Differential diagnosis of focal pneumonia in children. Dif diagnosis of pneumonia

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The need to carry out differential diagnostics arises from the frequently observed errors in the diagnosis of acute pneumonia, especially at the prehospital stage.

At least 30-40% of patients have pneumonia with initial examination is not recognized, and both hyper- and underdiagnostics are observed with approximately the same frequency.

The main reason for such an unsatisfactory diagnosis is the late appeal of patients for medical care.

In the hospital, according to pathological studies, pneumonia remains unrecognized in about 5% of patients.

As you know, differential diagnosis is carried out according to the leading syndrome. In the differential diagnosis of pneumonia, it is advisable to consider the infiltration of lung tissue (pulmonary infiltrate) determined by X-ray as the leading syndrome. In those rare cases when X-ray examination is various reasons not carried out, differential diagnosis can be carried out according to the syndrome of clinically determined pulmonary infiltration: increased vocal tremor and bronchophonia in a limited area, dullness of percussion sound, hard or bronchial breathing, local crepitus (listening to local moist rales is less characteristic).

An infiltrate is understood as a tissue site that has an accumulation of cellular elements usually not characteristic of it (inflammatory, eosinophilic, cancerous, lymphoid, leukemic, etc.), characterized by an increase in volume and increased density. In accordance with this, inflammatory, for example, in pneumonia and tuberculosis, cancerous, eosinophilic, leukemic infiltrates, infiltrates in malignant lymphomas, etc. are distinguished.

Thus, parenchymal changes in lung tissue in pneumonia are only one of the options for pulmonary infiltration. Infiltration is defined on a radiograph as a darkening of the lung tissue, which is not always easy to distinguish from other processes. Therefore, the list of diseases with which it is necessary to carry out differential diagnosis, expands due to these processes (atelectasis of a lobe or segment, pulmonary infarction, congestion in the lungs).

In the differential diagnosis of pneumonia, the doctor has the following tasks:

1) differentiation of pneumonia from other respiratory diseases;

2) differentiation of pneumonia from extrapulmonary diseases with manifestations of the lungs;

3) carrying out a differential diagnosis among the pneumonia itself in order to establish (at least presumably) the etiology of the disease, since pneumonia caused by various microorganisms are different nosological forms and require appropriate etiotropic treatment.

Differential diagnosis of lobar (segmental) pneumonia with other respiratory diseases

Differential diagnosis with other lung diseases has some features in lobar, segmental and subsegmental pneumonia. Lobar pneumonia, mainly pneumococcal, must be differentiated from tuberculous lobitis (as a variant of infiltrative pulmonary tuberculosis), caseous pneumonia, and atelectasis of a lobe or segment with obstructive pneumonitis.

Differential diagnosis with tuberculous lobitis and caseous pneumonia

Tuberculous lobitis and caseous pneumonia have much in common with lobar pneumonia: usually an acute onset, heat body, cough, sometimes with bloody sputum, chest pains, similar physical changes in the lungs, on x-ray examination - a darkening of the lobe with an increase in the affected lobe.

In favor of tuberculous lobitis are evidenced by:

1) heterogeneity of darkening on the roentgenogram with the presence of denser formations and areas of enlightenment (better seen on a tomogram), and especially focal shadows, both dense and soft, due to lymphogenous and bronchogenic seeding of the surrounding lung tissue infiltrate;

2) more frequent absence of leukocytosis and neutrophilic shift to the left in peripheral blood;

3) detection of mycobacterium tuberculosis in sputum (studies must be repeated - up to 3-5 times, especially if the upper lobe is affected);

4) the lack of effect of treatment in the "prescribed" time for pneumonia.

More significant differences with lobar pneumococcal pneumonia have caseous pneumonia - one of the most severe forms of pulmonary tuberculosis, the frequency of which has sharply increased in recent years due to the deterioration of social conditions.

Unlike pneumococcal, with caseous pneumonia there is severe and constant sweating, especially at night (with pneumococcal lobar pneumonia, sweating appears only during a crisis or when the disease is complicated by abscess formation), distinct symptoms of intoxication are usually not observed severe pain in the chest; after a few days from the onset of the disease, a large amount of greenish, purulent sputum begins to separate (with pneumococcal pneumonia, after a short period of separation of rusty sputum, a small amount of mucous sputum is separated); hectic fever is noted (does not happen with pneumococcal pneumonia); during auscultation, moist rales of increased sonority are usually determined by the end of the first week of the disease.

X-ray data of the lungs and sputum analysis are crucial for diagnosis. Caseous pneumonia radiographically from the first days of the disease is characterized by inhomogeneous darkening of the lung lobe (less often 1-2 segments), which consists of merging large, flocculent infiltrative foci with emerging areas of enlightenment due to rapidly advancing decay.

Within a few days, in place of these areas, numerous fresh caverns with bay-like outlines and a wide zone of inflammatory changes around are formed. Characterized by a rapid transition of the process to a neighboring lobe or to another lung with seeding of these departments, followed by the rapid development of new confluent foci with their disintegration.

