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Focal pneumonia differential diagnosis. Pneumonia

DIFFERENTIAL DIAGNOSIS FOR PNEUMONIA

Pneumonia– acute local infectious-inflammatory disease of the lungs involving the pathological process respiratory sections (alveoli, bronchioles), occurring with infiltration by inflammatory cells and intra-alveolar exudation.

Classification

By etiology:

ü bacterial (indicating the specific pathogen),

ü viral,

ü fungal

ü without specifying the pathogen.

Epidemiological:

ü out-of-hospital,

ü hospital,

ü aspiration,

against the background of immunodeficiency.

By severity:

ü not heavy,

ü heavy.

By localization: indicating a segment or several segments.

According to the nature of the flow:

ü prolonged (duration of the disease more than 1 month).

Complications:

ü pulmonary

§ parapneumonic pleurisy,

§ pleural empyema,

§ abscess and gangrene of the lungs,

§ destruction of the lungs,

§ bronchial obstruction,

§ acute respiratory failure (distress syndrome).

ü extrapulmonary

§ infectious-toxic shock,

§ acute cor pulmonale,

§ DIC syndrome,

§ sepsis,

§ myocarditis,

§ endocarditis,

§ pericarditis,

§ meningitis,

§ encephalitis,

§ acute psychosis.

An example of a diagnosis:

1. Community-acquired pneumonia localized in S 8-9 of the right lung, non-severe course. DN I.

2. Community-acquired lower lobe left-sided pneumonia, severe, complicated by exudative pleurisy. DN II.

Community-acquired pneumonia (CAP)– an acute disease that arose in a community setting (outside a hospital, or diagnosed in the first 48 hours from hospitalization.

Etiology

The etiology of CAP is directly related to the normal microflora that colonizes the upper respiratory tract. The most common pathogens:

ü Streptococcus pneumoniae (30-50% of cases),

ü Haemophilus influenzae (before 10%) .

Atypical microorganisms (which cannot be identified by bacterioscopy or culture on conventional nutrient media) play a significant role in the etiology of CAP; 8-30% of cases of the disease:

ü Chlamydophila pneumoniae, Mycoplasma pneumonia(total up to 25%),

ü Legionella pneumophila.

Rare (3-5%) pathogens of CAP include:

ü Staphylococcus aureus,

ü Klebsiella pneumoniae

ü enterobacteria.

In very rare cases, CAP can cause Pseudomonas aeruginosa(in patients with cystic fibrosis, in the presence of bronchiectasis).

From a practical point of view, it is advisable to distinguish groups of patients with CAP, taking into account age, concomitant pathology and severity of the disease (Table 1).

Table 1

Groups of patients with CAP and probable pathogens

Nosocomial (hospital, nosocomial) pneumonia (NP) – a disease that develops 48 hours or more after hospitalization, excluding infections that were present in the incubation period at the time the patient was admitted to the hospital.

Risk factors:

ü length of hospital stay,

ü previous antibacterial therapy,

ü presence of underlying chronic diseases,

ü specificity of the medical institution.

Highlight early hospitalization pneumonia that occurs during the period from 2 to 5 days of hospitalization, which is characterized by pathogens that are mostly sensitive to traditionally used antimicrobial drugs ( S. Pneumoniae, Enterobacteriaceae, H. Influenzae) and has a favorable prognosis.

Late hospital stay pneumonia develops after the 5th day of hospitalization and is characterized by a high risk of multidrug-resistant pathogens (P. aeruginosa, Escherichia coli, Klebsiella pneumoniae and Acinetobacter spp.) and a less favorable prognosis.

Also distinguished ventilator-associated pneumonia (VAP) – pneumonia in persons on mechanical ventilation.

Aspiration pneumonia (AP) can be either out-of-hospital or intra-hospital. APs complicate the patient's aspiration of food, vomit, blood, toxic and other agents into the lower respiratory tract, accompanied by penetration along with the aspirate pathogenic flora. Aspiration usually develops in persons with disorders of consciousness of varying depth due to:

ü heavy alcohol intoxication,

ü stroke,

ü anesthesia,

ü coma of various etiologies,

ü poisoning with sleeping pills,

ü convulsive conditions.

Aspiration can occur with cardiospasm or the presence of tracheoesophageal fistulas.

Anaerobes cause the development of AP:

ü Bacteroides melaninogenicus,

ü Fusobacterium nucleatum,

ü Peptosstreptococcusand etc.,

as well as some aerobes:

ü Escherichia coli

ü Staphylococcusaureus,

ü Pseudomonas aerugenosa.

Pneumonia in persons with immunodeficiency.

The main causes of immunodeficiency are:

ü HIV infection,

ü leukemia;

ü long-term (> 3 weeks) use of cytostatics or systemic glucocorticoids for the treatment of tumors, systemic diseases, in patients after organ transplantation.

In a general blood test, immunodeficiency is manifested by prolonged neutropenia (< 500 клеток в 1 мкл крови) в период диагностики или в предыдущие 60 дней.

The most likely etiology of pneumonia in immunocompromised individuals is:

ü S. aureus,

ü Pseudomonas aeruginosa,

ü S. pneumonia,

ü H. Influenza

ü E. coli.

A specific causative agent of pneumonia against the background of immunodeficiency is Pneumocystis carinii. More than 3/4 of Pneumocystis pneumonia are associated with HIV . The remaining cases account for patients with primary or secondary immunodeficiency, including with iatrogenic immunosuppression.

Diagnostic standard for examining a patient with pneumonia

Clinical criteria:

ü Acute febrile fever, intoxication,

ü Cough is dry or with sputum,

ü Chest pain associated with breathing,

ü Local dullness of percussion sound,

ü Locally audible bronchial breathing, an area of sonorous fine rales and/or crepitus, pleural friction noise.

Objective criteria:

ü leukocytosis > 10 G/l with a band shift > 10%, increased ESR;

ü infiltrative darkening on a plain radiograph of the chest organs;

ü identification of microorganisms in sputum during bacterioscopy with Gram staining of a smear, as well as verification of the microorganism and determination of its sensitivity to antibiotics during bacteriological examination;

ü blood oxygen saturation< 90% по данным пульсоксиметрии (является критерием тяжелой пневмонии и показанием для проведения кислородотерапии).

Listed criteria sufficient for the diagnosis and treatment of pneumonia on an outpatient basis, as well as during an uncomplicated course of the disease in an inpatient setting.

Additional Methods research:

ü CT scan(with damage to the upper lobes, lymph nodes of the mediastinum, a decrease in the volume of the lobe, suspected abscess formation, with the ineffectiveness of antibacterial therapy, with an obvious clinical picture of pneumonia, changes on the radiograph are absent or are indirect in nature, recurrent pneumonia with the same localization, prolonged pneumonia).

ü Serological study with an atypical course of pneumonia in the risk group in people who abuse alcohol, drugs, in the elderly and senile, with immunodeficiency.

ü Microbiological examination pleural fluid.

ü Biochemical blood test in severe cases of pneumonia with manifestations of renal and liver failure, in patients with chronic diseases, decompensation diabetes mellitus.

ü Cyto- and histological examination at risk for lung cancer in smokers over 40 years of age, with chronic bronchitis and a family history of cancer.

ü Bronchological examination: diagnostic bronchoscopy in the absence of effect from adequate therapy for pneumonia, if lung cancer is suspected, foreign body, performing a biopsy. Therapeutic bronchoscopy for abscess formation to ensure drainage.

ü Ultrasonography heart and abdominal organs if sepsis or infective endocarditis is suspected.

ü Isotope scanning lungs (pulmonary angiography if indicated) if PE is suspected.

Causes and nature of the atypical course of pneumonia.

Availability severe somatic diseases, severe immunodeficiency, old age and other factors can modify the course of pneumonia. Possible:

ü absence or low severity of physical signs of pulmonary inflammation;

ü absence of fever;

ü predominance of extrapulmonary symptoms (disturbances from the central nervous system and etc.);

ü absence of typical changes in peripheral blood;

ü absence of typical radiological changes, which may be due not only to the variant of pneumonia, but also to the location and timing of the study.

Features of the course of pneumonia depending on the etiology or variant.

For pneumococcal CAP is characterized by an acute onset, high fever (39-40°C), chest pain, severe course, arterial hypotension, large infiltrate, good response to penicillins.

Staphylococcal pneumonia often occurs after a history of viral infection, is characterized by an acute onset, severe course, small size of the infiltrate (focus, focus), a tendency to abscess formation, bullous changes in the lungs, and resistance to penicillins.

Haemophilus influenzae causes pneumonia in people suffering from chronic bronchitis, alcoholism and other chronic diseases, the sputum is viscous, viscous, often streaked with blood, characterized by a severe clinical course, large (polysegmental, lobar) infiltrates, and a tendency to abscess formation.

Mycoplasma Pneumonia usually occurs in people under 35 years of age, is very contagious, and therefore can occur in the form of epidemic outbreaks in groups. Characterized by an acute onset, high fever with chills, symptoms of upper respiratory tract infection (pharyngitis, laryngotracheitis), muscle pain and headaches, an increasing cough with a small amount of sputum, the course is usually not severe.

For legionella Pneumonia is also characterized by epidemic outbreaks among persons who work or visit damp, air-conditioned premises, severe clinical course, diarrhea, neurological symptoms, and impaired liver function.

The emergence aspiration pneumonia is usually preceded by a picture of a painful reflex cough, often accompanied by profuse salivation. Inflammatory foci are often multiple, of varying sizes, and often tend to merge. Infiltration, as a rule, is localized in the right lower lobe, which is due to the nature of the branching of the main bronchi, but it can also be bilateral. Aspiration pneumonia is characterized by:

ü documented aspiration or the presence of factors predisposing to the development of aspiration;

ü sputum with putrid smell;

ü pneumonia in the lower lobe of the right lung;

ü necrotizing pneumonia or abscess formation, pleural empyema;

ü no growth of microorganisms under aerobic conditions.

Pneumonia in immunocompromised patients characterized by an acute onset, severe course, chills with high intoxication, a tendency to a septic state, abscess formation of the lungs and other internal organs. Radiologically, lobar and segmental infiltrates with pleural effusion are typical.

For Pneumocystis pneumonia is characterized by a clinical picture of interstitial inflammation of the lung tissue: nonproductive cough for several weeks, severe shortness of breath (in 100% of patients) and symptoms of increasing respiratory failure, as well as the paucity of physical manifestations and features of radiological changes. X-ray manifestations at the onset of the disease may be absent, then a hilar decrease in pneumatization of the lung tissue and an increase in the interstitial pattern are revealed. In more than half of the cases, bilateral cloud-like infiltrates are detected (the “butterfly” symptom), and at the height of the disease, abundant focal shadows (“cotton-colored” lung) are detected, requiring differential diagnosis with disseminated tuberculosis. Up to 20% of Pneumocystis pneumonia can occur without a clear X-ray picture. A discrepancy between severe respiratory failure and moderate radiological changes is typical.

Fungal pneumonia is caused by fungi (micromycetes), often opportunistic: Aspergillus spp., Criptococcus neoformans, Candida spp. etc. Clinical manifestations of fungal pneumonia are nonspecific; it is impossible to make a diagnosis based only on clinical signs. Most frequent symptoms is refractory to antibiotics wide range fever (t > 38°C), lasting more than 96 hours, nonproductive cough, chest pain, hemoptysis, respiratory failure. Fungal pneumonia develops very quickly and is accompanied by high mortality. Mandatory diagnostic methods, along with radiographs, are: high-resolution CT, microscopic examination of respiratory substrates (sputum, BAL fluid, etc.) with mandatory culture on nutrient media. It should be taken into account that the detection of fungi in normally non-sterile biosubstrates (including sputum) is due to colonization, which does not require specific treatment.

Principles of pneumonia therapy

ü Adequate antibacterial therapy.

ü Detoxification.

ü Anti-inflammatory therapy.

ü Improvement of bronchial drainage.

ü Correction of microcirculatory disorders.

ü Symptomatic treatment.

Indications for hospitalization:

1. Severe pneumonia*.

ü BH ³ 30 / min.

ü Body temperature< 35,0 0 С или ³ 40,0 0 С.

ü blood pressure< 90/60 мм рт.ст.

ü Heart rate > 125/min.

ü Impaired consciousness.

ü Leukocytosis > 20.0 G/l or leukopenia< 4,0 Г/л

ü Hemoglobin< 90 г/л

ü Hematocrit< 30%

ü Creatinine > 176.7 µmol/l

ü SaO 2< 90% (по данным пульсоксиметрии)

ü PaO 2< 60 мм рт.ст. и/или PaCO 2 >50 mmHg when breathing room air

ü Pneumonic infiltration is localized in more than one lobe

ü Presence of complications: decay cavity(s), pleural effusion, ITS.

