1. PNEUMOCOCCAL PNEUMONIA
ESSENTIALS OF DIAGNOSIS
Productive cough, fever, rigors, dyspnea, early pleuritic chest pain.
Consolidating lobar pneumonia on chest radiograph.
Gram-positive diplococci on Gram stain of sputum.
Pneumococcus is the most common cause of community-acquired pyogenic bacterial pneumonia. Alcoholism, asthma, HIV infection, sickle cell disease, splenectomy, and hematologic disorders are predisposing factors. Mortality rates remain high in cases of advanced age, multilobar disease, hypoxemia, extrapulmonary complications, and bacteremia.
Presenting symptoms and signs include high fever, productive cough, occasional hemoptysis, and pleuritic chest pain. Rigors may occur initially but are uncommon later in the course. Bronchial breath sounds are an early sign.
There is often leukocytosis, or occasionally leukopenia, but neither finding should be used to make a decision about hospital admission (see When to Admit, below).
Diagnosis requires isolation of the organism in culture, although the Gram stain appearance of sputum can be suggestive. Sputum and blood cultures, positive in 60% and 25% of cases of pneumococcal pneumonia, respectively, should be obtained prior to initiation of antimicrobial therapy in patients who are admitted to the hospital. A good-quality sputum sample (less than 10 epithelial cells and greater than 25 polymorphonuclear leukocytes per high-power field) shows gram-positive diplococci in 80–90% of cases. A rapid urinary antigen test for Streptococcus pneumoniae, with sensitivity of 70–80% and specificity greater than 95%, can assist with early diagnosis. The use of procalcitonin to guide therapy is discussed below.
Pneumococcal pneumonia classically is a lobar pneumonia with radiographic findings of consolidation and occasionally effusion. However, differentiating it from other pneumonias is not possible radiographically or clinically because of significant overlap in presentations.
Parapneumonic (sympathetic) effusion is common and may cause recurrence or persistence of fever. These sterile fluid accumulations need no specific therapy. Empyema occurs in 5% or less of cases and is differentiated from sympathetic effusion clinically and by the presence of organisms on Gram-stained fluid or positive pleural fluid cultures.
Pneumococcal pericarditis is a rare complication that can cause tamponade. Pneumococcal arthritis also is uncommon. Pneumococcal endocarditis usually involves the aortic valve and often occurs in association with meningitis and pneumonia (sometimes referred to as Austrian or Osler triad). Early heart failure and multiple embolic events are typical.
Initial antimicrobial therapy for pneumonia is empiric (see Table 9–9 found in Chapter 9-11: Pneumonia) pending isolation and identification of the causative agent. Once S pneumoniae is identified as the infecting pathogen, any of several antimicrobial agents may be used depending on the ...