The tuberculous nature of the pulmonary process is confirmed by the detection of mycobacterium tuberculosis in the sputum.

It is much more difficult to carry out differential diagnosis of Friedlander and caseous pneumonia. As mentioned earlier, Friedlander pneumonia, like caseous pneumonia, is characterized by a more frequent lesion of the upper lobe, early development multiple destruction in the lungs, severe course.

Differentiation is carried out according to the above-mentioned features of X-ray changes and the results of the analysis of sputum and other biological substrates (bronchial secretions, smears from the larynx, bronchial washings, gastric contents) for Mycobacterium tuberculosis. Taking into account the dynamics of the pulmonary process under the influence of the therapy is of additional importance.

Differential diagnosis with obstructive pneumonitis

Lobar pneumonia must be differentiated from obstructive pneumonitis that develops in the atelectatic lobe. Most often, this process is based on bronchogenic lung cancer. Obstructive pneumonitis is indicated by the presence of clinical and radiological signs of atelectasis of a lobe or segment and the identification of clinical and laboratory signs inflammatory process in the lungs.

Differential diagnosis of subsegmental pneumonia with other respiratory diseases

In subsegmental pneumonia, infiltrative changes involve limited areas in the lungs. In these cases, differential diagnosis is carried out, first of all, with acute respiratory viral infection (ARVI), not complicated by pneumonia, infiltrative pulmonary tuberculosis, various forms of lung cancer and other malignant diseases with lung damage, chronic pneumonia and allergic processes in the lungs. It is quite obvious that the relevance of differential diagnosis with these diseases increases with a protracted course of pneumonia.

Differential diagnosis with ARVI and infiltrative pulmonary tuberculosis

As already noted, pneumonia, especially subsegmental, almost 70% of patients develop against the background of influenza and other acute respiratory viral infections; on the other hand, with pneumonia, ARVI is often mistakenly placed. Of greatest practical importance is the detection of pneumonia against the background of an acute respiratory viral infection.

The addition of pneumonia is evidenced by the deterioration of the general condition of the patient on the 3-7th day from the onset of ARVI, the appearance of a second wave of fever, increased dyspnea and cough with the discharge of a significant amount of sputum, identification of local changes in the lungs: a site with increased voice tremor and bronchophonia, dullness of percussion sound, hard breathing or breathing with a bronchial tinge, against which crepitus and moist rales are heard.

Listening to dry and moist wheezing, symmetrical on both sides, in the lungs is explained by the presence of acute bronchitis as a manifestation of an acute respiratory viral infection and does not directly indicate pneumonia. The diagnosis is confirmed by X-ray examination, which reveals infiltrative changes in the lungs.

Subsegmental (less often segmental) pneumonia must also be differentiated from infiltrative pulmonary tuberculosis, primarily with the most common rounded infiltrate, as well as cloudy infiltrate and periscissuritis, which is understood as tuberculous infiltrate located along the large or small interlobar fissures.

Let's name the main differences between infiltrative pulmonary tuberculosis and pneumonia:

1. More gradual and less noticeable onset of the disease. Acute onset of the disease is more often observed with cloudy infiltrates, periscissuritis and lobitis, but they account for 10-20% of all infiltrative forms of pulmonary tuberculosis.

2. Absence or slight severity of the syndrome of intoxication and catarrhal phenomena. In particular, the cough in patients is not expressed and has the character of "coughing". Often, with infiltrative tuberculosis, the first clinical symptom is hemoptysis, which appears as a "bolt from the blue" and already testifies to the disintegration of the infiltrate.

3. More often the upper lobe localization or in the VI segment of the lower lobe (subsegmental pneumonia is more often localized in the basal segments of the lower lobes).

4. Frequent detection of pallor of the face, profuse sweating at night, good tolerance of increased body temperature (the patient often does not feel its rise), scanty percussion and auscultatory data (more often single moist rales are heard, usually after coughing). The expression of GR Rubinshtein (1949) that in tuberculosis (more precisely, in its infiltrative form) "much is visible (meaning in X-ray examination) and little is heard" to this day retains its relevance.

5. As a rule, a normal or slightly increased number of leukocytes with a tendency to lymphocytosis. However, even with subsegmental pneumonia, an increase in leukocytes is absent in almost half of the patients. Therefore, only the detection of leukocytosis above 12x10 9 / l with a pronounced shift leukocyte formula left and erythrocyte sedimentation rate (ESR) above 40 mm / h may indicate pneumonia.

6. Indications of contact with a patient with tuberculosis.

X-ray examination, detection of mycobacterium tuberculosis in sputum, in some cases - bronchoscopy is of decisive importance for differential diagnosis. X-ray differences between subsegmental confluent pneumonia and tuberculous infiltrate are shown in Table 6.