* If at least one criterion is present, community-acquired pneumonia is regarded as severe

2. Ineffectiveness of initial antibiotic therapy in an outpatient setting for 48-72 hours.

3. Social indications (inability to organize adequate treatment of pneumonia at home).

Relative readings for hospitalization:

ü age over 60 years,

ü heavy accompanying illnesses(COPD, malignant neoplasms, diabetes mellitus, chronic renal failure, heart failure, alcoholism, drug addiction, exhaustion),

ü preferences of the patient and/or his family members.

To quickly navigate the management tactics of a particular patient, you can use the English CRB-65 scale.

Treatment of pneumonia

Mode: for the period of fever and intoxication - bed or semi-bed, with subsequent expansion.

Diet: complete, enriched with vitamins, including easily digestible foods, with thermal sparing and increasing the volume of fluid consumed.

Antibacterial therapy

Establishing a diagnosis of pneumonia is an absolute indication for prescribing antibacterial therapy. The first dose of antibiotic should be given within the first 4 hours of diagnosis!

A distinction is made between empirical therapy for pneumonia (with unknown etiology) and therapy for pneumonia of established etiology.

Antibacterial therapy for pneumonia of known etiology

S. pneumonia. The drugs of choice for treating pneumonia are aminopenicillins(amoxicillin - orally, ampicillin - parenterally), incl. inhibitor-protected (amoxicillin/clavulanate) and cephalosporins III generation (cefotaxime, ceftriaxone). Macrolide Antibiotics are an alternative for b-lactam allergies. They have high activity respiratory fluoroquinolones(levofloxacin, moxifloxacin), vancomycin And linezolid.

H. influenzae. The selection tools are aminopenicillins(amoxicillin - orally, ampicillin - parenterally), incl. inhibitor protected (amoxicillin/clavulanate), cephalosporins III generation (cefotaxime, ceftriaxone) fluoroquinolones

M. pneumonia, C. pneumonia. They have the greatest activity against “atypical” pathogens macrolides, tetracyclines(doxycycline), respiratory fluoroquinolones.

S. aureus. The drug of choice for pneumonia caused by MSSA is oxacillin, an alternative may be protected aminopenicillins, cephalosporinsI- IIgenerations, lincosamides. If MRSA is detected, glycopeptide antibiotics (vancomycin) or linezolid, and the latter should be preferred due to its pharmacokinetic characteristics.

Legionellaspp. In the treatment of Legionnaires' pneumonia, macrolides. Highly effective also fluoroquinolones(ciprofloxacin, ofloxacin, levofloxacin, moxifloxacin).

Enterobacteriaceae. III generation cephalosporins have the widest spectrum of action. Treatment of hospital-acquired pneumonia requires preliminary determination of sensitivity to antibiotics.

P. aeruginosa. The combination of ceftazidime and tobramycin is considered one of the most common treatment regimens for pseudomonas pneumonia. The high frequency of acquired resistance of this pathogen to antibiotics requires a preliminary assessment of sensitivity in each specific case.

Empirical treatment planning is based on the likely etiology of the disease (Table 2).

Table 2.

Empirical antibacterial therapy for community-acquired pneumonia in outpatient patients

Most Frequent

pathogens

Drugs of choice

Non-severe CAP in patients without concomitant diseases who have not taken AMPs for ≥2 days in the last 3 months

S. pneumoniae

M. pneumoniae

C. pneumoniae

H. influenzae

Amoxicillin orally or macrolide orally 1

Non-severe CAP in patients with concomitant diseases and/or who have taken antimicrobial medications for ≥2 days in the last 3 months

S. pneumoniae

H. influenzae

C. pneumoniae

S. aureus

Enterobacteriaceae

Amoxicillin/clavulanate,

amoxicillin/sulbactam orally ± macrolide orally

Respiratory fluoroquinolone (levofloxacin, moxifloxacin, gemifloxacin) by mouth

Note: 1 Macrolides are the drugs of choice if an “atypical” etiology of CAP is suspected ( C. pneumoniae, M. pneumoniae). Preference should be given to the most studied macrolides for CAP with improved pharmacokinetic properties (azithromycin, clarithromycin) or a favorable safety profile and minimal frequency drug interactions(josamycin, spiramycin).

Table 3.

Empirical antibacterial therapy for community-acquired pneumonia

at hospitalized patients

Most common pathogens

Pneumonia

not severe

currents 1

S. pneumoniae

H. influenzae

C. pneumoniae

S. aureus

Enterobacteriaceae

Benzylpenicillin IV, IM ± macrolide orally 2
Ampicillin IV, IM ± macrolide orally 2

Amoxicillin/clavulanate IV ± macrolide orally 2

Amoxicillin/sulbactam IV, IM ± macrolide 2

Cefotaxime IV, IM ± macrolide orally 2

Ceftriaxone IV, IM ± macrolide orally 2

Ertapenem IV, IM ± macrolide orally 2

Respiratory fluoroquinolone (levofloxacin, moxifloxacin) IV

Pneumonia

severe course 3

S. pneumoniae

Legionella spp.

S. aureus

Enterobacteriaceae

Amoxicillin/clavulanate IV + macrolide IV

Cefotaxime IV + macrolide IV

Ceftriaxone IV + macrolide IV

Ertapenem IV + macrolide IV

Respiratory fluoroquinolone (levofloxacin, moxifloxacin) IV + cefotaxime, ceftriaxone IV

Note:

1 Stepped therapy is preferred. If the patient’s condition is stable, oral administration of drugs is allowed immediately.

2 Preference should be given to the most studied macrolides for CAP with improved pharmacokinetic properties (azithromycin, clarithromycin) and/or a favorable safety profile and minimal frequency of drug interactions (josamycin, spiramycin).

3 If there are risk factors P. aeruginosa– infections (bronchiectasis , taking systemic glucocorticoids, broad-spectrum antibiotic therapy for more than 7 days during the last month, exhaustion) drugs of choice are ceftazidime, cefepime, cefoperazone/sulbactam, ticarcillin/clavulanate, piperacillin/tazobactam, carbapenems (meropenem, imipenem), ciprofloxacin. All of the above drugs can be used in monotherapy or combination with aminoglycosides of the II-III generation. If aspiration is suspected, it is advisable to use amoxicillin/clavulanate, cefoperazone/sulbactam, ticarcillin/clavulanate, piperacillin/tazobactam, carbapenems (meropenem, imipenem).

Initial effectiveness assessment therapy should be carried out in the first 48-72 hours. The main efficiency criteria are:

ü normalization of body temperature or its decrease< 37,5°С,

ü reduction of symptoms of intoxication,

ü reduction of shortness of breath and other manifestations of respiratory failure.

If the initially selected antibiotic is ineffective, it is first necessary to collect biomaterial for bacteriological research(sputum, lavage fluid), if this was not done initially, and then change the antibacterial drug (Table 4). Outpatient patients must be hospitalized.

Table 4.

outpatient patients

Drugs at stage 1 of treatment	Drugs at stage 2 of treatment	Comments
Amoxicillin	Macrolides	pneumoniae, M. pneumoniae)
Amoxicillin/clavulanate	Macrolides Respiratory fluoroquinolones	(WITH.pneumoniae, M. pneumoniae)
Macrolides	Amoxicillin Amoxicillin/clavulanate Respiratory fluoroquinolones	A possible reason for the ineffectiveness of macrolides is resistant pneumococci or gram(-) bacteria

Table 5.

Choice antibacterial drugs if the initial treatment regimen is ineffective in hospitalized patients

Drugs

at stage 1 of treatment

Drugs for

Stage 2 of treatment

Comments

Amoxicillin orally

Ampicillin IM

Macrolides (replace or add)

III generation cephalosporins

Amoxicillin/clavulanate

Macrolide

Possible “atypical” microorganisms (C. pneumoniae, M. pneumoniae, Legionella spp.), Gram(-) enterobacteria, S. aureus

Amoxicillin/clavulanate

Amoxicillin/sulbactam

Macrolides (add).

Respiratory

fluoroquinolones

Possible “atypical” microorganisms (WITH.pneumoniae, M. pneumoniae, Legionella spp.)

Cephalosporins

III generation

Macrolide (add)

Respiratory

fluoroquinolones

Possible “atypical” microorganisms (C. pneumoniae, M. pneumoniae, Legionella spp.)

Macrolides

Amoxicillin/clavulanate.

Respiratory

fluoroquinolones

A possible reason for the ineffectiveness of macrolides is resistant pneumococci or Gram(-) bacteria

Stepped antibacterial therapy for pneumonia

Stepped antibacterial therapy involves the two-stage use of antibacterial drugs with a transition from parenteral to non-parenteral (usually oral) route of administration in the shortest possible time, taking into account the clinical condition of the patient. The main idea of step therapy is to reduce the duration of parenteral administration of the antibiotic, which provides a significant reduction in the cost of treatment and a reduction in hospital stay while maintaining high clinical effectiveness of therapy. The optimal option for step therapy is the sequential use of two dosage forms the same antibiotic, which ensures continuity of treatment. It is possible to sequentially use antibacterial drugs that are similar in their microbiological properties.

Criteria for transition to oral administration as part of stepwise antibacterial therapy for CAP

ü normal (or close to normal) body temperature (less than 37.5°C) with two measurements with an interval of 8 hours,

ü reduction of shortness of breath,

ü no impairment of consciousness,

ü positive dynamics of other symptoms of the disease,

ü no malabsorption in gastrointestinal tract,

ü consent (inclination) of patients to oral treatment.

Injectable drug	Oral drug	Dose, g	Frequency of reception
PENICILLINS and CEPHALOSPORINS
Benzylpenicillin 2 million units IV (IM) 4 times a day or Ampicillin 1-2 g IV (IM) 4 times a day	Amoxicillin
Amoxicillin/clavulanate, IV 1.2 g 3-4 times a day	Amoxicillin/clavulanate
Cefotaxime IV (IM) 1.0-2.0 g 2-3 times a day or Ceftriaxone IV (IM) 1.0-2.0 g 1 time per day	Amoxicillin/clavulanate
MACROLIDES
Clarithromycin IV 0.5 g 2 times a day	Clarithromycin Clarithromycin extended release
Azithromycin IV 0.5 g once a day	Azithromycin
RESPIRATORY FLUOROQUINOLONES
Levofloxacin IV 0.5 g once a day	Levofloxacin
Moxifloxacin IV 0.4 g once a day	Moxifloxacin

Empirical therapy for hospital-acquired pneumonia

Since hospital-acquired pneumonia is characterized by a significant variety of etiologies, which makes it difficult to plan empirical therapy, once established clinical diagnosis The earliest possible microbiological diagnosis should be carried out:

ü microbiological examination of sputum (obtaining material during bronchoscopy may be indicated),

ü blood cultures for blood culture.

At pneumonia that developed in patients in general wards without risk factors, the means of choice for empirical therapy before establishing an etiological diagnosis may be parenteral cephalosporinsIIIgenerations in maximum doses. Alternatives are being considered fluoroquinolones. If there is evidence in favor pseudomonas etiology of pneumonia, it is advisable to prescribe a combination of antipseudomonas cephalosporinsIII- IVgenerations (ceftazidime, cefepime) with aminoglycosides (tobramycin, amikacin).

At pneumonia in patients in general wards with risk factors there is a high probability of the etiological role of pseudomonas and other “non-fermenting” microorganisms. Possible options for choosing antibiotics:

ü carbapinems (imipenem, meropenem),

ü antipseudomonal cephalosporins of III-IV generations in combination with aminoglycosides,

ü antipseudomonal penicillins (azlocillin, ticarcillin, piperacillin) in combination with aminoglycosides,

ü aztreonam in combination with aminoglycosides,

ü fluoroquinolones,

ü glycopeptides (vancomycin).

Empirical treatment of pneumonia that develops against the background of neutropenia.

Taking into account the specific etiology, empirical therapy includes glycopeptides, co-trimoxazole and antifungal drugs.

Aspiration pneumonia

The basis of empirical therapy for aspiration pneumonia is the need to use antibacterial drugs with pronounced antianaerobic activity (protected b-lactams, carbapenems, metronidazole).

Criteria for the sufficiency of antimicrobial therapy for CAP

ü Body temperature less than 37.5°C for at least three days in a row

ü No intoxication

ü Absence of respiratory failure (RR less than 20 per minute)

ü Absence of purulent sputum

ü The number of leukocytes in the blood is less than 10 G/l, neutrophils< 80%, юных форм < 6%

ü Absence of negative dynamics on the radiograph

Table 7.

