GENERAL EVALUATION OF CASES WITH COMMUNITY ACQUIRED PNEUMONIA

DUE TO C. PNEUMONIAE

C. Naz, F. Alatas, G. Durmaz*, G. Ak, H. Yıldırım,

M. Metintas, S. Erginel

Eskisehir Osmangazi University Departments of Chest Diseases and *Microbiology,

Eskisehir, Turkey

INTRODUCTION and AIM

Although the prevalence of C.Pneumonia, a mandatory intracellular pathogen, changes from year to year and geographical region, it is responsible from 6-34 % of all CAP.

Especially, the frequently seen cause of mix infections

Clinical findings differ from asymptomatic cases to serious pneumonia which threats life and coexisting disease determines the requirement of hospitalization and clinical course of disease.

The first findings are sore throat, head ache and hoarseness.

The progression of symptoms is slower than mycoplasma and viral pneumonias.

Extrapulmonary findings along with reactive air way disease may be seen.

Leukocyte number increases rarely. In some studies, it was notified that low CRP and high Alkaline Phosphatase levels may be assessed as clue for diagnosis.

There is not characteristic radiological specifications.

Lesions may involve one or more lobe and usually unilateral. Pleural fluid may develop in 8-30 % of all cases.

Diagnosis;

The isolation of C.pneumoniae or its antigen

Cell culture

EIA, DFA, PCR

Serological tests

CFT, MIF, EIA

The aim of this study was to evaluate the demographic, clinic, radiologic, laboratory findings and prognosis of patients diagnosed as pneumonia due to C. pneumoniae

MATERIALS and METHODS

C. pneumoniae specific Ig M,G, A and M. pneumoniae specific Ig M and G were determined by MIF and ELISA, respectively in sera taken before treatment and twenty first day of treatment of thirty eight CAP patients prediagnosed as atypical pneumonia.

The presence of Legionella antigen was investigated in urine samples of the same patients before treatment.

Blood, BAL and/or sputum samples were taken for gram stain and culture before treatment and were assessed by Department of Microbiology.

Twenty four cases accepted as acute infection due to C. Pneumoniae by MIF and did not grew any other pathogen in their cultures were evaluated.

The statistical evaluation was done by SPSS 10.0 package program.

Diagnostic criteria for C.pneumoniae;

- The titration of Ig M antibody ≥1/16

- The titration of Ig M antibody ≥1/16 and the titration of Ig G antibody ≥512

- Four fold increase of Ig M and G antibody titers in blood samples taken in acute and

convalescent periods.

RESULTS

Demographic results of patients

24 patient: 15 were male, 9 were women

Mean age: 58 years (21-79)

10 patient > 65 years old

14 patient < 65 years old

67 %of cases were smoker, 38% of patients were under antibiotic treatment at the time of admission.

Comorbid diseases; n=14

COPD: 6

Asthma: 2

Heart Failure: 3

Malignancy: 2

Cerebrovascular D: 1

57%

Cases

n %

Group 1 1 4

Group 2 13 54

Group 3a 3 13

Group 3b 6 25

Group 4 1 4

n %

Group 1 4 16.7

Group 2 9 37.6

Group 3 7 29

Group 4 4 16.7

n %

Score 1 13 54

Score 2 6 25

Score 3 5 21

PSI

CURB 65

Symptoms

n %

Fever 23 95.8

Cough 21 87.5

Sputum 19 79.2

Headache 17 70.8

Weakness 11 45.8

Arthralgia 11 45.8

Breathness 11 45.8

Nausea 10 41.7

Chest pain 5 20.8

Sweating 5 20.8

Vomiting 3 12.5

Confusion 2 8.3

The duration of symptomatic period was more than one week in 58% of cases.