The unconditional proof of the tuberculosis process is the detection of mycobacterium tuberculosis in sputum, especially with repeated studies. Mycobacteria are more often detected using fluorescence microscopy and bacteriological methods. The effectiveness of simple bacterioscopy, which is more often used in hospitals, is low.

Even with a content of 30,000 mycobacteria in 1 ml of sputum, positive results do not exceed 30%. Hence the expediency of repeated (up to 4-5 times or more) studies. The same facts indicate that negative results of simple bacterioscopy cannot serve as a basis for excluding tuberculosis.

Table 6. Radiological differences between subsegmental pneumonia and infiltrative tuberculosis

Sign	Subsegmental pneumonia	Infiltrative tuberculosis
Preferential localization	Lower lobe	Upper lobe (1st and 2nd segments), less often 6th segment of the lower lobe
The form	Wrong	Rounded, less often cloudy or oblong at the interlobar fissure (with periscissuritis)
Contours	Blurry	Clear
Intensity	Weak	Expressed
Focality	Absent	Against the background of the infiltrate and in the vicinity of it, soft (fresh) and dense foci are determined
Shadow lung root on the defeat side	Expanded	Regular
Path to the root (due to lymphangitis and fibrosis)	Missing or indistinct	There is
Resorption during treatment	Within 1-4 weeks	Within 6-9 months

Bronchoscopy with targeted biopsy can be used for the differential diagnosis of pneumonia, especially with a protracted course, and infiltrative tuberculosis. In both cases, endobronchitis is detected, and in case of tuberculosis in 15-20%, in addition, tuberculous lesions bronchus and post-tuberculous scars. The bronchial contents obtained during endoscopy are then used for bacterioscopic and cytological studies.

Differential diagnosis with lung cancer and malignant lymphoma

Subsegmental pneumonia must be differentiated from central and peripheral lung cancer, including one of the variants of peripheral cancer - bronchioloalveolar cancer (lung adenomatosis), originating from the epithelium of the bronchioles or alveoli.

Central cancer develops from the epithelium of large bronchi, more often segmental, less often lobar and main bronchi. It is accompanied by a cough with sputum production, hemoptysis, an X-ray examination reveals a tumor node, which, due to its low density, is poorly contoured on a conventional X-ray (better visible on a tomogram). With endobronchial growth, it rapidly leads to hypoventilation and atelectasis and is clinically often manifested by recurrent obstructive pneumonitis.

In connection with segmental or lobar darkening, such processes must be delimited, first of all, from pneumococcal and other lobar and segmental pneumonia. With exobronchial tumor growth, bronchial obstruction does not occur for a long time. Such a tumor reaches a significant size and, due to the peribronchial branched growth on the roentgenogram, gives an expanded root with uneven outer contours like "rays of the rising sun" or "janitor's broom".

The need for differential diagnosis with pneumonia arises only when the tumor is complicated by paracancrotic pneumonia. After carrying out antimicrobial therapy, the root darkening only decreases in size due to the resorption of pneumonia, while retaining the characteristic appearance described above after treatment.

It is more important to carry out the differential diagnosis of subsegmental pneumonia with peripheral lung cancer, which on the roentgenogram gives an infiltrative shadow of a rounded shape. The main differential diagnostic differences between these diseases are shown in Table 7.

Peripheral lung cancer is prone to disintegration with the formation of a cavity in the tumor. With this variant of peripheral cancer, differential diagnosis is carried out for abscess pneumonia.

Table 7. Differences between subsegmental pneumonia and peripheral lung cancer

Sign	Subsegmental pneumonia	Peripheral lung cancer
Age	Any age	More often in people over 40
Floor	Frequency does not depend on gender	More often in men
Start Diseases	As a rule, acute, with fever, cough, shortness of breath	More often invisible, without fever, cough and shortness of breath
Physical data	Common for pneumonia	Absent or scarce
Acute phase blood counts	Common for pneumonia	Moderate increase in ESR in the absence of other changes
X-ray data	Revealed during targeted examination: homogeneous darkening with indistinct outer contours with a gradual transition to healthy lung tissue	They can be detected during preventive and targeted examination: more often inhomogeneous darkening with clear, even or bumpy contours, short linear shadows can be detected on the outer surface, extending into the surrounding lung tissue (antennae)
The effect of antimicrobial therapy	Expressed	Absent, partial effect may be with paracancrotic pneumonia, however, the rounded shadow on the radiograph remains

Unlike disintegrating peripheral cancer, abscess pneumonia usually has a "breakthrough symptom", when a large amount of sputum is released in a short time, after which general state improves temporarily; further separation of a significant amount of sputum, often with a fetid odor, is observed. Elevated temperature body and high leukocytosis with a neutrophilic shift to the left, as well as pronounced symptoms of intoxication are also more characteristic of abscessed pneumonia.

There are also significant differences in the X-ray picture. The walls of the cavity, formed by a disintegrating tumor, are usually thick with an uneven, bay-like inner surface; the cavity itself is located eccentrically and, as a rule, does not contain liquid contents. In abscesses, the cavity is located centrally, usually has a horizontal fluid level and an uneven but clear inner contour.