Clinical signs and conditions not considered indications

to continue antibiotic therapy

Clinical signs	Explanations
Persistent low-grade fever (body temperature within 37.0-37.5ºС)	In the absence of other signs of bacterial infection, it may be a manifestation of non-infectious inflammation, post-infectious asthenia (autonomic dysfunction), drug fever
Persistence of residual changes on the radiograph (infiltration, increased pulmonary pattern)	Can be observed for 1-2 months after CAP
Dry cough	Can be observed for 1-2 months after CAP, especially in smokers and patients with COPD
Persistence of wheezing upon auscultation	Dry wheezing can be observed for 3-4 weeks or more after CAP and reflects the natural course of the disease (local pneumosclerosis at the site of the focus of inflammation)
Increase in ESR	Nonspecific indicator, not a sign of bacterial infection
Persistent weakness, sweating	Manifestations of post-infectious asthenia

Approximate timing of antibacterial therapy for known etiologies:

ü for pneumococcal pneumonia - at least 5 days,

ü for pneumonia caused by enterobacteria and Pseudomonas aeruginosa - 14 days,

ü for pneumonia caused by staphylococci - 10 days,

ü for pneumonia caused by pneumocystis - 14-21 days,

ü for pneumonia caused by Legionella - 21 days,

ü for pneumonia complicated by abscess formation – more than 30 days

In cases where, against the background of an improvement in the clinical picture, by the end of the 4th week from the onset of the disease it is not possible to achieve complete radiological resolution of focal infiltrative changes in the lungs, one should speak of prolonged CAP.

In such a clinical situation, one should first of all establish possible factors risk of a protracted course of the disease:

ü age over 55 years;

ü alcoholism;

ü the presence of concomitant disabling diseases of internal organs (COPD, congestive heart failure, renal failure, malignant neoplasms, diabetes mellitus, etc.);

ü severe pneumonia;

ü multilobar infiltration;

highly virulent pathogens ( L. pneumophila, S. aureus, gram-negative enterobacteria);

ü smoking;

ü clinical ineffectiveness of initial therapy (persistent leukocytosis and fever);

ü secondary bacteremia;

ü secondary resistance of pathogens to antibiotics (age > 65 years, β-lactam therapy within the previous 3 months, immunodeficiency diseases/conditions).

Algorithm of action for slowly resolving pneumonia

If clinical improvement is not observed and the patient does not have risk factors for slow resolution of CAP, then differential diagnosis with diseases such as:

ü local bronchial obstruction (tumor);

ü tuberculosis;

ü congestive heart failure;

ü drug fever, etc.

Detoxification therapy

ü saline solutions (physiological, Ringer's, etc.) 1000-3000 ml,

ü glucose 5% - 400-800 ml/day,

ü hemodez 400 ml/day.

Solutions are administered under the control of central venous pressure and diuresis.

Oxygen therapy- through a mask, catheters, mechanical ventilation, depending on the degree of respiratory failure.

Anti-inflammatory therapy

NSAIDs (aspirin, ibuprofen, diclofenac, etc.) orally or parenterally.

Improving bronchial drainage

ü Atrovent, Berodual through a nebulizer 4 times a day,

ü mucoregulators (ambroxol, acetylcysteine orally or inhaled)

Correction of microcirculatory disorders

ü heparin 20,000 units/day,

ü rheopolyglucin 400 ml/day.

Immune replacement therapy

ü Gabriglobin (Gabreglobine) 1 dose – 2.5 g, course of treatment 2.5-10 g 1 time/day for 3-10 days

IN general complex therapeutic measures necessarily include therapeutic exercises. Breathing exercises not only improve ventilation and blood circulation, but are also a means of preventing complications (hypostasis, atelectasis, pleural adhesions, etc.). For uncomplicated pneumonia, the rehabilitation treatment program can begin and end in a hospital setting. In severe cases of the disease, after hospital treatment, patients can be sent to specialized sanatoriums and rehabilitation departments. The use of complex restorative treatment leads in the vast majority of cases to the patient’s recovery and restoration of ability to work.

Physiotherapy atpneumonia is aimed at eliminating inflammation, achieving faster resorption of the inflammatory focus, improving the function of external respiration, lymph and blood circulation of the bronchopulmonary system, restoring impaired immune status, providing a hyposensitizing effect.

Contraindications: severe intoxication, body temperature above 38°, stage II-III heart failure, pulmonary hemorrhage and hemoptysis, thromboembolism, infarction-pneumonia, pneumothorax, suspected neoplasm.

In the first days of the disease influence is prescribed electric field UHF on the chest in continuous (power 40-100 W) or pulsed (4.5-6 W) modes. The UHF electric field has anti-inflammatory, improves blood circulation, analgesic, improves nervous system function, and desensitizing effects. UHF should not be prescribed for destructive pneumonia. Also recommended inhalation phytoncides, bronchodilators, alkaline solutions, herbal decoctions with expectorant action, erythema ultraviolet irradiation chest (usually in separate fields) corresponding to the affected lobe of the lung, one field daily. A good effect at the infiltration stage is achieved by using galvanization chest against the background of antibiotic therapy for 20-40 minutes, which is carried out with intravenous drip after 1/2 - 2/3 of the solution volume has been consumed, and with intramuscular administration - 1-1.5 hours after injection. This increases the concentration of the drug in the inflammatory focus.

During the permission period inflammatory focus is prescribed Microwave therapy on the area of the lesion or lower lobes of the lungs. Unlike UHF, the microwave electric field does not act on the entire body, but locally, on the inflammatory area. The same principle is used inductothermy(treatment with a high-frequency alternating magnetic field), using low-thermal and thermal doses. Inductothermy has a sedative, antispasmodic, analgesic effect, decreases tissue muscle tone, expands blood vessels, inactive capillaries open, blood flow increases, the activity and intensity of phagocytosis and nonspecific immunity increase, and the function of the sympathoadrenal system improves.

During the same period, the disease is carried out magnetic therapy using low frequency (50 Hz) magnetic field in continuous or intermittent modes, which has a beneficial effect on the functions of cardio-vascular system, determining the advantage of this method in the treatment of patients with concomitant cardiovascular pathology. Contraindications for magnetic therapy are the general serious condition of the patient, body temperature above 38 o C, severe hypotension, stage III hypertension, bleeding or tendency to bleeding, systemic blood diseases, cachexia, recurrent thrombophlebitis, skin defects in the area of treatment

To improve the resorption of the inflammatory focus and eliminate bronchospasm, pain, and difficult sputum discharge, use electrophoresis calcium, magnesium, heparin, aminophylline, aloe extract, ascorbic acid, lysozyme. In this case, one electrode (100-150 cm 2) is placed in the interscapular region, the second - taking into account the localization of the source of inflammation.

During the period of resolution of the inflammatory focus, use inhalation with expectorants, mucolytics, restorative drugs, as well as thermotherapy– applications of ozokerite, paraffin, silt and peat mud. In the 2-3rd week, you can prescribe climatotherapeutic procedures (daytime stay on the veranda, air baths).

All methods are combined with exercise therapy and massage. Physiotherapy exercises are indicated on the 2-3rd day from the moment body temperature normalizes. Use exercises to increase respiratory mobility chest wall, stretching of pleural adhesions, strengthening the respiratory muscles and abdominal muscles.

During treatment prolonged pneumonia Hardening methods (water rubdowns, douses, showers), climatotherapy (in a sanatorium or rehabilitation department), general UV irradiation, aerosol therapy with expectorants, mucolytic and restorative drugs are becoming more important.

Clinical examination.

Dispensary observation is carried out for 6 months with visits to the local therapist 1, 3 and 6 months after discharge. A general blood test, sputum test, fluorogram, spirogram are performed twice, after 1 and 6 months, a biochemical blood test - once after 6 months. If necessary, consultations with an ENT doctor, dentist and pulmonologist are carried out. Wellness activities: vitamin therapy, exercise therapy, sauna, sanitization of foci of infection, prevention of acute respiratory viral infections and influenza, smoking cessation, referral to specialized sanatoriums.

Control questions on this topic.

1. Definition of pneumonia.

2. Classification of pneumonia.

3. Clinical and instrumental signs of pneumonia.

4. The main pathogens of pneumonia.

5. Features of the course of pneumonia depending on the pathogen.

6. Principles of pneumonia therapy.

7. Empirical choice of antibiotic.

8. Step therapy.

9. Criteria for effectiveness and antibiotic withdrawal.

10. Complex therapy pneumonia.

11. Prolonged course of pneumonia: causes and tactics.

12. Physiotherapy of pneumonia.

13. Follow-up after past pneumonia.

Diagnostic algorithm for community-acquired pneumonia

Diagnostic search algorithm for nosocomial pneumonia

Pulmonary tuberculosis

Regardless of the clinical variant of pneumonia and the form of pulmonary tuberculosis, when carrying out differential diagnosis between these diseases, it is necessary, first of all, to use well-known methods for diagnosing pulmonary tuberculosis as a nosological unit.

Analysis of anamnesis data

The following anamnestic data suggest the presence of tuberculosis in a patient:

presence of tuberculosis in the patient’s family;
the patient has previously had tuberculosis of any localization;
determining the course of the disease. An acute onset and severe course are observed in acute miliary pulmonary tuberculosis and caseous pneumonia; in other forms of tuberculosis, the onset of the disease is usually gradual, often completely imperceptible. Acute lobar pneumonia has an acute onset, focal pneumonia begins gradually, but the duration initial period, of course, significantly less than with pulmonary tuberculosis;
information about previous diseases. Diseases such as exudative pleurisy, frequently recurring fibrinous (dry) pleurisy, prolonged low-grade fever of unknown origin and unexplained malaise, sweating, weight loss, prolonged cough(especially if the patient does not smoke) with hemoptysis may be manifestations of pulmonary tuberculosis.

Analysis of data from external examination of patients

Previous tuberculosis can be indicated by retracted irregular scars in the area of previously affected cervical lymph nodes, and tuberculosis of the spine that once took place can be indicated by kyphosis.

Rapidly developing severe intoxication and the patient's serious condition are more characteristic of lobar or total pneumonia and are not characteristic of tuberculosis, with the exception of acute miliary tuberculosis and caseous pneumonia.

Analysis of physical data obtained during examination of the lungs

Unfortunately, there are no physical symptoms that are absolutely pathognomonic for pulmonary tuberculosis. Data such as changes in vocal tremors, bronchophony, bronchial breathing, crepitus, wet and dry rales, pleural friction noise can be observed both in pulmonary tuberculosis and in nonspecific lung diseases, including pneumonia.

However, the following features of physical data characteristic of pulmonary tuberculosis may have a certain diagnostic value:

localization of pathological percussion and auscultation phenomena mainly in the upper parts of the lungs (of course, this is not an absolute rule);
the paucity of physical data in comparison with the data of X-ray examination (the aphorism of old doctors “little is heard, but much is seen in pulmonary tuberculosis and much is heard, but little is seen in non-tuberculous pneumonia”). Of course, this pattern does not apply to all forms of tuberculosis, but can be observed in focal, miliary tuberculosis, and tuberculoma.

Setting up tuberculin tests

Tuberculin tests (tuberculin diagnostics) are based on the determination of tuberculin allergy - increased sensitivity of the body to tuberculin resulting from infection with virulent mycobacterium tuberculosis or BCG vaccination.

The most commonly used intradermal Mantoux test is where 0.1 ml of tuberculin is injected into the skin of the inner surface of the middle third of the forearm. The test results are assessed after 72 hours by measuring the diameter of the papule using a transparent millimeter ruler. The transverse (relative to the axis of the arm) diameter of the papule is recorded; the reaction is considered negative when the diameter of the papule is from 0 to 1 mm, doubtful - with a diameter of 2-4 mm, positive - with a diameter of 5 mm or more, hyperergic - with a diameter of 17 mm or more in children and adolescents and 21 mm or more in adults . Hyperergic reactions also include vesicular-necrotic reactions, regardless of the size of the infiltrate.

Positive and especially hyperergic tuberculin test may indicate the presence of pulmonary tuberculosis. However, the final diagnosis of pulmonary tuberculosis is made only on the basis of a comprehensive clinical, laboratory and x-ray examination of the patient, and, of course, the results of tuberculin tests are also taken into account.

Microbiological diagnosis of tuberculosis

Determination of Mycobacterium tuberculosis in sputum, bronchial lavage water, and pleural exudate is the most important method diagnosis of tuberculosis. Classic microbiological methods are used: bacterioscopy, cultural examination or seeding, biological test on laboratory animals susceptible to tuberculosis infection.

