, the abdominal cavity (low pressure space). The increase in portal blood pressure and decrease in albumin (a protein that is carried in the blood) may be responsible in forming the pressure gradient and resulting in abdominal ascites. Other factors that may contribute to ascites are salt and water retention. The circulating blood volume may be perceived low by the sensors in the kidneys as the formation of ascites may deplete some volume from the blood. This signals the kidneys to reabsorb more salt and water to compensate for the volume loss. Some other causes of ascites related to increased pressure gradient arecongestive heart failure and advanced kidney failure due to generalized retention of fluid in the body. In rare cases, increased pressure in the portal system can be caused by internal or external obstruction of the portal vessel, resulting in portal hypertension without cirrhosis. Examples of this can be a mass (or tumor) pressing on the portal vessels from inside the abdominal cavity or blood clotformation in the portal vessel obstructing the normal flow and increasing the pressure in the vessel (for example, the Budd-Chiari syndrome). There is also ascites formation as a result of cancers, called malignantascites. These types of ascites are typically manifestations of advanced cancers of the organs in the abdominal cavity, such as, colon cancer,pancreatic cancer, stomach cancer, breast cancer, lymphoma, lung cancer, or ovarian cancer. Pancreatic ascites can be seen in people with chronic (long standing)pancreatitis or inflammation of pancreas. The most common cause of chronic pancreatitis is prolonged alcohol abuse. Pancreatic ascites can also be caused by acute pancreatitis as well as trauma to the pancreas.

What are the types of ascites?

Traditionally, ascites is divided into 2 types; transudative or exudative. This classification is based on the amount of protein found in the fluid. A more useful system has been developed based on the amount of albumin in the ascitic fluid compared to the serum albumin (albumin measured in the blood). This is called the Serum Ascites Albumin Gradient or SAAG.

Ascites related to portal hypertension (cirrhosis, congestive heart failure, Budd-Chiari) is generally greater than 1.1.

Ascites caused by other reasons(malignant, pancreatitis) is lower than 1.1.

What are the risk factors for ascites?

The most common cause of ascites is cirrhosis of the liver. Many of the risk factors for developing ascites and cirrhosis are similar. The most common risk factors include hepatitis B, hepatitis C, and long standing alcohol abuse. Other potential risk factors are related to the other underlying conditions, such as congestive heart failure, malignancy, and kidney disease.

What are the symptoms of ascites?

There may be no symptoms associated with ascites especially if it is mild (usually less than about 100 400 ml in adults). As more fluid accumulates, increased abdominal girth and size are commonly seen. Abdominal pain, discomfort, and bloating are also frequently seen as ascites becomes larger. Shortness of breath can also happen with large ascites due to increased pressure on the diaphragm and the migration of the fluid across the diaphragm causing pleural effusions (fluid around the lungs). A cosmetically disfiguring large belly, due to ascites, is also a common concern of some patients. Abdomen: The belly, that part of the body that contains all of the structures between the chest and the pelvis. The abdomen is separated anatomically from the chest by the diaphragm, the powerful muscle spanning the body cavity below the lungs. See the entire definition of Abdomen Abdominal: Relating to the abdomen, the belly, that part of the body that contains all of the structures between the chest and the pelvis. The abdomen is separated anatomically from the chest by the diaphragm, the powerful muscle spanning the body cavity below the lungs. See the entire definition of Abdominal Abdominal cavity: The cavity within the abdomen, the space between the abdominal wall and the spine. See the entire definition of Abdominal cavity Abdominal pain: Pain in the belly (the abdomen). Abdominal pain can come from conditions affecting a variety of organs. The abdomen is an anatomical area that is bounded by the lower margin of the ribs above, the pelvic bone (pubic ramus) below, and the flanks on each side. Although abdominal pain can arise from the tissues of the abdominal wall that surround the abdominal cavity (the skin and abdominal wall muscles), the term abdominal pain generally is used to describe pain originating from organs within the abdominal cavity (from beneath the skin and muscles). These organs include the stomach, small intestine, colon, liver, gallbladder, and pancreas. See the entire definition of Abdominal pain Abnormal: Not normal. Deviating from the usual structure, position, condition, or behavior. In referring to a growth, abnormal may mean that it is cancerous or premalignant (likely to become cancer). Acute: Of abrupt onset, in reference to a disease. Acute often also connotes an illness that is of short duration, rapidly progressive, and in need of urgent care. See the entire definition of Acute Acute pancreatitis: Sudden inflammation of the pancreas. The pancreas abruptly becomes inflamed and then gets better. Some people have more than one attack but recover fully after each one. See the entire definition of Acute pancreatitis Albumin: The main protein in human blood and the key to the regulation of the osmotic pressure of blood. Chemically, albumin is soluble in water, precipitated by acid, and coagulated by heat. See the entire definition of Albumin Alcohol abuse: Use of alcoholic beverages to excess, either on individual occasions ("binge drinking") or as a regular practice. For some individuals-children or pregnant women, for example-almost any amount of alcohol use

may be legally considered "alcohol abuse," depending on local laws. Heavy alcohol abuse can cause physical damage and death. Amylase: An enzyme produced in the pancreas and salivary glands that helps in the digestion of starches. Elevation of blood amylase is common inpancreatitis. Analysis: A psychology term for processes used to gain understanding of complex emotional or behavioral issues. Anesthesia: Loss of feeling or awareness. A general anesthetic puts the person to sleep. A local anesthetic causes loss of feeling in a part of the body such as a tooth or an area of skin without affecting consciousness. Regional anesthesia numbs a larger part of the body such as a leg or arm, also without affecting consciousness. The term "conduction anesthesia" encompasses both local and regional anesthetic techniques. Many surgical procedures can be done with conduction anesthesia without significant pain. In many situations, such as a C-section, conduction anesthesia is safer and therefore preferable to general anesthesia. However, there are also many types of surgery in which general anesthesia is clearly appropriate. Ascites: Abnormal buildup of fluid in the abdomen. Ascites can occur as a result of a number of conditions, including severe liver disease and the presence of malignant cells within the abdomen. Bacteria: Single-celled microorganisms which can exist either as independent (free-living) organisms or as parasites (dependent upon another organism for life). See the entire definition of Bacteria