Of the others malignant neoplasms, with which it is necessary to differentiate pneumonia, should be called malignant lymphomas - lymphosarcoma and especially lymphogranulomatosis of the lungs. This does not mean the most common primary lesion of the intrathoracic lymph nodes with lymphogranulomatosis, in which the differential diagnosis is carried out according to the syndrome of enlarged lymph nodes, but the primary lesion of the bronchopulmonary tissue.

In these cases, the growth of a specific granuloma often begins in the wall of the bronchus and, with endobronchial growth, leads to obstruction of the bronchus, atelectasis and recurrent obstructive pneumonitis. But more often the granuloma, growing, sinks into the lung tissue and leads to the formation of a polycyclic tumor of significant size, which radiographically gives a picture of the infiltrate. In this regard, the disease often proceeds under the guise of pneumonia.

The similarity is enhanced by the presence of a cough with a small amount of sputum and such signs of lymphogranulomatosis as fever, neutrophilic leukocytosis with stab shifts, which in this situation are perceived as "evidence" of pneumonia. Against pneumonia, they say the clarity of the peripheral contours of the darkening, the lack of improvement, and even the tendency of the infiltrative shadow to increase, despite the ongoing antimicrobial therapy. The diagnosis is confirmed by a puncture biopsy and when extrapulmonary signs of lymphogranulomatosis appear.

Differential diagnosis with chronic pneumonia and allergic lung lesions

Subsegmental (less often segmental) pneumonia must be differentiated with exacerbation chronic pneumonia... Unlike "acute" in chronic pneumonia:

1) in the anamnesis there are indications of a repeated nature of inflammation with localization in the same areas of the lung, a wavy course of the disease with a change in periods of exacerbation (usually in a transitional season) and remission;

2) during auscultation, the sonorous nature of wet wheezing draws attention (due to increased resonance due to pneumosclerosis);

3) during X-ray examination, infiltration is determined against the background of pneumosclerosis, which is better documented as the infiltrative changes decrease under the influence of treatment.

Allergic lesions of the lungs, with which it is necessary to differentiate pneumonia, proceed in the form:

1) eosinophilic pulmonary infiltrate (ELI) also called flying ELI, simple pulmonary eosinophilia or Leffler's syndrome (described by Leffler in 1932);

2) prolonged pulmonary eosinophilia;

3) allergic pneumonitis;

4) allergic alveolitis.

The need to exclude allergic processes in the lungs is dictated by the tasks of treatment, since the appointment and especially persistent use of antibiotics for allergic processes not only does not give an effect, but leads to a deterioration in the condition and often - to death.

Differences from pneumonia are:

1) the absence or weak severity of clinical manifestations in ELI (cough, percussion and auscultatory data), for example, only occasionally single dry and intermittent fine bubbling moist rales are heard;

2) mucous sputum, in small quantities, contains eosinophils, Charcot-Leiden crystals;

3) normal (less often subfebrile) temperature.

Most characteristic features eosinophilic pulmonary infiltrate is eosinophilia of blood (more than 8-10, more often 20-50, sometimes up to 70%) with a normal or slightly increased number of leukocytes and detection of homogeneous infiltrative darkening of significant sizes without clear external boundaries, often rounded, reminiscent of tuberculous rounded or cloudy infiltration. The infiltrate is more often located in the upper parts of the lung, sometimes several infiltrative shadows are determined.

Characteristically fast, after 3-4, less often 5-7 days, the disappearance of the infiltrate. It is believed that if the infiltration persists for more than 10 days, then the diagnosis of ELI becomes doubtful. However, some authors admit the duration of eosinophilic pulmonary infiltrate up to 4 weeks. The protracted course of eosinophilic pulmonary infiltrate is explained by the permanent intake of an allergen into the body, for example, by continuing to take the "guilty" drug, and is morphologically characterized by the development of allergic vasculitis. In this regard, in all cases when ELI develops against the background of drug treatment, it is recommended to cancel the drugs.

At prolonged pulmonary eosinophilia (DLE)(synonym - eosinophilic pneumonia), described by Carrington in 1969, infiltrates in the lungs and eosinophilia in the peripheral blood persist for more than 1 month. Persons of middle age, mainly women, are ill. Clinical symptoms are more pronounced than with ESA: moderate fever, cough with phlegm, shortness of breath, symptoms of intoxication, dullness of percussion sound, moist rales are observed.

In the study of blood, small leukocytosis and eosinophilia are revealed, although the latter is less pronounced than with ELI, and in some cases is absent, which complicates the differential diagnosis with pneumonia. In lung biopsies, eosinophilic infiltration of the alveoli and interstitial tissue is found. DLE can be an independent pathological process, but it often turns out to be a debut or one of the manifestations of systemic allergic reactions, including autoimmune diseases such as polyarteritis nodosa.