Pulmonary tuberculosis

Analysis of anamnesis data

The following anamnestic data suggest the presence of tuberculosis in a patient:

presence of tuberculosis in the patient’s family;
the patient has previously had tuberculosis of any localization;
determining the course of the disease. An acute onset and severe course are observed in acute miliary pulmonary tuberculosis and caseous pneumonia; in other forms of tuberculosis, the onset of the disease is usually gradual, often completely imperceptible. Acute lobar pneumonia has an acute onset, focal pneumonia begins gradually, but the duration of the initial period, of course, is much less than with pulmonary tuberculosis;
information about previous diseases. Diseases such as exudative pleurisy, frequently recurring fibrinous (dry) pleurisy, prolonged low-grade fever of unknown origin and unexplained malaise, sweating, weight loss, prolonged cough (especially if the patient does not smoke) with hemoptysis can be manifestations of pulmonary tuberculosis.

Analysis of data from external examination of patients

Analysis of physical data obtained during examination of the lungs

However, the following features of physical data characteristic of pulmonary tuberculosis may have a certain diagnostic value:

localization of pathological percussion and auscultation phenomena mainly in the upper parts of the lungs (of course, this is not an absolute rule);
the paucity of physical data in comparison with the data of X-ray examination (the aphorism of old doctors “little is heard, but much is seen in pulmonary tuberculosis and much is heard, but little is seen in non-tuberculous pneumonia”). Of course, this pattern does not apply to all forms of tuberculosis, but can be observed in focal, miliary tuberculosis, and tuberculoma.

Setting up tuberculin tests

A positive and especially hyperergic tuberculin test may indicate the presence of pulmonary tuberculosis. However, the final diagnosis of pulmonary tuberculosis is made only on the basis of a comprehensive clinical, laboratory and x-ray examination of the patient, and, of course, the results of tuberculin tests are also taken into account.

Microbiological diagnosis of tuberculosis

Determination of Mycobacterium tuberculosis in sputum, bronchial washings, and pleural exudate is the most important method for diagnosing tuberculosis. Classic microbiological methods are used: bacterioscopy, cultural examination or seeding, biological test on laboratory animals susceptible to tuberculosis infection.

Sputum analysis is one of the main and most common methods. To increase the sensitivity of the method, the flotation method is used, in which mycobacteria are extracted from an aqueous suspension of sputum using liquids with a relative density lower than that of water (xylene, toluene, gasoline, benzene). At the same time, the detection rate of mycobacteria increases by no less than 10% compared to conventional microscopy.

Smears are prepared from native sputum. Staining is done using the Ziehl-Nielson method. Mycobacteria are found in the preparation in the form of thin straight or slightly curved bright red rods.

IN last years began to use the method of fluorescent microscopy. The method is based on the ability of mycobacterial lipids to perceive luminescent dyes and then glow when irradiated with ultraviolet rays. Mycobacterium tuberculosis under fluorescent microscopy gives a bright red or fluorescent yellow glow on a green background (depending on the type of dye). Luminescence microscopy significantly increases the efficiency of the bacterioscopic method for detecting Mycobacterium tuberculosis.

The culture method (cultural method for detecting Mycobacterium tuberculosis) is more sensitive compared to the bacterioscopic method. It detects Mycobacterium tuberculosis in sputum when there are several dozen viable individuals in 1 liter. Various nutrient media are used for the cultivation of Mycobacterium tuberculosis. As a standard medium for the primary isolation of the pathogen, WHO experts recommend Lowenstein-Jensen medium (solid egg medium), on which good growth Mycobacterium tuberculosis is obtained 15-25 days after inoculation of bacterioscopically positive material.

When bacterioscopically negative material (sputum) is sown on solid nutrient media, the average duration of mycobacterial growth is 20-46 days, however, individual strains can grow up to 60-90 days. This is why sputum cultures should be kept in a thermostat for at least 3 months. Then microscopy of a smear from the grown colonies, stained by Ziehl-Neelsen, is performed. Mycobacterium tuberculosis is found in the form of bright red or dark red rods.

A biological test is the most sensitive method for detecting Mycobacterium tuberculosis. It is used when the results of bacterioscopy and sputum culture are negative, but there is still suspicion of tuberculosis. The test consists of introducing guinea pig specially treated sputum of the patient. Then the pig is slaughtered after 3 months and if the result of the biological test is positive, it is found morphological characteristics tuberculosis in organs and tissues. During the autopsy, fingerprint smears are taken from the organs for bacterioscopic examination. In the absence of macroscopic signs of tuberculosis in the organs, cultures are taken from the lymph nodes, spleen, liver, lungs and specially treated material onto solid nutrient media.

The biological method, due to its labor intensity, is used relatively rarely.

In the diagnosis of pulmonary tuberculosis, the leading role belongs to x-ray research methods. L.I. Dmitrieva (1996) suggests using them as follows:

mandatory radiographic diagnostic minimum (large-frame fluorography, plain radiography);
in-depth x-ray examination (radiography in two mutually perpendicular projections; fluoroscopy; standard tomography);
additional X-ray examination (various methods of radiography and tomography, including computed tomography and magnetic resonance imaging).

Characteristic radiological manifestations of individual forms of pulmonary tuberculosis are presented below.

Focal pulmonary tuberculosis

Focal pulmonary tuberculosis is a clinical form characterized by a limited inflammatory process (the size of the lesions is about 10 mm) and an asymptomatic clinical course. The main clinical features of focal pulmonary tuberculosis are as follows:

long-term chronic wave-like course with alternating phases of exacerbation and subsidence. This course is not typical for acute pneumonia;
absence of clear clinical manifestations even in the acute phase, and even more so in the compaction phase; with pneumonia, as a rule, the symptom of intoxication is significantly expressed, especially with lobar pneumonia;
characterized by prolonged coughing without or with the release of a small amount of sputum (even if the patient is not a smoker);
listening to fine wheezing in a limited area of the lung and, as a rule, after coughing;
characteristic x-ray picture.

Radiological manifestations of focal pulmonary tuberculosis can be divided into three main groups):

fresh forms are distinguished by blurred foci of various shapes and sizes, sometimes merging against the background of pronounced lymphangitis;
subacute forms are characterized by more sharply defined foci due to pronounced productive changes;
fibrous-indurative changes with a predominance of linear strands over focal shadows.

With an exacerbation of focal tuberculosis, a zone of perifocal inflammation appears around old lesions and the development of new lesions is possible against the background of dense old lesions.

Infiltrative pulmonary tuberculosis

Infiltrative pulmonary tuberculosis is a clinical form characterized by a predominantly exudative type of inflammatory process with a tendency to the rapid formation of caseous necrosis and destruction.

In size, tuberculosis infiltrates are small (diameter from 1.5 to 3 cm), medium (from 3 to 5 cm) and large (more than 5 cm).

Clinical symptoms of infiltrative pulmonary tuberculosis are determined by the size of the lesion and the phase of the process.

The following clinical and radiological variants of infiltrative pulmonary tuberculosis are distinguished:

cloud-shaped variant - characterized by a gentle, non-intense homogeneous shadow with fuzzy contours. In this case, rapid formation of decay and a fresh cavity is possible;
round variant - manifests itself as a round, homogeneous, low-intensity shadow with clear contours, the diameter of the shadow is more than 10 mm;
lobitis - the infiltrative process affects the entire lobe, the shadow is inhomogeneous with the presence of decay cavities;
periscissuritis - an extensive infiltrate, localized at interlobar fissures and often causing the development of interlobar pleurisy, while the shadow on one side has a clear outline, on the other, its outlines are blurred;
lobular variant - characterized by an inhomogeneous shadow formed as a result of the merging of large and small foci.

It is very difficult to differentiate infiltrative pulmonary tuberculosis and acute pneumonia based on clinical signs, since there is a great similarity in the clinical manifestations of both of these diseases. As a rule, infiltrative tuberculosis, like acute pneumonia, occurs with high body temperature, severe symptoms of intoxication, and physical findings are also similar. However, unlike pneumonia, hemoptysis is much more often observed with infiltrative tuberculosis. Very rarely, tuberculosis infiltrate is asymptomatic or low-symptomatic. In making the diagnosis of infiltrative pulmonary tuberculosis, the leading role is played by x-ray examination of the lungs, a sharply positive tuberculin test, determination of mycobacteria in sputum, and a clear positive effect of antituberculosis therapy.

In addition, it should be taken into account that all clinical and radiological variants of infiltrative tuberculosis are characterized not only by the presence of an infiltrative shadow, but also by bronchogenic contamination in the form of fresh foci both in the lung in which there is an infiltrate and in the second lung. Quite often, with tuberculous infiltrate, there is a “path” running from the infiltrate to the root of the lung, caused by inflammatory peribronchial and perivascular changes (this is clearly visible on radiographs). Finally, it should be taken into account that, despite the fact that tuberculous infiltrate can be located in any part of the lung, it is still most often localized in the region of the second bronchopulmonary segment and on an anterior radiograph is most often detected in the lateral zone of the subclavian region.

Caseous pneumonia

Caseous pneumonia is a clinical form of pulmonary tuberculosis, characterized by pronounced exudative inflammation of the entire lobe of the lung or most of it, which is quickly replaced by caseous-necrotic changes (“curdled” decay) with subsequent formation of cavities. The course of caseous pneumonia is severe.

Miliary pulmonary tuberculosis

Miliary pulmonary tuberculosis is the dissemination of the tuberculous process with the formation of small foci (1-2 mm) with a predominantly productive reaction, although caseous-necrotic changes are also possible. The disease begins acutely, body temperature rises to 39-40°C, intoxication syndrome is expressed sharply, patients are worried severe weakness, sweating (debilitating night sweats are possible), anorexia, weight loss, shortness of breath, persistent dry cough. During percussion of the lungs, there are no significant changes in the percussion sound; during auscultation of the lungs, a small amount of dry rales may be heard due to the development of bronchiolitis. Thus, there is a certain similarity in the clinical manifestations of severe pneumonia and miliary pulmonary tuberculosis.

Disseminated pulmonary tuberculosis

Disseminated pulmonary tuberculosis is a clinical form characterized by the formation of many tuberculous foci. According to the course, acute, subacute and chronic form disseminated pulmonary tuberculosis. Spicy and subacute forms are characterized by a severe course, patients have high body temperature, chills, night sweats, a very pronounced intoxication syndrome, and a disturbing cough, usually dry, less often with sputum production. Severe shortness of breath may develop. When auscultating the lungs, you can hear fine bubbling rales and crepitus in the upper and middle sections. The main diagnostic method is x-ray.

In acute disseminated tuberculosis, focal shadows are detected in the lungs, evenly distributed from the apexes to the diaphragm - a picture of dense dissemination of small and medium-sized soft foci.

Subacute disseminated tuberculosis is characterized by the appearance of larger soft foci merging with each other. The lesions have a tendency to decay and rapid formation of cavities.

Chronic disseminated pulmonary tuberculosis usually develops unnoticed, its clinical course is long, periodic dissemination of the process in the lungs may not give a clear clinical picture or occur under the guise of pneumonia, exacerbation chronic bronchitis. Fibrinous or exudative pleurisy often develops. Physical data in chronic disseminated pulmonary tuberculosis are scarce: a shortening of the percussion sound can be detected, mainly in the upper parts of the lungs; under areas of dullness, hard vesicular breathing can be heard, sometimes fine bubbles or single dry rales (due to damage to the bronchi). Chronic disseminated pulmonary tuberculosis, both acute and subacute, can be complicated by decay and cavity formation. In this case, a tetrad of symptoms is characteristic: cough with sputum, hemoptysis, moist rales, Mycobacterium tuberculosis in the sputum.

The progression of the process in chronic disseminated pulmonary tuberculosis leads to increased development of fibrosis and cirrhosis of the lungs.

Thus, disseminated pulmonary tuberculosis is quite difficult to distinguish from pneumonia. The decisive role in diagnosis belongs to X-ray method research.

The main radiological signs of disseminated pulmonary tuberculosis are (M. N. Lomako, 1978):

bilateral lesions;
polymorphism of focal shadows;
alternation of clearly defined lesions with fresh, poorly contoured lesions;
localization of lesions in the upper posterosternal regions (segments 1-2);
different sizes of lesions in different parts of the lungs: in the upper sections the lesions are larger, with clear contours and even the presence of calcareous inclusions; in the lower sections the lesions are smaller in size with more vague contours;
symmetrical location of lesions in both lungs in acute, asymmetrical in chronic disseminated pulmonary tuberculosis;
the appearance of decay cavities as the process progresses;
progressive development of fibrosis and cirrhosis.

Differential diagnosis of pneumonia, pulmonary tuberculoma, cavernous and fibrous-cavernous pulmonary tuberculosis is not difficult due to the fact that these forms of tuberculosis have clear radiological manifestations.

Tuberculoma is an isolated and encapsulated by connective tissue cheesy-necrotic lesion of a round shape more than 1 cm in diameter.

In X-ray imaging, tuberculoma appears as a clearly defined formation of a homogeneous or heterogeneous structure against the background of an intact lung. It is localized mainly in segments 1-2.6. Its shape is round, the edges are smooth. For the most part, tuberculoma has a homogeneous structure. However, in some cases, its structure is heterogeneous, which is due to calcifications, foci of clearing, and fibrous changes.

