Atypical pneumonia is the infectious and inflammatory damages of lungs caused by uncharacteristic (atypical) activators – hlamidiya, mycoplasmas, legionella, viruses. Atypical pneumonia proceeds with the phenomena of a general malaise, high fever, oznoba, perspiration, muscular and a headache, cough, short wind. In hard cases pulmonary heart failure can develop and come death of the patient. Diagnosis of atypical pneumonia demands the accounting of data of an epidanamnez, identification of the activator (the IFA, RIF, PTsR methods, cultural crops, etc.), carrying out a X-ray analysis of lungs. Taking into account an etiology treatment of atypical pneumonia is carried out antimicrobic (macroleads, ftorkhinolona, tertratsiklina) and antiviral himiopreparata. The main difficulty of therapy is that against some virus causative agents of atypical pneumonia effective medicines are not found so far.
The term "atypical pneumonia" since the end of the 30th years of the XX century in clinical medicine began to call the interstitsialny pneumonia caused by uncharacteristic activators, having features of a clinical current, diagnostics and treatment. Unlike the "typical" pneumonia caused by bacterial kokkovy flora, cases of an atypical inflammation can be caused by mycoplasmas, hlamidiya, koksiyella, klebsiyela, salmonellas, and also viruses. The pandemic of atypical pneumonia which flashed in the world in 2002-2003 was caused by a coronavirus and captured the People's Republic of China, Vietnam, Hong Kong, the USA, Canada and 30 more countries of the world. Then 8,5 thousand diseased and over 900 died people became the victims of epidemic. For designation of this type of atypical pneumonia in pulmonology the term "a syndrome of an acute respiratory disease (SARS) and "heavy sharp respiratory syndrome" (HSRS) was entered. Complexity of search of etiotropny therapy and prevention of atypical pneumonia consists in a constant mutation of a coronavirus that does not remove a problem of relevance of SARS and today.
Today the numerous group of infectious agents treats so-called atypical microorganisms - causative agents of atypical pneumonia. Atypical pneumonia can be caused by mikoplazmenny (Mycoplasma pneumoniae) and a chlamydial (Chlamydophila pneumoniae) infection, legionelly (Legionella spp.), koksiyelly (Coxiella burnetti), viruses (respiratory viruses of paraflu 1, 2 and 3; flu A and B; EpsteinBarr virus, respiratory sintsitialny virus), causative agents of leptospirosis (Leptospira spp.), tulyaremiya (Francisella tularensis), hantavirusam, coronavirus TORSO (SARS-CoV), etc. Despite significant differences of the epidemiological and microbiological characteristic of activators, and also a patomorfologichesky picture of infectious process, these microorganisms are united by resistance to antibiotics of a penicillinic row and other β-lactams, and also the general approaches to laboratory verification.
Infection with atypical pneumonia occurs usually at close contact in collectives; a way of transfer - airborne. A susceptibility to SARS high regardless of age: among having atypical pneumonia people more young than 40 years having good health prevail. The incubatory period at atypical pneumonia lasts from 3rd to 10 days. Depending on the activator allocate the following main forms of atypical pneumonia: mikoplazmenny pneumonia, Q fever, legionellezny pneumonia, chlamydial pneumonia, heavy sharp respiratory syndrome, etc.
Atypical mikoplazmenny pneumonia
Atypical mikoplazmenny pneumonia makes about 10-20% of cases of all pneumonias at children and teenagers and 2-3% of cases – at adults. In children's collectives the focal epidemic outbreaks of mikoplazmenny pneumonia are possible. Clinically respiratory mycoplasmosis can proceed in the form of a nazofaringit, tracheitis, bronchitis, atypical pneumonia.
Course of mikoplazmenny pneumonia, as a rule, easy or medium-weight. After the incubatory period (3-11 days) there comes the short prodromalny period (1-2 days) during which dryness of mucous top airways, irritation in a throat, dry cough, a headache and an insignificant indisposition disturbs. The clinic of actually atypical mikoplazmenny pneumonia is characterized by the subfebrilny temperature which is not rising above 38 °C; pristupoobrazny unproductive cough which disturbs about 2-3 weeks. In 20-30% of cases mikoplazmenny pneumonia is bilateral.
In hard cases atypical mikoplazmenny pneumonia proceeds with the high fever expressed by intoxication, an artralgiya, a mialgiya, nasal bleedings, polymorphic rash on skin, cervical lymphadenitis, an albuminuriya and a mikrogematuriya gepatosplenomegaliy, dystrophic changes of a myocardium. However usually, in comparison with a bacterial inflammation, mikoplazmenny pneumonia has more sluggish and erased current. Complications of mikoplazmenny pneumonia can be the deforming bronchitis, bronkhiolit, bronkhoektaza, a pneumosclerosis.