Allergic pneumonitis, also called pneumonia-like allergic lung disease, is more often a sign of a drug disorder, although it can develop with exposure to other allergens. Allergic pneumonitis is a localized process in the lungs, often one-sided, which, according to clinical and radiological data, cannot be distinguished from pneumonia. Often the pleura is affected with the possible development of an effusion.

The idea of ​​the allergic nature of the pulmonary process is suggested by:

1) the development of the disease against the background of taking medications (more often drugs of the penicillin series, sulfonamides, cephalosporins, furazolidone, furadonin, adelfan, dopegit, vitamin B 1, cocarboxylase and many others);

2) the presence of other clinical manifestations of allergies (skin rashes, asthmatic bronchitis, conjunctivitis, etc.);

3) the presence of moderate blood eosinophilia in some patients;

4) inefficiency antibacterial therapy;

5) improvement of the condition after elimination of contact with the suspected allergen, for example, after the cancellation of the "guilty" drug. To clarify the diagnosis, some authors recommend provocative, for example, intradermal allergic tests, as well as various methods for detecting drug allergies in vitro (inhibition of leukocyte migration, lymphocyte blast transformation reaction).

Allergic pneumonitis often overlaps with common pneumonia. In these cases, at the beginning of the disease, antibiotics have a certain effect, but then the reverse development of the process stops, despite the change in the antibiotic (antibiotics); moreover, the process spreads to neighboring parts of the lungs, and sometimes destructive changes develop and hemoptysis appears, which is explained by hemorrhagic vasculitis and microcirculation disorders.

Pulmonary destruction in allergic pneumonitis develops as a result of aseptic necrosis and, unlike abscess pneumonia, its formation is not preceded by the separation of purulent sputum with a smell, and the cavity itself does not initially contain fluid. In the future, its secondary infection often occurs with the formation of an abscess.

Allergic pneumonitis can be suspected based on the signs listed above. The most important argument in favor of allergic pneumonitis is the improvement in the condition after the withdrawal of antibiotics and the appointment of glucocorticoids.

Pneumonia must be differentiated from acute forms of alveolitis (bronchioloalveolitis). Recall that alveolitis are divided into idiopathic fibrosing alveolitis (ELISA), exogenous allergic alveolitis (EAA) and toxic fibrosing alveolitis (TFA).

With ELISA, the etiology of the disease is unknown; having begun, it progresses steadily, leading to diffuse pneumosclerosis, a decrease in the respiratory surface, pulmonary and pulmonary heart failure.

EAA is an allergic reaction (type III according to Gell and Coombs) from the respiratory system to the effects of various allergens. A source of EAA can be thermophilic actinomycetes contained in moldy hay ("farmer's lung"), antigens of various fungi ("brewer's lung", "cheesemaker's disease", allergic aspergillosis, etc.), components of cotton, hemp, flax (byssinosis - cotton ), animal hair ("furrier lung"), waste products of birds with antigenic properties, especially excrement in large quantities in the form of dust in the air of premises where the bird is kept ("poultry breeder lung", in particular "pigeon breeder lung"), various medicines (antibiotics, sulfonamides, cordarone, trypsin, chymotrypsin, streptase, urokinase and other enzymes, pituitrin, X-ray contrast agents, etc.).

The listed substances more often cause EAA when they enter the body by inhalation, less often - inside or parenterally. Among the various forms of EAA, farmer's lung, poultry farmer's lung, and drug-induced allergic alveolitis are more common. EAA manifestations appear 4-8 hours after the allergen enters the body.

TPA develops as a result of exposure to the alveoli of various toxic substances: irritating gases (hydrogen sulfide, chlorine, ammonia, etc.), metals in the form of vapors, fumes (manganese, mercury, zinc, etc.), plastics, herbicides. TPA can be caused by various drugs, for example, nitrofuran derivatives (furadonin, furazolidone), sulfonamides, cytostatic agents (chlorbutin, cyclophosphamide, methotrexate, myelosan, azathioprine, vincristine, etc.), anaprilin, and many others.

Acute form alveolitis, which proceeds almost the same for all variants of the disease, is almost always taken for pneumonia at first. Symptoms common to both diseases are: acute onset in most patients with an increase in body temperature up to 38-40 ° C, the appearance of shortness of breath, cough, chest pain (in some patients), aggravated by a deep breath; crepitus and small bubbling rales in the lungs, neutrophilic leukocytosis with a shift to the left, aneosinophilia. At the same time, in 40-45% of patients, the disease begins gradually with the onset of shortness of breath, dry cough, and fatigue.

Doubts about the diagnosis of "pneumonia" appear when analyzing subjective and objective clinical symptoms... Noteworthy is the high intensity of shortness of breath and its steadily progressing nature, which in most patients is accompanied by acrocyanosis or general cyanosis. In a number of patients, quite early due to pulmonary hypertension signs of right ventricular hypertrophy and its decompensation appear: expansion of the borders of the heart to the right, emphasis and splitting of the II tone on pulmonary artery, enlargement of the liver, symptoms of overload of the right heart on emission computed tomography (ECG).