The most important differential diagnostic feature, not typical for pneumonia, is the presence of a double path in tuberculoma, which goes from tuberculoma to the root of the lung. This track is caused by dense peribronchial and perivascular infiltration. Often a capsule is detected around the tuberculoma. Focal shadows may be found in the lung tissue around the tuberculoma. During the period of exacerbation of the tuberculosis process, the X-ray image of tuberculoma is less clear than in the remission phase; even a focus of decay may appear. With the progressive course of tuberculoma, with the development of communication between it and the draining bronchus, Mycobacterium tuberculosis may appear in the sputum.

Tuberculoma is sometimes difficult to distinguish from peripheral lung cancer. The most reliable method for diagnosing tuberculoma is bronchoscopy with biopsy followed by cytological and bacteriological examination.

Exudative pleurisy

The need for differential diagnosis of pneumonia with exudative pleurisy is due to a certain similarity in the symptoms of both diseases - the presence of shortness of breath, symptoms of intoxication, increased body temperature, and a dull percussion sound on the affected side. The main distinguishing features are the following:

a significantly more pronounced lag in breathing of the corresponding half of the chest with exudative pleurisy than with pneumonia;
greater intensity of dull sound during percussion with exudative pleurisy than with lobar pneumonia. The dullness of the percussion sound in case of exudative pleurisy is considered absolute (“femoral”), it increases significantly downward, and during percussion the pessimeter finger seems to feel resistance. With pneumonia, the intensity of percussion sound is less;
absence of auscultatory phenomena over the area of dullness (no vesicular and bronchial breathing, voice tremors, bronchophony);
intense dense homogeneous darkening with a superior oblique border during an X-ray examination of the lungs, mediastinal shift to the healthy side;
detection of fluid in the pleural cavity using ultrasound and pleural puncture.

Pulmonary infarction

Pulmonary infarction occurs due to pulmonary embolism. The main signs that distinguish it from pneumonia are:

the appearance at the beginning of the disease of intense chest pain and shortness of breath, then an increase in body temperature; with lobar pneumonia, the relationship between pain and increased body temperature is reversed: as a rule, they are observed sudden increase body temperature, chills; after this, chest pain appears, sometimes with pneumonia, a simultaneous increase in body temperature and chest pain is possible;
absence of severe intoxication at the onset of pulmonary embolism;
hemoptysis is a common sign of pulmonary infarction, however, this can also be observed with pneumonia, but with a pulmonary infarction, almost pure scarlet blood is released, and with pneumonia, mucopurulent sputum mixed with blood is coughed up (or “rusty sputum”);
smaller area of lung damage (as a rule, less than the size of the lobe) in contrast, for example, to lobar damage in pneumococcal pneumonia;
a sharp decrease in the accumulation of the isotope in the infarction zone (due to a sharp disruption of capillary blood flow) during radioisotope scanning of the lungs;
characteristic ECG changes, suddenly appearing - deviation electrical axis heart to the right, overload of the right atrium (high pointed wave Pvo II and III standard leads, in lead aVF), rotation of the heart around the longitudinal axis clockwise with the right ventricle forward (appearance of deep wave 5 in all chest leads). These ECG changes can also be observed in acute lobar pneumonia, but they are much less pronounced and observed less frequently;
the presence of thrombophlebitis of the veins of the lower extremities;
characteristic radiological changes are bulging of the cone a.pulmonalis, the focus of darkening has the shape of a strip, less often - a triangle with the apex directed to the root of the lung.

Lungs' cancer

Lung cancer is a common disease. From 1985 to 2000, the number of patients with lung cancer will increase by 44%, and mortality - by 34.4%. The following methods are used to diagnose lung cancer.

Analysis of anamnesis data

Lung cancer affects men more often, especially those over 50 years of age. As a rule, they abuse smoking for a long time. Many patients have occupational hazards that contribute to the development of lung cancer: working with carcinogenic chemicals, nickel, cobalt, chromium compounds, iron oxides, sulfur compounds, radioactive substances, asbestos, radon, etc. Great importance in the diagnosis of lung cancer, the appearance of symptoms such as persistent cough, change in voice tone, the appearance of blood in the sputum, increased body temperature, lack of appetite, weight loss, and chest pain. The significance of these anamnestic data increases even more if they are combined with deformation or blurring of the root of the lungs, first identified during an x-ray examination.

Peripheral lung cancer develops from the epithelium of small bronchi or from the epithelium of the alveoli and can be located in any part (segment) of the lung. However, it is most often localized in the anterior segments of the upper lobes of the lungs.

Radiological manifestations of peripheral cancer largely depend on the size of the tumor. Radiological signs of peripheral lung cancer can be characterized as follows:

a small tumor (up to 1-2 cm in diameter), as a rule, manifests itself as a darkening center of irregular round, polygonal shape; medium and large sized cancers have a more regular spherical shape;
The intensity of the shadow of a cancerous tumor depends on its size. With a node diameter of up to 2 cm, the shadow has a low intensity; with a larger tumor diameter, its intensity increases significantly;
very often the tumor shadow has an inhomogeneous character, which is due to the uneven growth of the tumor and the presence of several tumor nodules in it. This is especially noticeable with large tumors;
the contours of tumor darkening depend on the phase of tumor development. The tumor is up to 2 cm in size and has an irregular polygonal shape and unclear contours. When the tumor size is up to 2.5-3 cm, the darkening has a spherical shape, the contours become radiant. With dimensions of 3-3.5 cm in diameter, the contours of the tumor become clearer, however, with further growth of peripheral cancer, the clarity of the contours disappears, the tuberosity of the tumor is clearly visible, and sometimes decay cavities are identified in it;
characteristic is Rigler's symptom - the presence of a notch along the contour of the tumor, which is due to uneven growth of cancer;
Quite often, with peripheral lung cancer, a “path” to the root of the lung is visible, caused by lymphangitis, peribronchial and perivascular tumor growth;
X-ray examination over time reveals progressive tumor growth. According to V.A. Normantovich (1998), in 37% of patients tumor doubling occurs within 17-80 days; in 43% of patients - 81-160 days, in 20% of cases - 161-256 days;
in advanced cases, the tumor compresses the corresponding bronchus, and atelectasis of the lung lobe develops.

More detailed X-ray signs of cancer and bronchial compression are detected using X-ray tomography and computed tomography of the lung.

When differentially diagnosing acute pneumonia and peripheral lung cancer, the following circumstances must be taken into account:

in acute pneumonia, under the influence of rational antibacterial therapy, positive dynamics appear quite quickly - a decrease in the severity and then the complete disappearance of the darkening focus; with cancer, such dynamics are not observed;
typical for acute pneumonia positive symptom Fleischner - good visibility of small bronchi against a dark background; this sign is not observed in lung cancer;

Central cancer of the upper lobe and middle lobe bronchi is manifested by darkening of the entire lobe or segment with a decrease in the volume of the lung lobe. X-ray tomography reveals the symptom of the stump of the lobar bronchus. Cancer of the main bronchus is characterized of varying severity its stenosis up to complete stenosis with the development of atelectasis of the entire lobe of the lung. Stenosis of large bronchi is clearly detected by X-ray tomography and computed tomography.

An important diagnostic method is bronchographic examination, which reveals a break (“amputation”) of the bronchus when the tumor covers its lumen.

Bronchoscopy

Bronchoscopy with multiple biopsies of the bronchial mucosa is of great importance in the diagnosis of lung cancer. During bronchoscopy, direct signs of lung cancer can be identified: endobronchial, endophytic or exophytic tumor growth, infiltrative changes in the bronchial wall. A tumor growing peribronchially is manifested by indirect signs: protrusion, rigidity of the bronchial wall, looseness of the mucous membrane, unclear pattern of the cartilaginous rings of the lobar and segmental bronchi. Along with a biopsy of the bronchial mucosa, a bronchial washout is performed, followed by cytological examination flushing

In 1982, Kinsley et al. described the method of fibrobronchoscopy with simultaneous ultraviolet irradiation of the bronchial mucosa. The method is based on the fact that bronchogenic cancer cells have the property of selectively accumulating hematoporphyrin derivative compared to healthy tissues and then fluoresce under ultraviolet rays. When using this technique, the fiberoptic bronchoscope is equipped with a special ultraviolet irradiation source, a light guide, a filter and a focused image intensifier.

In some cases, during bronchoscopy, a transbronchial puncture biopsy of a lymph node suspicious for metastasis is performed.

Cytological examination of sputum

It is necessary to test sputum for cancer cells at least 5 times. Cancer cells can be detected in the sputum of 50-85% of patients with central and 30-60% of patients with peripheral lung cancer.

Cytological examination of pleural exudate

The appearance of exudative pleurisy in lung cancer indicates an advanced tumor process. In this case, the pleural fluid is often hemorrhagic in nature; cytological examination reveals tumor cells.

Needle biopsy of palpable peripheral lymph nodes

Palpable peripheral lymph nodes (cervical, axillary, etc.) indicate metastasis of lung cancer. A puncture biopsy of these lymph nodes provides verification of cancer metastasis in 60-70% of patients.

Immunological diagnostic methods

Immunological methods for diagnosing cancer have not yet become widespread. clinical application. However, according to literature data, in the complex diagnosis of lung cancer, the detection of tumor markers in the blood: carcinoembryonic antigen, tissue polypeptide antigen, lipid-bound sialic acids may have a certain diagnostic value. It is necessary to take into account the non-specificity of these tumor markers; they can be detected in the blood in cancer of other organs (liver, stomach, etc.).

Transthoracic puncture

Transthoracic puncture is performed under X-ray television control and is the main method for verifying the diagnosis of peripheral cancer, confirming the diagnosis in 65-70% of cases.

Acute appendicitis

The need for differential diagnosis of acute appendicitis and pneumonia arises when it is localized in the lower lobe of the right lung. This is most often observed in children. Right lower lobe pneumonia is often accompanied by pain and muscle tension in the right half of the abdomen, including in the right iliac region.

The main differential diagnostic differences between right-sided lower lobe pneumonia and acute appendicitis are as follows:

with pneumonia, pain in the right iliac region does not increase when moving the hand deeper during palpation of the abdomen; in acute appendicitis, the pain increases sharply, and at the same time the tension in the abdominal muscles increases;
with pneumonia, pain intensifies with breathing; with acute appendicitis, this relationship is not typical or is poorly expressed; however, when coughing, abdominal pain increases in both pneumonia and acute appendicitis;
in acute appendicitis, the temperature in the rectum is significantly higher than the temperature in the axillary region (the difference exceeds GS), in acute pneumonia there is no such pattern;
thorough percussion and auscultation, x-ray examination of the lungs reveal symptoms of acute pneumonia in the lower lobe of the right lung, which serves as the main criterion for differential diagnosis.

Cardiogenic pulmonary edema

The need for differential diagnosis of pneumonia and cardiogenic pulmonary edema (“congestive lung”) is explained by the presence of similar symptoms: cough with sputum (sometimes mixed with blood), shortness of breath, crepitus and fine rales in the lower parts of the lungs. The following circumstances serve as differential diagnostic differences:

the presence in patients with “congestive lungs” of symptoms of decompensated cardiac diseases (heart defects, post-infarction cardiosclerosis, severe arterial hypertension, diffuse myocarditis, exudative pericarditis, etc.);
with “congestive lungs”, as a rule, an increase in the size of the heart is detected, atrial fibrillation is more often detected, episodes of cardiac asthma and pulmonary edema are observed (the clinic of these conditions is described in the chapter “Acute circulatory failure”);
Pulmonary edema almost always occurs as a bilateral process; upon auscultation of the lungs, crepitus and fine rales are heard in the lower parts of both lungs;
X-ray changes in the lungs during congestion depend on the severity of the congestive process. At the stage of interstitial edema, intensification and deformation of the pulmonary pattern are revealed, thanks to the shadows of longitudinal projections of overcrowded small vessels. With further progression stagnation and filling of the alveoli with transudate, bilateral darkenings appear (often round in shape) without clear boundaries, mainly in the medial areas of the middle and lower fields. With significantly pronounced stagnation, an increase in the roots of the lungs is determined - they take on the shape of a butterfly;
congestion in the lungs develops, as a rule, against the background of other clinical manifestations of circulatory failure (severe peripheral edema, ascites, enlarged painful liver);
in the absence of concomitant pneumonia, congestion in the lungs is not accompanied by pronounced laboratory signs of inflammation;
X-ray changes of a congestive nature are significantly reduced and may even disappear completely after successful treatment of heart failure;
Sometimes in the sputum of patients with congestion in the lungs, alveolar epithelial cells are found, the protoplasm of which contains in excess phagocytosed grains of the hemoglobin derivative - hemosiderin.