Physical examination was normal in one patient, rhonchus was observed in three cases which had not obstructive pulmonary disease previously

62%

38% Unilateral

Bilateral

Radilogical findings

29%

8%63%

Lober

Multilober

Interstitial

Laboratuary Findings

Before therapy

(Ort ±SD)

3.Day (Mean ±SD) 21.Day (mean ±SD)

Leukocyte

(mm3/c)

12104.1±5704.03 8975.0 ±4163.94* 8083.33 ±2216.86

Plt (mm3/c) 328625.0±39366 356250±30610.6 357458.3±29251.6

Fibrinogen 712.00± 36.53 658.45± 30.79* 498.79± 31.16

CRP(mg/dl) 18.75± 2.44 10.33± 1.37 2.05 ± 0.48

ESR (mm/hr) 78.58± 5.09 71.87± 5.78 43.82 ± 6.94

D-Dimer (ng/ml)

1699.41±204.05 1433.16 ±198.74* 968.20 ±181.15

: p< 0.001 Compared with before therapy levels*: p<0.05 Compared with before therapy levels

Leukocyte levels

0

2000

4000

6000

8000

10000

12000

14000

Before therapy 3.day 21.day

CRP

0

2

4

6

8

10

12

14

16

18

20

Before therapy 3. day 21.day

D-dimer levels

0

200

400

600

800

1000

1200

1400

1600

1800

Before therapy 3.day 21.day

ESR levels

0

10

20

30

40

50

60

70

80

90

Before therapy 3.day 21.day

Fibrinogen levels

0

100

200

300

400

500

600

700

800

Before therapy 3.day 21.day

Before Therapy (Mean ±SD)

3.day (Mean ±SD) 21.day (Mean ±SD)

BUN (mg/dl) 19.16±1.69 14.58 ± 1.35 13.11 ± 1.32*

Cr (mg/dl) 0.86 ± 0.3 0.74 ± 0.2 1.10 ± 1.4

Na (mEq/L) 137.62 ± 0.85 139.12 ± 0.96 139.62 ± 0.85

Alb (g/dl) 3.13 ± 0.12 3.17 ± 0.6 3.6 ± 0.13

LDH (U/L) 631.58 ± 42.78 1196.83 ± 672.98 433.79 ± 39.80

AST (U/L) 53.95 ± 7.65 51.33 ± 10.5 29.5 ± 4.65

: p<0.001 Compared with before therapy levels

*: p<0.05 Compared with before therapy levels

Before therapy (Mean ±SD)

3.day (Mean ±SD) 21.day (Mean ±SD)

ALT (U/L) 49.70 ± 8.9 53.95 ± 11.2 33.08 ± 4.33*

CK (U/L) 199.12 ± 52.28 140.95 ± 46.36 48.29 ± 6.01

GGT (U/L) 59.7 ± 11.26 87.58 ± 19.64 54.12 ± 10.21

ALP (U/L) 267.83 ± 28.68 277.54 ± 22.97 243.54 ± 26.1

*: p<0.05 Compared with before therapy levels: p<0.01 Compared with before therapy levels

Sterile BAL samples in twelve cases and sputum samples in twenty cases were negative for quantitative culture.

The blood culture were negative for 24 cases.

Complications: n=2

MV was applied to one patient due to respiration insufficiency.

Exitus: n=1 (%4)

CONCLUSIONS

We evaluated that C. pneumoniae is an important agent in patients with atypical pneumonia.

Redundancy of patients in our serie may be due to comorbid diseases. Since C. pneumoniae is one of the frequent cause in COPD patients and heart disease patients.

The clinical course, laboratory and radiological findings of our cases were compatible with previous studies.

Mortality rate was low as declared in literature.

Is C. pneumoniae the unique responsible pathogen in our cases? Otherwise is mix infection in question?

Second pathogen was not isolated with culture methods. However, some of the patients were under antibiotic treatment at the time of admittance.

As a result, we should remember C. Pneumoniae as the pathogen of pneumonia especially in patients with atypical pneumonia clinic, smoker and have comorbid diseases like cardio-pulmonary diseases.