Cough in acute alveolitis is usually dry and only in 20-25% of patients is accompanied by the separation of a small amount of mucous sputum. Physical examination data do not correspond to the diagnosis of pneumonia: vague and variable percussion changes (more often a percussion tone with a box shade, sometimes not changed or somewhat shortened), crepitus is heard over all fields of the lungs, mainly in the lower sections (due to damage to the alveoli) and fine bubbling wet rales (due to the defeat of the bronchioles).

Initially, in the exudative phase of the disease, tender crepitus is heard, then, as fibrosis of the lungs develops, voiced crepitus (sclerosiphonia). Crepitus and small bubbly moist rales are heard in 75% of patients.

Radiographically, in contrast to bacterial pneumonia, the diffuse nature of the pulmonary process is determined: a sharp increase in the pulmonary pattern with a predominance of interstitial edema, against which in all parts of the lungs infiltrative changes are determined in the form of flakes, small-focus darkening or large areas of infiltration, mainly in the lower parts of the lungs, by the type of "frosted glass". It is somewhat more difficult to distinguish non-bacterial pneumonia (mycoplasma, chlamydial) from alveolitis by the X-ray picture. Here you have to evaluate all clinical picture, as well as the dynamics of pulmonary changes under the influence of treatment.

Differential diagnostics also take into account:

1) the discrepancy between moderate intoxication, on the one hand, and the prevalence of lung damage, on the other;

2) lack of effect and even progression of the pulmonary process against the background of antimicrobial therapy;

3) a history of allergies to various substances and medicines what can be observed with EAA, and the effect of compounds that can have a toxic effect on the respiratory tract (to exclude TFA);

4) the presence of extrapulmonary signs of allergy (skin rash, Quincke's edema, allergic rhinitis, conjunctivitis), which may indicate EAA.

The diagnosis of alveolitis is confirmed by cytological methods in the study of biopsies of lung tissue (open lung biopsy is the method of choice) and lavage fluid.

Differential diagnosis of pneumonia with diseases of other organs and systems

Pneumonia must be differentiated from diseases of other organs and systems, which give various manifestations on the part of the lungs, primarily with diseases of cardio-vascular system leading to stagnation in the pulmonary circulation, with pulmonary manifestations in diffuse diseases connective tissue(DZST) and lung infarction.

Common signs of hypostasis and pneumonia are shortness of breath, cough with a small amount of sputum, dullness of percussion sound in the lower sections (with hypostasis due to swelling of the interstitial tissue), listening to crepitus and wet rales. With hypostasis, wheezing is determined on both sides, although often they are heard mainly on the right, but, most importantly, there is a variability of wheezing with a change in body position and with deep breathing (their decrease and even complete disappearance).

Distinctive signs of pneumonia, including pneumonia against the background of hypostasis (hypostatic pneumonia) from isolated hypostasis are a sudden deterioration of the patient's condition, increased shortness of breath, cough, increased body temperature (in these cases, even a temperature of 36.9-37 ° C may indicate accession complications, since hypothermia is characteristic of heart failure), some increase in bronchophonia, the appearance in the lower-posterior parts of the lungs of hard breathing or breathing with a bronchial shade, the asymmetric nature of the heard wheezing. An essential role in diagnostics is assigned to X-ray examination.

Lung damage with DZST (pneumonitis), in particular with systemic lupus erythematosus and rheumatoid arthritis may be mistaken for pneumonia. In both diseases, there is cough, shortness of breath, chest pain during breathing, an increase in body temperature, dullness of the percussion sound over the lower parts of the lungs, with auscultation - hard or weakened breathing, moist, mainly small bubbling rales of various sonorities. Radiological changes can also be similar to pneumonia with DZST: an increase in the pulmonary pattern in the lower and middle parts of the lungs, against which infiltrative foci are determined.

The main differences between pneumonitis and pneumonia are: the presence of signs of DZST, the ineffectiveness of antimicrobial therapy, the virtual absence of sputum separation, the high standing of the diaphragm and bilateral symmetrical changes in the lungs with the presence of focal-mesh enhancement and deformation of the pulmonary pattern, as well as one- or two-sided disc-shaped atelectasis located parallel to the diaphragm and associated with both damage to the lungs and the diaphragmatic pleura, positive dynamics under the influence of glucocorticosteroids.

Pulmonary infarction is usually a consequence of thromboembolism of medium-sized branches of the pulmonary artery. The cause of embolism is more often thrombophlebitis (phlebothrombosis) of the lower extremities and small pelvis, which developed after childbirth and surgical interventions, especially on the pelvic organs. Lung infarction can also develop as a result of local thrombosis in the pulmonary arteries in persons with heart defects, hypertension, coronary artery disease with severe heart failure, in patients with neoplasms of various localization, in persons who have been on bed for a long time.