As feature of atypical pneumonia of a mikoplazmenny etiology serves discrepancy of fizikalny data to radiological signs, lack of effect of antibacterial therapy by penicillin or tsefalosporina. Auskultativny changes appear for 3-5 days and are characterized by weakening of breath, the minimum quantity of damp rattles. Perkutorny changes over lungs are expressed poorly. It is possible to establish the diagnosis of atypical pneumonia only according to a X-ray analysis of lungs in 2 projections: at the same time weak or sredneintensivny non-uniform infiltration of pulmonary fabric ("indistinct" shadows), sharp change of the bronchial and vascular drawing with the advent of diffusion looplike and mesh elements is defined. For exact verification of the activator resort to laboratory methods of diagnosis of atypical pneumonia: to bacteriological crops of a phlegm, washouts from a nasopharynx on nutrient mediums; To IFA, RSK, radio immune analysis, RIF, PTsR.
Timely and adequate etiotropny therapy promotes bystry regress of clinical displays of atypical mikoplazmenny pneumonia. Meanwhile, radiological changes can remain is long, up to 4-6 weeks. In therapy of the atypical pneumonia caused by a mycoplasma macroleads (, erythromycin), linkozamina () by a basic course not less than 7 days and additional - 2 days after subsiding of symptoms are used. It is at the same time carried out symptomatic (febrifugal, mukolitichesky, bronkholitichesky) therapy, at a bronkhiolita glucocorticosteroids are appointed.
Atypical chlamydial pneumonia
Microorganisms from the sort Chlamydophila (S. of trachomatis, S. of pneumoniae) possess a tropnost to epitelialny cages of urinogenital system, a conjunctiva, bronchial tubes, lungs, causing urogenital clamidiosis, chlamydial conjunctivitis, an acute bronchitis, pneumoclamidiosis in the person. Not less than 10% of cases of all pneumonias fall to the share of chlamydial pneumonia. Incidences of atypical chlamydial pneumonia are most often subject children and teenagers, and also people of advanced and senile age. Chlamydophila pneumoniae is sometimes long exists in an organism, without causing infectious manifestations.
The pneumonia caused by a chlamydial infection can begin as a SARS with the phenomena of rhinitis and pharyngitis. It is followed by temperature increase of a body to 38-39 °C, emergence of muscular and articulate pains, short wind, dry cough sometimes with office of poor quantity of a mucous phlegm. At a third of patients with atypical chlamydial pneumonia the cervical limfadenopatiya is noted. In 80% of cases inflammatory process happens bilateral. The atypical pneumonia associated with a chlamydial infection has not heavy, but often long current. The long persistirovaniye of hlamidiya can lead to an organism allergization activator anti-genes with development of chronic obstructive bronchitis and bronchial asthma.
Fizikalny changes at atypical chlamydial pneumonia remain 7-10 days, and radiological – up to 12-30 days. Stetoakustichesky inspection reveals dry and damp rattles in lungs. Radiological changes are characterized by melkoochagovy and/or interstitsialny infiltration more often from two parties. Presence at an organism of a hlamidiya decides on the help cultural, microscopic, by IFA, PTsR of a research of biological environments. The greatest diagnostic value at atypical chlamydial pneumonia has definition of IgA, IgG, IgM to anti-genes of proteins of an external membrane.
As medicines of etiotropny action at atypical chlamydial pneumonia serve tetratsiklina and macroleads. The course of therapy has to proceed not less than 10-14 days as short cycles can promote synchronization and a retsidivirovaniye of pneumoclamidiosis. In certain cases resort to purpose of ftorkhinolon (a sparfloksatsin, an ofloksatsin, etc.), doxycycline.
Atypical legionellezny pneumonia
Atypical legionellezny pneumonia makes 8-10% of all cases of a pulmonary inflammation. Legionellezny pneumonia or "a disease of legionaries" belongs to group of diseases – the legionellez proceeding with defeat of various departments of a respiratory path. The causative agent of atypical pneumonia - the gramotritsatelny aerobic palochkoobrazny bacterium of Legionella pneumophila which is often living in air conditioning systems and water supply (conditioners, ultrasonic sprays of water, humidifiers of the IVL systems, water supply systems etc.). Penetration of the activator into lungs happens in the aerosol way.
Atypical legionellezny pneumonia occurs mainly among persons of middle and advanced age. Smoking, immunosupression, a chronic renal failure contributes to its emergence. The infection develops in summer months more often and is registered in the form of sporadic cases or mass flashes. This form of atypical pneumonia proceeds as share pneumonia, with involvement in pathological process of terminal bronchioles and alveoluses, a massive ekssudation and the expressed hypostasis of interstitsialny fabric in a defeat zone.
Atypical legionellezny pneumonia has a heavy clinical current. The symptomatology is characterized by rise in temperature during 24-48 h to 40 °C and above, the strongest oznoba and a headache. At the same time cough joins: in the beginning dry, then – with office of a mucous or mucopurulent phlegm. In 20% of cases the blood spitting is noted. The overall picture is burdened by short wind, muscular and pleural pains, nausea, vomiting, diarrhea, tachycardia, abdominal pains. As the most terrible complications of atypical legionellezny pneumonia serve the respiratory insufficiency and a secondary renal failure leading to death of patients.
