atypical pneumonia.pptx

atypical pneumonia
defination approach lab diagnosis

1. Atypical pneumonia Dr. Rasika Deshmukh

2. Definition Typical vs atypical pneumonia Approach Clinical picture Lab diagnosis Treatment

3. Definition D istinct clinical entity characterized by gradual onset of constitutional and respiratory symptoms associated with an unusual radiographic pattern of pulmonary infection(1940)   Characterized by constitutional symptoms and upper and lower respiratory tract involvement and can have a protracted clinical course with gradual resolution . The lack of typical findings of lobar consolidation on chest radiographs, failure to isolate a pathogen with use of routine bacteriologic testing methods, and lack of response to penicillin therapy are also common features of this group of microorganisms Atypical Pneumonia: Definition, Causes, and Imaging Features, Nicholas P. Dueck , RadioGraphics Vol . 41, No. 3 , 2019

4. Typical vs atypical pneumonia Typical pneumonia Atypical pneumonia Causative organism are typical Causative organism are atypical bacteria, viruses, fungus, parasites, non infective caused like chemical, irradiation Immuno-competant Immuno -suppressed Clinical and laboratory findings limited to the lungs Systemic infectious disease with a pulmonary component like GI or CNS Unilateral involvement Bilateral involvement follow alveolar pattern follow interstial pattern Neutrophilic infiltrates Lymphocytic infiltrates Chest x-ray will show lobar or segmental homogenous opacity in over 80% of typical bacterial pneumonia. Chest x-ray will show diffuse patchy or GGO >>> lobar or segmental homogenous opacity . Classically response to BL/BL-BI combination therapy These do not have cell wall or are intracellular. Hence, do not responds to BL/BL-BI combination therapy Public health concerns , can cause HAP Outbreak

5. The atypical pneumonias: clinical diagnosis and importance B.A. Cunha , Clin Microbiol Infect.  2006; 12: 12–24

6. Atypical Pneumonia: Definition, Causes, and Imaging Features, Nicholas P. Dueck , RadioGraphics Vol . 41, No. 3 , 2019 IP: 2-4 weeks IP: 2-10 days Pontanic fever IP:1-2 days IP: 3-4 weeks

7. IP: 3-5 days IP: 5- 14 days IP: 2-3 weeks

8. Dueck NP. Published Online: April 09, 2021 https://doi.org/10.1148/rg.2021200131

9. Mycoplasma pneumonia Posteroanterior (PA) chest radiograph shows bronchial wall thickening and mid and lower lung zone predominant heterogeneous opacities involving both lungs symmetrically . There is relative sparing of the lung apices .  Axial chest CT image (lung window) obtained at the level of the ventricles shows diffuse bilateral centrilobular nodules (arrow), peribronchovascular ground-glass opacities , and bronchial wall thickening , findings commonly seen in mycoplasma pneumonia. Atypical Pneumonia: Definition, Causes, and Imaging Features, Nicholas P. Dueck , RadioGraphics Vol . 41, No. 3 , 2019

10. Axial chest CT images (lung window) show multilobar ground-glass opacities and sublobar consolidation of the right lower lobe. Bilateral small-volume pleural effusions are present. Legionella : chest radiograph shows a right infrahilar and basilar consolidation (arrow).

11. Chlamydia pneumonia-PA view chest radiograph shows a sublobar consolidation in the left lower lobe (arrow) with rounded morphology. Axial chest CT image (lung window) shows peripheral consolidation and ground-glass opacities characteristic of lobar pneumonia. No tree-in-bud micronodules or bronchial mucoid impaction are depicted.

12. F tularensis : PA chest radiograph shows subtle left suprahilar and peripheral left upper lobe nodular opacities (arrows).  Axial chest CT images (lung windows) obtained above peripheral solid nodules (arrows) in the left upper lobe

13. Mycoplasma Pneumoniae Chlamydophila Pneumoniae Legionellae Gram staining : Chlamydiae are gram-negative they are poorly stained. Other stains : Such as Castaneda, Machiavello or Giemenza stain are better method to detect chlamydiae from samples.The inclusion bodies can be detected in cytoplasm. DIF is used as for direct detection of inclusion bodies in clinical material, can also be used for culture confirmation. Sensitive is good but the specificity is low (non-specific fluorescence). Gram stain : appear as faint pleomorphic gram-negative rods or coccobacilli Other stains : Silver impregnation and Giemsa stains can be used. DIF using monoclonal or polyclonal sera is more specific but sensitivity is poor than culture. It is more useful in advanced stage of disease. Microscopy

14. Mycoplasma Pneumoniae Chlamydophila Pneumoniae Legionellae Primary isolation : Standard solid medium : Containing PPLO agar, horse serum and penicillin. Standard liquid medium : Containing PPLO broth, glucose and penicillin and phenol red (indicator). Diphasic medium : solid phase and Liquid phase SP-4 medium : contains fetal bovine serum. Hayflick modified medium : Containing heart infusion broth incubated at 37°C for 5-7 days or sometimes even up to 1- 3 weeks. Liquid medium : turbidity and color change (R TO Y) Solid medium : fried egg appearance, Dienes phenomenon>>royal blue C. pneumoniae call be isolated from HEp2 or human fibroblast cell line . Incubated at 10% CO2 for 48-72 hrs. Cell lines are stained to demonstrate the presences of inclusion bodies highly sensitive (80-90%) and specific (100%) Buffered charcoal, yeast extract (BCYE) agar: incubated at 37°C in 5% CO2 for 3- 5 days. Colonies are round with an entire edge, glistening, convex, green or pink iridescent and have granular or speckled opalescence resembling ground glass motile, catalase positive and oxidase negative Hippurate hydrolysis test is positive Autofluorescence of colonies under UV light.