Pulmonary embolism (PE) begins suddenly with shortness of breath, which can reach the degree of suffocation and is accompanied by diffuse cyanosis. Along with this, about half of the patients have chest pains (behind the breastbone, in the back or side sections), and 1/3 of the patients have hemoptysis. The presence of severe and acutely appearing shortness of breath, not adequate to the volume of the lesion (at first even without detectable changes in the lungs), often in combination with vascular insufficiency, the absence or weak severity of symptoms of intoxication and febrile reaction in the first 1-2 days of the disease can serve distinctive features PE from pneumonia.

In that early period distinct physical changes on the part of the lungs may not be detected, and an X-ray examination reveals an increase in the transparency of the lung tissue in the affected area with regional disappearance or weakening of the vascular pattern. Along with this, it is at the onset of the disease with the defeat of a larger branch or several segmental arteries that acute pulmonary heart syndrome develops.

Clinically, this is manifested by an increase in the heart beat, an accent of the II tone over the pulmonary artery, and a Graham-Still diastolic murmur. On the roentgenogram, a bulging of the pulmonary cone, a sharp expansion and chopped-off of the roots of the lung are revealed. The ECG reveals changes in the S 1 Q 3 type, that is, a deep S wave in I and a deep Q wave in III standard leads, as well as an increase in the ST segment and the appearance of a negative T wave in the III standard lead, while in the I and II standard leads the ST segment is shifted down.

With the development of a lung infarction (usually by the end of 1-3 days), dullness of the percussion sound is determined, more often in the subscapularis, weakened breathing, a small amount of dry and wet rales, quite often pleural friction noise. Radiographically, in typical cases (with the capture of one segment of the lung), a homogeneous darkening of a triangular shape with the base facing the pleura and the apex towards the hilum of the lung is found. Sometimes the darkening can take the form of a linear horizontal shadow above the diaphragm, the shape of a pear or a rocket with frequent involvement of the pleura with the presence of exudate and pleural adhesions.

In contrast to pneumonia, with a pulmonary infarction, an increase in body temperature is "delayed" and develops only as the development of infarction pneumonia, usually 2-4 days after embolization. The differentiation of infarction pneumonia from pneumonia of a different nature due to the similarity of the clinical and radiological picture is possible only when taking into account the dynamics of the development of the disease and the presence of background diseases that can lead to PE or local thrombosis of the pulmonary artery.

It should be borne in mind that thrombophlebitis of the deep veins of the legs and especially the pelvic veins is not always recognized clinically. Radiographically, with infarction pneumonia, it is often not possible to delimit the zone of infarction from peri-infarction inflammation. In such cases, the shadow of a lung infarction in the form of a uniform sharply outlined darkening is revealed only after the perifocal infiltration is resolved (after 1-2 weeks of treatment), it persists for another 1-3 weeks, after which the infarction resolves or is replaced by pneumosclerosis.

For the differential diagnosis of PE and pneumonia, lung scan can be used. The absence of changes on the scan is indicative of PE, while a positive result, reflecting a decrease or absence of perfusion, does not allow judging the nature of the disease, since it is observed not only in PE, but also in pneumonia and a number of other diseases. According to indications, angiopulmonography is performed.

The nature of differential diagnosis with other diseases is often determined by extrapulmonary symptoms (syndromes) of pneumonia itself or its complications. Among them, according to our data, the pseudo-abdominal syndrome, which develops due to damage to the diaphragmatic pleura with localization of pneumonia in the lower lobe, is of the greatest practical importance.

The presence of severe pain in upper section abdomen, often nausea and vomiting, high body temperature, leukocytosis with a neutrophilic shift to the left explains why it is sometimes mistaken for an "acute abdomen" and the patient is subjected to unnecessary surgery. Correct diagnosis is facilitated by the identification of symptoms of pneumonia, which is possible only with an impartial (that is, according to the generally accepted plan) clinical examination of the patient. Symptoms from the abdomen also differ significantly.

With pneumonia, abdominal pains are reflected in nature and are observed in the absence of peritonitis. In this regard, the tension of the abdominal muscles is expressed indistinctly, indistinctly, and most importantly, it is of a fickle nature, significantly decreasing until it completely disappears when the patient's attention is distracted. In contrast to the "acute abdomen", with dynamic observation, the abdominal syndrome in pneumonia does not increase.

Pneumonia due to developing hypoxia and intoxication often leads to an exacerbation coronary artery disease (CHD), especially often to the appearance (sometimes for the first time) of cardiac arrhythmias (paroxysmal tachycardia or paroxysmal form of atrial fibrillation, polytopic extrasystoles). Doctors correctly associate these rhythm disturbances with ischemic heart disease, but pneumonia, which served as their provocateur, is often not diagnosed. This is also facilitated by the fact that secondary pneumonia in patients with cardiovascular diseases usually proceeds without an increase in temperature, and the deterioration of the condition, the appearance (or increase) of shortness of breath, cough, moist wheezing in the lungs is associated with the development of left ventricular failure due to ischemic heart disease and arrhythmia. In the diagnosis of pneumonia, an important role is given to X-ray examination.

