Clinical Manifestations

The incubation period for pneumonia is variable, depending on the causative organism, but pneumococcal pneumonia has a fairly uniform pattern. There may be a brief prodrome of coldlike symptoms, but usually the onset is sudden, with shaking chills and a rapid rise in temperature, followed by a rise in heart and respiratory rates. Cough productive of "rusty" blood-tinged sputum and dyspnea are usual. Most patients experience pleuritic chest pain. In severe cases, there can be inadequate oxygenation of blood, leading to cyanosis. If untreated, the fever and other symptoms persist for at least 7 to 10 days, when a "crisis" may occur consisting of sweating with defervescence and spontaneous resolution. With antibiotic treatment, the fever usually falls within 48 hours. Untreated, or inadequately treated, the disease may progress to dyspnea, shock, abscess formation, empyema, and disseminated infection. When empyema occurs, surgical drainage is essential.

Diagnosis is based on the classic history and physical findings. Dullness to percussion is detected over the involved lobe(s) of lung, and auscultation may reveal decreased air entry, crepitant rales, bronchophony, whispering pectoriloquy, and variable alteration in fremitus, which reflects the pathological state of the lung tissue as it progresses through edema to consolidation and resolution or suppuration. Confirmation of the diagnosis is made by chest X-ray, and the specific pathogen is identified in sputum stains and culture. Treatment consists of rest, hydration, oxygen if necessary, and antibiotics. The selection of the last is based on, or endorsed by, the culture results.

In the nonlobar forms of pneumonia with diffuse inflammation, the history may be atypical and physical examination unreliable. In these cases, chest X-ray and special cultures may be necessary. In some cases, the precise identity of the pathogen is confirmed by serologic tests for specific and/or nonspecific antibodies (viral and mycoplasma pneumonia) or by immunofluorescence techniques (Legionella). When the patient is unable to cough or the inflammation is nonpyogenic, lung biopsy for microscopic inspection and culture is required (Pneumocystis).

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