The above signs make it possible to distinguish pneumonia from congestion in the lungs. However, it should be taken into account that pneumonia can develop against the background of congestion in the lungs. In this case, an asymmetric darkening is detected by X-ray, most often in the lower lobe of the right lung, and laboratory signs of an inflammatory process appear.

Pneumonitis in systemic vasculitis and diffuse connective tissue diseases

With systemic vasculitis and diffuse connective tissue diseases, focal opacities in the lower parts of the lungs or peribronchial, perivascular infiltration, increased pulmonary pattern. In the differential diagnosis of pneumonia, attention should be paid to the characteristic clinical manifestations of systemic vasculitis and systemic connective tissue diseases (systematic lesions, articular syndrome, usually the involvement of the kidneys in the pathological process, erythematous skin rashes, hemorrhagic rashes, etc.), corresponding laboratory manifestations, ineffectiveness antibacterial therapy and the positive effect of treatment with glucocorticosteroids.

Etiological diagnosis

Currently, the problem of timely and successful etiological diagnosis has become extremely urgent. An accurate etiological diagnosis is the key to correct and successful treatment of pneumonia.

The main methods for establishing the etiological diagnosis of pneumonia are:

Thorough analysis of clinical, radiological and laboratory features pneumonia depending on its etiology.
Microbiological examination of sputum, sometimes bronchial lavage, pleural effusion with quantitative assessment of microflora content. Sputum should be collected in a sterile container after preliminary rinsing of the mouth. To increase the effectiveness of the study, it is advisable to first process the sputum using the Mulder method. To do this, take a purulent piece of sputum and thoroughly wash it in a sterile isotonic sodium chloride solution successively in three Petri dishes for 1 minute in each. This helps remove mucus containing microflora of the upper respiratory tract and oral cavity from the surface of the lump of mucus. It is advisable to take at least three lumps from different parts of the sputum. After this, the sputum is cultured on selective biological media. The number of microbial bodies in 1 ml of sputum is also counted.

The causative agents of pneumonia in a given patient are considered to be those microorganisms that are sown from sputum in the amount of 1,000,000 or more microbial bodies per 1 ml.

Simultaneously with sputum inoculation on selective biological media, sputum smears are made, followed by bacterioscopy. One smear is stained using the Romanovsky-Giemsa method for cytological analysis (the type and number of leukocytes, the presence of bronchial and alveolar epithelium, erythrocytes, atypical cells, etc. are determined). The second smear is stained with Gram and the abundance of microflora, the presence of gram-positive and gram-negative microorganisms, and their intra- or extracellular localization are assessed. But first it is necessary to establish that the drugs belong to sputum and not to the oral mucosa. The criteria for Gram-stained preparations to be classified as sputum are:

the number of epithelial cells, the main source of which is the oropharynx, is less than 10 per total number of cells counted;
predominance of neutrophilic leukocytes over epithelial cells;
predominance of microorganisms of one morphological type. Bacterioscopy of sputum smears stained by Gram allows us to tentatively suggest the causative agent of pneumonia. Thus, when gram-positive diplococci are detected, one should think about pneumococcus; chains of gram-positive cocci are characteristic of streptococcus, clusters of gram-positive cocci are characteristic of staphylococcus; short gram-negative rods - for Haemophilus influenzae; In addition, gram-negative microorganisms include Moraxella, Neisseria, Klebsiella, and Escherichia coli.

Immunological studies. Immunological methods that allow verification of the causative agent of pneumonia include the identification of bacterial agents using immune sera in a counter immunoelectrophoresis reaction; determination of titers of specific antibodies (using enzyme immunoassay, indirect hemagglutination reaction, complement fixation reaction). The role of determining specific antibodies in blood serum especially increases when using the method of paired sera (a significant increase in antibody titer when repeated testing after 10-14 days compared to the titers obtained at the onset of the disease).

How is differential diagnosis of pneumonia carried out?

How is differential diagnosis of pneumonia carried out? This question interests many patients. Very often this disease is called pneumonia (pneumonia). As a rule, we are accustomed to the fact that pneumonia is severe. The main symptoms are fever, cough and weakness. But it turns out that there are several types of this disease. In order to recognize this disease and distinguish it from other lung diseases, a differential diagnosis of pneumonia is carried out.

What is characteristic of pneumonia?

The most common cause of pneumonia is an infection that is accompanied by damage to the lung tissue. Doctors distinguish pneumonia from bronchitis by the degree of localization of the inflammatory process in the lungs. If inflammatory process occurs in the alveoli, it is believed that this is pneumonia. If there is inflammation of the bronchi, then we are talking about bronchitis.

But sometimes inflammation in the alveoli is not associated with infectious causes, in which case doctors diagnose pulmonitis. In addition, damage to the lung tissue can occur as a result of exposure to chemicals, radiation exposure, or may be a consequence of injury.

Is there a difference between pneumonia and bronchitis?

Differences between diseases:

During the inflammatory process, fluid accumulates in the alveoli, and gas exchange may occur.
If the development of pneumonia is expected, then in the areas of the lungs that are affected by the inflammatory process, there is no gas exchange. Fluid accumulates in the globules of the lungs.
With bronchitis, the inflammatory process occurs in the bronchi, which are responsible for the air conductivity of the lung tissue. Based on this, bronchitis and pneumonia affect different parts of the lung tissue.
A person who suffers from a cough and high temperature will not be able to independently distinguish the symptoms of pneumonia from bronchitis. Only a doctor can find differences in the clinical picture of these diseases.
Both diseases are accompanied by cough and high fever. Mucopurulent or purulent sputum is released. Patients often complain of lack of air. The patient is worried about nausea, which is the cause of intoxication.

How is the differential diagnosis made?

In order to distinguish between bronchitis and pneumonia, the doctor prescribes examinations:

fluorography;
X-ray.

Pneumonia is characterized by the appearance of foci of infiltration, which are absent in bronchitis.

The doctor also conducts a survey of the patient. When the lungs are affected, the cough can be either dry or with sputum; often the sputum contains pus mixed with mucus.

There is one more symptom that you need to notify your doctor about. Sometimes streaks of blood appear in the sputum. In this case, differential diagnosis of pneumonia and tuberculosis is required. In this case, it is extremely necessary to take an x-ray of the lungs.

Some patients may attribute this to nose bleed or bleeding gums. However, bloody sputum can be a sign of tuberculosis or even cancer. It is very important not to waste time.

Signs of pneumonia are increased body temperature, as well as localization of chest pain on the left or right in the scapular region.

Pneumonia is characterized by pain when coughing or breathing. Substernal pain is more characteristic of bronchitis.

Sometimes patients complain of lack of air, but it is difficult to separate bronchitis and pneumonia based on this criterion. A similar symptom is common to both diseases.

What types of pneumonia are there?

Differential diagnosis of pneumonia is carried out depending on the type of disease. According to the modern classification, the cause of the disease is divided into the following factors:

If infection with the disease occurred at home or in the office, a diagnosis of community-acquired pneumonia is made.
Sometimes patients become ill in the hospital or after being discharged from it, and a diagnosis of hospital-acquired or nosocomial pneumonia is made.
If the disease develops as a result of lung injury, then aspiration pneumonia is diagnosed.
Pneumonia often develops as a result of radiation exposure.
Sometimes the disease occurs in people with severe immunodeficiency.

Almost anyone can get pneumonia. It often occurs in children. However, children and the elderly are at risk for this disease. Therefore, you should get vaccinated regularly.

It is very important to choose the right doctor. You should trust the treatment of the disease only to a specialist who has extensive experience.

Treatment of the disease requires the use of antibiotics. Flu medications, which are widely advertised today, can only blur the clinical picture.

Do not forget that in the distant past, pneumonia was considered a fatal disease. Without using antibiotics you can die. Depending on the severity of the disease, the doctor may recommend treatment at home or in a hospital.

Give more detailed information The table that your doctor will familiarize you with can help you differentiate between pneumonias.

How can you quickly cure pneumonia?

The doctor makes a forecast of the rate of cure of the disease after a thorough examination of the patient. Much depends on the patient's condition. Many people believe that antibiotics can cure illness. Yes, modern medicine has wide range antibiotics. But the fact is that antibiotics provide a favorable prognosis in the treatment of the disease.

However, antibiotics cannot speed up recovery. On average, the duration of treatment for the disease is about 21 days. If a person has good immunity, then he can recover in 10 days. In patients who suffer from HIV, the illness can last from 2 to 3 months. But the course of antibiotic treatment does not continue all this time.

Prevention of the disease is of great importance. It consists of hardening. After suffering from pneumonia, you should avoid contact with people who suffer from colds.

Pneumonia often develops after an acute respiratory infection. That is why acute respiratory infections need to be treated with all seriousness. It is very important to maintain bed rest during a cold. If you cannot cope with a cold, and the symptoms only increase, you need to consult a doctor.

There are a number of diseases that can complicate the course of the disease when the patient suffers from cancer, tuberculosis, diabetes or HIV.

Pneumonia must be treated under the strict supervision of a doctor.

Diagnosis of pneumonia in children

Laboratory diagnosis of pneumonia

A peripheral blood test should be performed in all patients with suspected pneumonia. Leukocytosis more than 10-12x109/l and band shift more than 10% indicate a high probability of bacterial pneumonia. When pneumonia is diagnosed, leukopenia less than 3x109/l or leukocytosis more than 25x109/l are considered unfavorable prognostic signs.

Biochemical blood test and study of the acid-base state of the blood - standard methods examinations of children and adolescents with severe pneumonia. those in need of hospitalization. The activity of liver enzymes, the level of creatinine and urea, and electrolytes are determined.

The etiological diagnosis is established mainly for severe pneumonia. A blood culture is performed, which gives positive result in 10-40% of cases. Microbiological examination of sputum in pediatrics is not widely used due to technical difficulties in collecting sputum in the first 7-10 years of life. But in cases of bronchoscopy, microbiological examination is used; the material for it is aspirates from the nasopharynx, tracheostomy and endotracheal tube. In addition, to identify the pathogen, puncture of the pleural cavity and culture of punctate pleural contents are performed.

Serological research methods are also used to determine the etiology of the disease. Increase in titers of specific antibodies in paired sera taken during the acute period and the period of convalescence. may indicate mycoplasma or chlamydial etiology of pneumonia. Reliable methods are also considered to be the detection of antigens using latex agglutination, counter immunoelectrophoresis, and ELISA. PCR, etc. All these methods, however, take time, do not affect the choice of treatment tactics and have only epidemiological significance.

Instrumental methods for diagnosing pneumonia

The “gold standard” for diagnosing pneumonia in children is an X-ray examination of the chest organs, which is considered a highly informative and specific diagnostic method (the specificity of the method is 92%). When analyzing radiographs, the following indicators are assessed:

size of lung infiltration and its prevalence;
presence or absence of pleural effusion;
the presence or absence of destruction of the pulmonary parenchyma.

All this data helps determine the severity of the disease and choose the right antibiotic therapy. Subsequently, with clear positive dynamics in the clinical manifestations of community-acquired pneumonia, there is no need for control radiography (upon discharge from the hospital or when the child is being treated at home). It is more advisable to carry out control radiography no earlier than 4-5 weeks from the onset of the disease.

X-ray examination of dynamics during the acute period of the disease is carried out only if there is progression of symptoms of lung damage or if signs of destruction and/or involvement of the pleura in the inflammatory process appear. In cases of complicated pneumonia, mandatory X-ray monitoring is carried out before the patient is discharged from the hospital.

For hospital-acquired pneumonia, it must be remembered that if pneumonia develops 48 hours before death, then an X-ray examination may give a negative result. Such X-ray negative pneumonia (when radiography performed 5-48 hours before the patient’s death did not reveal pneumonic infiltration in the lungs) is observed in 15-30% of cases. The diagnosis is established only clinically on the basis of severe respiratory failure, weakened breathing; There may often be a short-term rise in temperature.

A radiographic study of the dynamics of hospital-acquired pneumonia in the acute period of the disease is carried out when the symptoms of lung damage progress or when signs of destruction and/or involvement of the pleura in the inflammatory process appear. If there is a clear positive trend in the clinical manifestations of pneumonia, a control radiography is performed upon discharge from the hospital.

When assessing the condition of children previously hospitalized for any pathology and children with severe community-acquired pneumonia, special attention should be paid to the condition and effectiveness of respiratory function, in particular pulse oximetry readings. In severe pneumonia and hospital-acquired pneumonia, especially VAP, it is also necessary to monitor indicators such as respiratory rate, pulse rate, blood pressure, acid-base status, diuresis, and in children in the first six months of life - body weight.

Computed tomography (CT) is used if necessary when carrying out differential diagnosis, since CT has 2 times higher sensitivity compared to plain radiography when identifying foci of infiltration in the lower and upper lobes of the lungs.