15. Mycoplasma Pneumoniae Chlamydophila Pneumoniae Legionellae Antigenic Detection Direct immunofluorescence test Capture ELISA assay :use monoclonal antibodies against P1 adhesin antigen. Antibody Detection Specific Antibody Detection Tests(serum) after about 1 week of illness, and peak at 3-6 weeks and decline gradually. lgM elevated in children, lgA antibody detection(choice). lmmunofluorescence assays , Latex agglutinalion assays ELISA using protein Pl antigens Non s pecific Antibody Detection ( obselete ) Cold agglutination test: Streptococcus MG tests Antibody Detection ELISA based formats are also available using recombinant LPS antigen. Microimmunfluorescence (MIF) test uses the species and serovar specific MOMP (major outer membrane protein) antigen. Detects IgM and IgG separately Single high titer of >1:512 is diagnostic, however fourfold rise of titer at 2-3 weeks interval is more significant Antibody detection : epidemiologic purpose. Indirect immunofluorescent antibody test and enzyme immunoassays are available. A single titer of more than 1:128 or fourfold rise in titer is considered as significant. Urinary antigen : ELISA detects serogroup I specific soluble antigens in urine. Advantages: rapid, cheaper, easy to perform,highly sensitive, and specific Antigen in urine is detectable 3 days after the onset and disappears over 2 months. The test not affected by prior antibiotic administration

16. 5ml, 13x100mm tube, package of 20

17. Rapid immunochromatographic assay for the qualitative detection of IgM antibodies by intecasi ( China) Specimen: serum or plasma  Test result: 15-20 minutes Storage temperature: 2-30℃ Shelf life: 24 months Kits per pack: 20/40/50 Sensitivity: 94.83% Specificity : 96.01%

18. primer set consists of Amplification of a conserved and mycoplasma -specific 16S rRNA gene region using two primers. highly-sensitive and -specific PCR assay LOD;10 CFU/ml Samples can be prepared in 10 minutes contains primers, Taq polymerase, and dNTPs is included 20 runs per kit 35 cycle PCR

19. Research use

20. Urine sample 3 drops sandwich solid phase immunochromatographic assay TAT : 10 mins Rapid Test Kit BinaxNOW ® Enzyme Immunoassay (EIA) Legionella Pneumophila Serogroup 1 Antigen Urine Sample 22 Tests Pack size:22 Urine sample 2-5 drops immunochromatographic assay TAT : 15 mins SD bioline rapid kits

21. Mycoplasma Pneumoniae Chlamydophila Pneumoniae Legionellae PCR available targeting M. pneumoniae specific 16S rRNA gene and P1 adhesin gene NAAT is highly sensitive and specific, takes less time, and detects even few copies of DNA from the sample. differentiate the species and serovars . currently the diagnostic assays of choice for chlamydia infection as recommended by the CDC, Polymerase chain reaction (PCR) Ligase chain reaction (LCR) Transcription-mediated amplification (TMA) PCR treatment Oral azithromycin , 500 mg on day 1, then 250 mg on day 2 to 5 . Doxycycline Levofloxacin Tetracycline or erythromycin (500 mg four times a day) is recommended for 14days. Azithromycin (Choice) Levofloxacin ,

22. Francisella tularensis Coxiella Burnetii gram-negative coccobacillus with bipolar appearance, nonmotile and capsulated biosafety level 3 laboratory Culture : BCG agar (blood cysteine glucose agar) CHAB agar ( cysteine heart agar supplemented with 9% heated sheep blood) incubated at 37° C for 2-4 days aerobically .Colonies are blue-gray , slightly mucoid zone of β - hemolysis catalase positive, oxidase negative and H2 S positive Antibody detection : mainstay Agglutination tests (latex and tube agglutination) and ELISA are available. a small pleomorphic gram-negative coccobacillus . It is extremely fastidious biosafety level 3 laboratory. cell culture: It can be done using human embryonic lung fibroblast cell lines Antibody detection: most commonly used Indirect immunofluorescence assay :sensitive, specific and method of choice In chronic infections, antibodies to phase I antigens are elevated, whereas in acute rise of antibodies to phase II antigens. lgM :7- 10 days of infection IgG:14-20 days after infection Complement fixation test detects lgG antibodies to phase II antigens.

23. Francisella tularensis Coxiella Burnetii PCR assay: outer-membrane proteins. It can also differentiate between subspecies QpH1 plasmid : acute QpRS plasmid: chronic Treatment Francisella tularensis Chlamydophila Psittaci Coxiella Burnetii Gentamicin (choice) given 5 mg/kg for 7- 10days Tetracycline is the drug of choice, given 250 mg four times a day for at least 3 weeks to avoid relapse. Erythromycin (500 mg four times a day by orally) is given as alternate. Doxycycline (1 00 mg tw ice daily for 14 days) is the drug of choice. Quinolones are also effective.

24. BioFire ® Respiratory Panel

25. BioFire ® Respiratory Panel 2.1 Hands on time: 1 min TAT:60-70 mins Cost per test: Rs. 20,000- 30,000

26. QIAstat-Dx ® Respiratory SARS-CoV-2 Panel Hands on time: 1 min TAT:70 – 75 mins Cycles: 40 cycles Cost per test: Rs. 6000- 7000

27. Thank you