At diagnosis of atypical legionellezny pneumonia epidemiological data, the heavy clinical course of pneumonia, results of tool and laboratory researches are considered. At an auskultation in lungs damp rattles are listened. By means of a X-ray analysis (KT, MPT of lungs) the roundish infiltrates occupying not less than one share of a lung and tending to merge are defined. At a third of patients pleurisy with a small amount of a pleural exudate comes to light.
As a rule, crops of blood and a phlegm on existence yield negative result. The diagnosis of atypical legionellezny pneumonia manages to be confirmed by crops on special environments of a trakhealny aspirat, lavazhny liquid, a pleural exudate. For the purpose of receiving necessary biological material trakhealny aspiration, a bronkhoskopiya with a phlegm fence, a bronkhoalveolyarny unleavened wheat cake, a pleural puncture is carried out. Also RIF, IFA diagnostics is used.
The progressing deterioration in a state at the atypical pneumonia caused legionelly often dictates need of the transfer of the patient to IVL. Clinical improvement, as a rule, appears for 4-5 days after the beginning of intensive application of antibiotics (erythromycin, rifampicin, doxycycline, ciprofloxacin). Fever at atypical legionellezny pneumonia on average proceeds about 2 weeks; permission of infiltrates in pulmonary fabric takes up to 1 month. In certain cases after atypical pneumonia there are sites of a limited pneumosclerosis in lungs. The convalescence proceeds slowly, is long weakness and fatigue remains.
Atypical pneumonia (heavy sharp respiratory syndrome)
Atypical pneumonia – a little-known form of the sharp respiratory infection affecting the lower airways. It is known that causative agents of atypical pneumonia is the TORSO (SARS) - the coronavirus entering into the Coronaviridae family. Now epidemiological, laboratory and clinical studying the TORSO coronavirus continues. Most of the patients with atypical pneumonia in 2002-2003 made faces of 25-70 years; isolated cases of incidence of children to 15 years are celebrated. The main mechanism of transfer of a coronavirus - airborne, however identification of the activator in urine and excrements does not exclude a possibility of fecal and oral infection.
The incubatory period at atypical pneumonia makes 2-7, in some cases - 10 days. In the beginning symptoms of atypical pneumonia low-specific: the disease demonstrates from high fever (above 38 °C) which is followed by oznoba, perspiration, headaches, a mialgiya. In some cases at height of a feverish state vomiting and diarrhea is noted.
For 3-7 days of atypical pneumonia dry cough, short wind, the progressing gipoksemiya develops. The accruing hypoxia is followed by cyanosis of a nasolabial triangle, tachycardia, dullness of warm tones, hypotonia. In the next 6-7 days at a part of patients improvement health and subsiding of symptomatology is observed; in other cases - the respiratory distress syndrome demanding transition to IVL develops. In the last group of patients the high lethality from toksiko-infectious shock, sharp respiratory and heart failure, the accompanying complications is noted.
Lack of reliable diagnostic test systems of a heavy sharp respiratory syndrome and complexity of differential diagnosis of a disease in an initial stage, dictates need to assume atypical pneumonia at the patients visiting within 10 days epidemic unsuccessful areas, and also the persons suffering from a feverish state with symptoms of respiratory defeat.
Auskultativno at atypical pneumonia is defined weakening of breath, a krepitation, damp melkopuzyrchaty rattles. At percussion obtusion of a pulmonary sound comes to light. Radiological at the height of atypical pneumonia bilateral interstitial infiltrates on the periphery of pulmonary fields are found. In laboratory tests of blood the limfopeniye, thrombocytopenia, increase in level of hepatic enzymes, change of gas composition of blood (decrease in saturation of O2 blood) come to light. For identification of the causative agent of atypical pneumonia IFA, RIF, molecular tests are used.
As atypical pneumonia is a new and poorly studied disease, effective etiologichesky therapy is not developed yet. According to WHO recommendations, at atypical pneumonia inclusion in the scheme of treatment of several antimicrobic medicines is necessary (ftorkhinolon, ß lactams, tsefalosporin, tetratsiklin). These measures allow to prevent stratification of a bacterial infection.
The basis of antiviral therapy of atypical pneumonia is made by use of the ribavirin having activity concerning coronaviruses. Further corticosteroids are added to therapy. There are messages of the Hong Kong pulmonologists on successful experience of treatment of atypical pneumonia by means of transfusion of plasma of blood of the patients who transferred SARS. At atypical pneumonia carrying out a kislorodoterapiya, infusional therapy for removal of intoxication, purpose of diuretics for prevention of hypostasis of lungs is obligatory, for symptomatic therapy by protivokashlevy and expectorant means.
Forecast and profilaktika
The forecast of atypical pneumonia depends on a disease form: at mikoplazmenny and chlamydial pneumonia it, as a rule, favorable for life; at legionellezny and especially the TORSO infection – very serious. For the purpose of prevention of infection and spread of atypical pneumonia of WHO recommends to abstain from visit epidemic of adverse regions; to identify strict the persons arriving from these areas; to carry out disinfection of vehicles; to use individual masks of single application in need of contact with patients, suspicious concerning an infection. Now work on creation of an effective vaccine and specific tests of early diagnosis of atypical pneumonia continues.