Fiberoptic bronchoscopy and other invasive techniques are used to obtain material for microbiological research in patients with severe immune disorders and for differential diagnosis.

Differential diagnosis of pneumonia in a child

When carrying out differential diagnosis, it is necessary to take into account the age of the child, since at different age periods pathological processes in the lungs have their own characteristics.

In infancy, the clinical picture of respiratory failure can be caused by conditions such as aspiration, foreign body in the bronchi, previously undiagnosed tracheoesophageal fistula, gastroesophageal reflux, malformations of the lungs (lobar emphysema), heart and large vessels, cystic fibrosis and α-antitrypsin deficiency. In children of the second or third years of life and at an older age (up to 6-7 years), Kartagener syndrome should be excluded; pulmonary hemosiderosis; nonspecific alveolitis; selective IgA deficiency.

Differential diagnosis at this age should be based on the use (in addition to lung radiography and peripheral blood analysis) of endoscopic examination of the trachea and bronchi, lung scintigraphy, angiography, sweat and other tests for cystic fibrosis, determination of the concentration of a-antitrypsin, study of blood immunogram and others research.

At any age it is necessary to exclude pulmonary tuberculosis. In the absence of positive dynamics of the process within 3-5 days (maximum - 7 days) of therapy, the protracted course of community-acquired pneumonia, its resistance to the therapy, it is necessary to expand the examination plan both to identify atypical pathogens (S. psittaci, Ps. aerugenozae, Leptospira, Coxiella burneti). and for the diagnosis of other lung diseases.

In patients with severe immune defects, when shortness of breath and focal infiltrative changes appear on a chest x-ray, it is necessary to exclude the involvement of the lungs in the main pathological process (for example, in systemic connective tissue diseases), as well as lung damage as a consequence of the therapy (drug-induced lung injury, radiation pneumonitis .d.).

What is pulmonary tuberculosis: differential diagnosis and clinical picture

Often in medical practice pulmonary tuberculosis is detected, differential diagnosis of which should be carried out with various diseases (pneumonia, atelectasis, sarcoidosis). Currently, pulmonary tuberculosis is one of the biggest problems. The thing is that about 2 billion people are infected with Mycobacterium tuberculosis. This disease has enormous social significance due to the difficulty of treatment, the possibility of an aerosol transmission mechanism, as well as a high mortality rate. What are the etiology, clinical picture, differential diagnosis and treatment of pulmonary tuberculosis infection?

Characteristics of pulmonary tuberculosis

Tuberculosis is a chronic disease caused by mycobacteria, which can affect various organs, including the lungs. Pulmonary tuberculosis most often occurs in adults. The causative agent of this infection is very resistant to the environment. Due to their structure, mycobacteria have become highly resistant to many modern anti-tuberculosis drugs. The infectious agent is transmitted by the following mechanisms:

aerosol;
fecal-oral;
contact;
vertical.

The transmission of mycobacteria through the air through coughing is of greatest importance. The airborne route is relevant only in the presence of an active form of the disease, when bacteria are found in sputum and can be released into the environment. The vertical mechanism is rare. The risk group among those infected includes people aged 20 to 40 years. Risk factors are:

overcrowding of teams;
close contact with a sick person;
sharing utensils with the patient;
decreased immunity;
presence of HIV infection;
drug use;
presence of chronic alcoholism;
the presence of chronic lung pathology;
general exhaustion of the body;
malnutrition (lack of vitamins);
a history of diabetes mellitus;
unfavorable living conditions;
stay in places of deprivation of liberty.

Clinical symptoms

The clinical manifestations of pulmonary tuberculosis are quite varied. They are determined by the form of the disease. The most common symptoms are:

increased body temperature;
increased sweating at night;
decreased appetite;
weight loss;
weakness;
decreased performance;
dyspnea;
chest pain;
cough;
hemoptysis;
enlarged lymph nodes.

Knowing these signs is necessary for a correct diagnosis. Differential diagnosis is often based on the symptoms of the disease, and not just the results of laboratory and instrumental studies. The most common complaint of patients in this situation is cough. With pulmonary tuberculosis, it is first dry, then with sputum. The patient may cough for several minutes without stopping. Often when you cough, purulent sputum is released. The cough is often accompanied by shortness of breath and chest pain. In addition to coughing, hemoptysis may occur.

Diagnostic measures

Today, the diagnosis of pulmonary tuberculosis involves:

conducting a tuberculin test;
Diaskin test;
microbiological examination of sputum or biopsy;
performing chest x-rays;
general blood and urine tests.

The Mantoux test allows you to assess the state of immunity and determine infection. The test result can be negative, positive or doubtful. A negative result indicates the absence of disease. An important place is occupied by differential diagnosis. To clarify the diagnosis, differential diagnosis is carried out with the following diseases: lobar pneumonia, eosinophilic pulmonary infiltrate, actinomycosis, atelectasis, lung cancer, infarction.

Differential diagnosis

Each form of tuberculosis has its own characteristics. The following types of pulmonary tuberculosis are distinguished: primary, miliary, disseminated, infiltrative, tuberculoma. Clinical forms also include caseous pneumonia. Infiltrative pulmonary tuberculosis is very often detected. At the same time, areas of compaction form in the lung tissues. The infiltrate can occupy an area of several segments or lobes of the organ. It can be very difficult to distinguish from nonspecific pneumonia. The first difference is that with pneumonia the severity of inflammatory processes is much less, while upon physical examination (listening to the lungs) severe symptoms are noted. With infiltrative tuberculosis, on the contrary, changes in tissues prevail over the results of physical examination.

Secondly, with tuberculosis and nonspecific pneumonia, different segments of the lung are affected. With tuberculosis, segments 1, 2 and 6 most often suffer, with pneumonia – 3, 4, 5, 7, 9, 10. Thirdly, anamnesis data are important. With pneumonia, there are often indications of hypothermia or pathology of the upper respiratory tract. Infiltrative tuberculosis can also be recognized clinically. It does not occur as acutely as pneumonia. Cough with tuberculosis is not as frequent, but longer lasting. Intoxication is more pronounced with pneumonia. The temperature rises slightly. With pneumonia it can reach 40 degrees. Fourthly, there are differences in the x-ray picture.

With infiltrative tuberculosis, a heterogeneous shadow, cavities with decay, calcifications, a Gohn's lesion and petrification in the area of the roots of the lungs are found. The Mantoux test for pneumonia is often false positive. Histological examination is of great value. In pneumonia, neutrophils and macrophages are detected, while in tuberculosis, epithelial cells, lymphocytes, and Pirogov-Langhans cells are detected.

The most valuable distinguishing feature of tuberculosis is the presence of Mycobacterium tuberculosis in the sputum.

Tuberculosis and other diseases

In some cases, tuberculosis infection can be mistaken for an eosinophilic infiltrate. This condition is associated with exposure to an allergen. Unlike pulmonary tuberculosis, it is characterized by:

an increase in eosinophils in the blood;
rapid regression;
the presence of darkening with unclear contours, which can be localized in any part of the lung.

A course similar to tuberculosis is observed with actinomycosis, the main symptom of which is chest pain. In the sputum of this disease, structural elements (drusen) of actinomycetes are detected. With actinomycosis, subcutaneous infiltrates or fistulas often form. Differential diagnosis can be made with atelectasis. The latter is characterized by collapse of the lung tissue. Unlike tuberculosis, with atelectasis the main symptoms are shortness of breath, difficulty breathing, and cyanosis. An x-ray shows a decrease in the volume of the affected segment of the lung or an entire lobe. The shadow is uniform and has clear contours. In addition, there is a displacement of healthy tissue towards the lesion.

Difference between caseous and lobar pneumonia

Caseous pneumonia is one of the clinical forms of tuberculosis. It is characterized by cheesy inflammation of the lung tissue. It is often a complication of fibrous-cavernous tuberculosis. It is necessary to be able to distinguish it from focal (lobar) pneumonia. Firstly, sputum in lobar pneumonia is rusty in color, while in caseous pneumonia it is mucopurulent. Secondly, with lobar pneumonia, auscultatory signs are more pronounced. Thirdly, during laboratory testing, lobar pneumonia is indicated by the detection of pneumococci. Urobilin, casts, and protein are found in the urine. In case of caseous pneumonia, mycobacteria are persistently detected.

Fourthly, during X-ray examination, lobar pneumonia most often affects 1 lung. In this case, the lower lobe is affected, whereas with caseous pneumonia, the upper lobe of the lung is involved in the process. After the correct diagnosis is made, treatment is carried out. For this purpose, anti-tuberculosis drugs are used. The first row includes Isoniazid, Rifampicin, Pyrazinamide, Ethambutol, Streptomycin. Thus, tuberculosis has a number of distinctive features that make it possible to exclude other lung diseases.

The fine line between diseases is best understood by doctors. In daily practice, doctors have to:

to deal with differential diagnosis lung cancer and pneumonia;
treat infectious complications in cancer patients;
prevent inflammation of the lungs due to cancer of the respiratory tract.

In such cases, the doctor must work at the intersection of two specialties: pulmonology and oncology.

The difficulty of identifying obstructive pneumonitis and its differentiation from chronic pneumonia is indicated by the following figures: in 1969, according to F.G. Uglova and T.T. Bogdan, 91% of patients with cancer pneumonia were initially diagnosed with chronic pneumonia. Out of a thousand, in 452 patients the error was not detected for more than a year.

Today, half of those who die from undiagnosed lung cancer have chronic pneumonia listed in their medical records.

Fatal errors are explained by the similarity of symptoms and the fact that lung or bronchial cancer is accompanied by pneumonia.

Clinical symptoms of cancer appear late: at the stage of impaired bronchial drainage function, developed inflammatory process, collapse of the lung walls (atelectasis).

Until this point, regular antibiotics provide temporary improvement. On a radiograph after a course of therapy, 15-20% of patients demonstrate restoration of the patency of the affected bronchus and a decrease in the inflamed area around it.

When determining the disease, radiation diagnostic methods are primarily used:

large-frame fluorography;
radiography in two standard projections;
targeted radiography.

After this, the nature of the darkening is studied. On radiographs, the shadows of the tumor have clear edges, in later stages - with processes. The tumor node does not shrink after a course of antibiotic treatment. Cases of central lung cancer, bronchial cancer with inflammation and pneumonia on a radiograph can be very similar: the opacities in both cases can be homogeneous or heterogeneous. The differences lie in the clear contours of the tumor, sometimes of a bizarre shape, and the pronounced shadow of the hilar node.

computed tomography;
bronchoscopy;
bronchography.

To standard x-ray projections one of the named hardware diagnostic methods is prescribed. The choice depends on the age and condition of the patient. Patients over 65 years of age usually do not undergo bronchography.

There are a number of contraindications for bronchoscopy, including: hypertension, exacerbation of asthma, strokes and heart attacks, mental illness. High-resolution tomograms and bronchograms most clearly demonstrate the difference between opacities in pneumonia and cancer.

At the stage of clarifying the diagnosis, a course of intensive anti-inflammatory drug therapy is started. If there is no significant improvement in the first 2 weeks, there are prerequisites for an oncological diagnosis.

Disease markers are looked for in samples:

sputum;
washouts of the bronchial mucosa;
tissue biopsies.

Based on the results of the examination, pneumonia is determined by:

acute onset;
physical inflammatory phenomena;
fast therapeutic effect from taking antibiotics;
positive change on the x-ray 14 days after the start of the course.

Signs that help diagnose focal lung lesions were tabulated by Professor of the Belarusian State Medical University, Head of the 1st Department of Internal Diseases A.E. Makarevich.

Table 1. Differential diagnosis of focal lung lesions.

Sign	Focal pneumonia	Peripheral lung cancer
Age	At any age, but more often in people under 50 years of age	More common in people over 50 years of age
Floor	Equally common in men and women	More common in male smokers
Onset of the disease	Usually acute with fever	May be unnoticeable or with increased temperature
Cough	At first there may not be	Often absent
Dyspnea	With large damage to lung tissue	May be missing
Hemoptysis	Rarely	Rarely
Chest pain	Occurs when the pleura is involved	Possible
Intoxication	Not expressed	Often not expressed
Physical data	Pronounced: the breathing pattern changes and moist rales appear	Scanty or absent
Laboratory data	Leukocytosis, an increase in ESR, which decreases after the resolution of pneumonia	Moderate increase in ESR with normal leukocyte count
X-ray data	Sharply expressed, the lower lobes are more often affected, focal shadows are homogeneous, the boundaries are blurry, increased pulmonary pattern, enlarged roots of the lung	Initially, the shadow of the tumor is low-intensity with unclear contours and “antennae”
Effect of antibiotics	Expressed, reverse development of the process after 9-12 days	There is no or false positive dynamics, but changes during X-ray examination persist

Specifics of pneumonia in cancer patients

tumor and drug intoxication of the body;
exhaustion;
anemia;
operations with blood loss;
irradiation;
dysbiosis.

Infection can occur at home, but the most dangerous thing is to become a victim of a “hospital infection.” Today, combinations of several types of bacteria or bacteria and fungi are considered particularly aggressive. Such complications are difficult to treat due to the resistance of microbes to known drugs.

According to the Russian Oncological scientific center them. N.N. Blokhin RAMS (Moscow), a third of cancer patients die from infectious complications. Autopsy provides information on 43% of patients with unrecognized manifestations of infection.

Of all types of infectious complications of cancer treatment, pneumonia accounts for an average of about 39%. In this case, pneumonia significantly complicates the postoperative period, reduces the quality of life, and becomes the reason for repeated operations.

Diagnosis of pneumonia in oncology is difficult because it occurs without pronounced symptoms. There may be no wheezing, bronchophony, or a sharp increase in temperature. X-rays or CT scans can provide clarity, but most patients will require additional preparation.

In cases where it is difficult to apply radiation diagnostic methods, they practice bronchoalveolar lavage. Examination of the resulting fluid reveals the causative agent of the disease.

On tomograms:

bacterial infections are visible as darkening;
fungal - look like many lesions with a light rim;
viral - similar to a network.

Approaches to the treatment of complications after radiation and chemical therapy are radically different: for radiation pneumonitis, the use of glucocorticoids is effective. Toxic damage lungs with bleomycin and nitrosourea derivatives are neutralized with cytostatics and other drugs.

If pneumonia is suspected during cancer treatment, antimicrobial agents are prescribed empirically until the diagnosis is clarified.

Pneumonia of bacterial origin is treated with III-IV generation cephalosporins, their combination with aminoglycosides or fluoroquinolones, taking into account the patient’s condition. According to research by N.V. Dmitrieva, I.N. Petukhova and A.Z. Smolyanskaya, such a course leads to success of 71-89%.

Proper antibiotic therapy not only speeds up recovery, but also prevents the cultivation of new strains of drug-resistant bacteria.

All kinds of diseases of the respiratory system are quite similar to each other and cause almost the same negative consequences for the body when inflammation occurs. Inflammation of the lung tissue can be caused not only by diseases of the respiratory system or pathogenic microorganisms, which include bacteria, viruses and fungi, but also by all sorts of disruptions to the functioning of other organs, for example, with stroke, allergies or problems with the central or peripheral nervous system.

In the international classification of diseases, the inflammatory process in the lung tissues is called pneumonia, and popularly – pneumonia, which has a branched classification according to etiology, location, and also the nature of its course.

This disease is very dangerous for humans, it can develop very quickly and sometimes latently, leave a large number of serious complications, both pulmonary and non-pulmonary in nature, and also has a high mortality rate.

Treatment of pneumonia is much more effective and simpler if the disease was detected on early stages and treatment was started immediately.

What is the differential diagnosis of pneumonia

To detect any disease, including pneumonia, there are certain diagnostic methods: laboratory (all kinds of tests of tissues, fluids, secretions), instrumental (representing a hardware study of the patient: tomography, X-ray, ultrasound), differential diagnosis and simple examination.

Differential diagnosis of pneumonia is a research method according to which the diagnosis is made by excluding diseases with similar manifestations in the patient.

This research method is used when the exact cause of the disease is not known for certain, for example, a runny nose can be allergic, viral, bacterial or, in general, the result of a malfunction of any organs, and a third of cancer patients initially make an incorrect diagnosis, trying to treat a non-existent disease, while while oncology is quietly growing.

In order to immediately and accurately determine any disease and identify its cause, it is necessary to literally thoroughly analyze the body of a sick person, and sometimes his mind. Neither one nor the other, alas, is possible even with the most modern equipment and scientific technologies, so doctors are often forced to act at random or by exclusion.

During this research method, the doctor collects as much data as possible about the patient, his lifestyle, all reactions occurring in his body, analyzes the medical history and compares all new data obtained with a list of presumptive diagnoses and their characteristics. In modern medicine, sometimes even computer differential diagnostics of pneumonia and other diseases, including mental ones, is used, which makes comparisons using a computer.

Based on the results obtained, the patient is given a differential diagnosis, which can be confirmed clinically.

Setting the differential The diagnosis of pneumonia and any other disease occurs as follows:

First, the symptoms and the range of most suitable diagnoses are fully determined.
Then, the most detailed detailed characteristics of the disease and the leading variants that this disease may correspond to are compiled.
At the third stage, they are compared.
Further, by applying mental effort and a certain amount of imagination of the diagnostician, the most likely option is isolated and an accurate diagnosis is established.

At first glance, this research method seems very far-fetched and unreliable, however, in the vast majority of cases it is the most effective when the symptoms raise some doubts, and has a very high percentage of accuracy.

Differential diagnosis of pneumonia is simply necessary when the patient has any concomitant diseases of the respiratory system or other organs that can drown out or distort its symptoms and confuse them. This method The study allows in this case to isolate pneumonia from the symptoms of the underlying disease and begin treatment on time.

Focal pneumonia and lung cancer

One of the cases where differential diagnosis simply cannot be avoided is pneumonia due to lung cancer, which has a number of specific features.

Firstly, against the background of cancer in the lung tissues, patients always develop acute pneumonia, which until recently claimed the lives of such patients faster than the cancer itself, until it was discovered.

The inflammatory process begins directly in the area of tumor formation, is caused by a combination of a large number of pathogens and aggravates its growth, which, in turn, stimulates the development of pneumonia.

Symptoms of pneumonia are often practically unnoticeable against the background of cancer, because, really, what can deterioration in health, weakness and increased temperature mean against the background of such terrible disease, and even more so chemotherapy.

Accidentally see the beginning of inflammation when instrumental methods research is also impossible, because the tumor physically covers it, and during a tomographic study it absorbs all the chemical markers introduced into the blood, which color the tumor and do not respond to other problems.

In addition, lung cancer during the period of metastasis and pneumonia have very similar main symptoms: sputum, cough, chest pain, difficulty breathing, shortness of breath, hemoptysis, etc.

In addition to lung cancer itself, a similar effect is produced by metastases in the respiratory system from the main tumor located in another organ. Before metastasis, lung cancer is completely asymptomatic.

Only minor differences can identify exactly how pneumonia has begun. Signs of pneumonia:

How the disease begins: a bright, acute onset.
Description of the cough: it may be absent at first, be of varying degrees of productivity, and may or may not bring satisfaction to the patient.
Description of shortness of breath: begins with a large area of damage or swelling.
How does hemoptysis occur: rarely acute stages diseases in severe form.
Characteristics of chest pain: most often associated with breathing and movement.
Severity of intoxication: varies, depending on severity.
Physical data: moist rales are heard in the lungs and the breathing pattern changes.
Reaction to antibiotics: after one to one and a half weeks of taking antibiotics, the process reverses.
Laboratory test results: a very strong increase in ESR and leukocytosis.
X-ray: the roots of the lung are enlarged (the places of their attachment to the main bronchi and vessels), the pulmonary pattern is enhanced, the affected area itself looks uniform with blurry edges.

The following characteristics are observed in cancer:

The most common age of the patient is over fifty years old, with a significant predominance of smokers.
Most common patient gender: none.
How the disease begins: gently and imperceptibly with a gradual increase in temperature.
Description of cough: often absent.
Description of shortness of breath: may be absent.
How does hemoptysis occur: it appears only when metastases break through into the pleural area.
Characteristics of chest pain: sometimes absent, but more often present.
Severity of intoxication: not expressed.
Physical data: there are no changes in breathing or the sound of proper lung function.
Response to antibiotics: either completely absent, or the patient begins to feel better, but the X-ray results do not change.
Laboratory test results: leukocytes are normal, and ESR is moderately elevated.
X-ray: the tumor does not have clear contours and “antennae”, and in the initial stages its shadow is poorly defined.

These are the main points of difference between one disease and another, by which the attending physician may suspect the onset of cancer or, conversely, pneumonia against its background. But there are diseases that have even fewer specific differences, the key point of delimitation of which may be such an insignificant sign as the patient’s gender and age, or whether he belongs to the majority according to some statistical data.

Pneumonia and tuberculosis

Bacterial pneumonia and tuberculosis are also similar in their manifestations, since they both represent a bacterial infection of the lung tissue. They have even more in common than with oncology, and tuberculosis can also provoke a heap of pneumonia if another pathogen joins the Koch bacilli on the tissue weakened by them.

How to understand that you do not have pneumonia, but tuberculosis:

Most common age of patient: none.
The most common gender of the patient: male.
How the disease begins: acute with cough, fever and a small number of symptoms.
Description of cough: dry, more like coughing.
Description of shortness of breath: present with severe damage to the internal tissues of the lung.
How does hemoptysis occur: very often and the more advanced the stage, the stronger.
Characteristics of chest pain: none or very rarely.
Severity of intoxication: severe and constantly progressive.
Physical data: no or subtle changes in breathing.
Reaction to antibiotics: practically absent. Only 5% of patients feel relief while maintaining the x-ray picture.
Laboratory test results: leukocytes and ESR remain normal.
X-ray: changes most often form in the upper lobes, have clear contours and can be located in the form of tracks from the root of the lung or the original area of the disease.

Pneumonia and bronchitis

Pneumonia and advanced bronchitis are indeed very similar in their external manifestations and the patient’s sensations, moreover, if the infection spreads from the bronchi to the alveoli, then one disease will be reclassified as another.

Children have a rather strong tendency to such degeneration of the disease, and a preliminary differential diagnosis of pneumonia cannot be made without instrumental research, which in the early stages is not very effective, can be determined by certain signs: the most striking pattern of symptoms: an even higher temperature, worsening condition, cough, the appearance of purulent mucus in the sputum, etc.

Pneumonia and lung abscess

Lung abscess, on the contrary, is a consequence of pneumonia and more severe form its manifestations, when purulent cavities with atrophied tissue appear in the lung tissues. The symptoms of abscess formation may be lost against the background of symptoms of pneumonia, and on an x-ray may not be visible against the background of general inflammation, and by missing such an important point, the doctor may even lose the patient.

An abscess can manifest itself in the form of decreased breathing, extreme intoxication, an even greater temperature jump, as well as increased pain in the affected area. After an abscess ruptures, there is a high probability of developing sepsis or pleurisy, however, after this the patient’s condition temporarily improves slightly.

Pneumonia and pulmonary embolism

TPA - thromboembolism pulmonary artery, according to the background signs, it may look like pneumonia, but during it, in addition to the main symptoms of oppression of the lung tissue, severe shortness of breath, cyanosis (pallor or blue discoloration of the nasolabial triangle and tissues), tachycardia (increased heart rate), pressure drop of more than 20% from normal levels.

Diagnosis of pneumonia or pulmonary embolism is based on a more thorough study of tests and the patient’s previous diseases. With pulmonary embolism, pneumonia can develop against the background of a general weakening of the body and depression of the lung tissue, in particular. And pulmonary embolism can be a consequence of operations, the use of hormonal drugs, or be the result of prolonged bed rest.

Pneumonia and pleurisy

Pleurisy can be either a consequence of pneumonia or an independent disease and even its cause.

It is almost impossible to see pleurisy using conventional methods, and there are practically no symptoms, but X-rays of the lungs show lesions that change their location from time to time, which is not observed with pneumonia.

Differential diagnosis is an excellent method that allows you to both diagnose pneumonia in the early stages and identify the most hidden ailments. However, it requires a lot of experience from the diagnostician, or at least his extensive knowledge base and careful attention to the most seemingly insignificant details that can put a final, but so important for the patient, point in the examination.

Focal pneumonia differential diagnosis. Pneumonia

How is differential diagnosis of pneumonia carried out?

What is characteristic of pneumonia?

Is there a difference between pneumonia and bronchitis?

How is the differential diagnosis made?

What types of pneumonia are there?

How can you quickly cure pneumonia?

Diagnosis of pneumonia in children

Laboratory diagnosis of pneumonia

Instrumental methods for diagnosing pneumonia

Differential diagnosis of pneumonia in a child

What is pulmonary tuberculosis: differential diagnosis and clinical picture

Characteristics of pulmonary tuberculosis

Clinical symptoms

Diagnostic measures

Differential diagnosis

Tuberculosis and other diseases

Difference between caseous and lobar pneumonia

Specifics of pneumonia in cancer patients

What is the differential diagnosis of pneumonia

Focal pneumonia and lung cancer

Pneumonia and tuberculosis

Pneumonia and bronchitis

Pneumonia and lung abscess

Pneumonia and pulmonary embolism

Pneumonia and pleurisy

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