The presence of severe pain in the chest with left-sided pneumococcal pneumonia dictates the need to exclude myocardial infarction, an increase in the severe course of liver pneumonia with impaired functions - acute hepatitis or exacerbation of chronic hepatitis, irritation meninges(meningism) in some forms of pneumonia is the reason for the exclusion of meningitis.

If the patient first comes under the supervision of a doctor with the development of complications such as respiratory distress syndrome (RDS) and infectious toxic shock (ITSH), then the differential diagnosis is carried out for these syndromes. At the same time, to confirm the connection of RDS with pneumonia, the doctor should exclude other options for RDS (with sepsis, chemical poisoning, etc.) and hemodynamic pulmonary edema. Physical and radiological signs of pneumonia will come to light only after a few days, as pulmonary edema is eliminated.

ITS is also observed not only in pneumonia, but also in many other bacterial infections. Its connection with pneumonia is much easier to establish in the initial stages of shock, when its symptoms (general anxiety, alternating with lethargy of consciousness, shortness of breath, nausea, vomiting, tachycardia, moderate hypotension) do not mask the symptoms of pneumonia. With the progression of ITSH, when hypothermia, pulmonary edema, oliguria, hypoxic ECG changes resembling infarction develop, the presence of pneumonia can only sometimes be assumed on the basis of a careful study of the history and the absence of other reasons for the development of shock. In most cases, pneumonia at this stage of ITS is not diagnosed, and the origin of the shock itself is often associated with myocardial infarction.

Possibilities for differentiating pneumonia by etiology

At the 3rd stage of differential diagnosis, pneumonia is distinguished by etiology. As a leading syndrome, and at this stage, we recommend using the nature of radiographically determined pulmonary infiltration. With a lobar or segmental lesion and the presence of an appropriate clinical and laboratory picture, the doctor diagnoses pneumococcal pneumonia, but he must make a differential diagnosis with Friedlander and Legionella pneumonia according to the principles outlined above.

In rare cases, a lobar (segmental) lesion can be observed with staphylococcal infiltrate and confluent pneumonia of another bacterial etiology ("pseudolobar pneumonia"), which have an insufficiently delineated clinical and radiological picture and course. In these cases, the probability of establishing an etiological diagnosis without special laboratory research much lower.

From non-lobe and non-segmental pneumonia, it is necessary, first of all, to strive to isolate mycoplasma and chlamydial pneumonia according to clinical and radiological data. This is of great practical importance due to the peculiarities of the etiotropic treatment of these pneumonias.

Radiographically, they are characterized by the presence of infiltrative changes in the form of spotty or subsegmental (less often larger) opacities against the background of diffuse enhancement of the pulmonary pattern, and the strengthening of the pulmonary pattern in the first 1-2 weeks of the disease precedes the development of infiltrative changes. These features of the X-ray picture, if identified and received a correct assessment, can serve as a starting point for differential diagnosis.

Similar x-ray changes can be observed in viral-bacterial pneumonia, in which viral intoxication leads to toxic edema of the interstitial tissue with increased pulmonary pattern, and bacterial pneumonia - to infiltrative changes. However, viral-bacterial pneumonia in terms of clinical and laboratory parameters practically does not differ from other bacterial pneumonia and, as a rule, can be distinguished from mycoplasma and chlamydial pneumonia.

Clinically, mycoplasma and chlamydial pneumonia are characterized by the presence of extrapulmonary manifestations, the scarcity of the physical picture on the part of the lungs, a prolonged course of the disease, including a febrile period, a normal or slightly increased number of leukocytes, and often a group nature of the disease.

Although there are certain differences between mycoplasma and chlamydial pneumonia, for example, the development of the disease with symptoms acute respiratory disease (ARI) and the presence of a painful, debilitating cough in mycoplasma pneumonia and the development of the disease without a previous ARI syndrome and an almost constant presence of hepatolienal syndrome in chlamydial pneumonia, but without special laboratory studies it is not possible to reliably distinguish between these two forms of pneumonia. At the same time, this does not affect the nature of the therapeutic measures, since the etiotropic therapy of mycoplasma and chlamydial pneumonia is the same.

In other forms of subsegmental pneumonia, the etiology of the disease is established presumably taking into account the place of occurrence, clinical and radiological picture, course of the disease, epidemiological situation, age, nature of background diseases and the effect of therapy.

In all cases, it is necessary to strive for etiological diagnosis by laboratory methods.

Saperov V.N., Andreeva I.I., Musalimova G.G.

Lung diseases of various origins have similar symptoms. It takes time to carry out microbiological examinations and X-ray images, which, unfortunately, is very short for the doctor and the patient. In conditions where you need to take a quick correct solution, the physician's ability to determine the cause of the disease according to clinical and anamnestic data comes to the fore. For this purpose, methods of differential diagnosis have been developed.

First of all, pneumonia is differentiated from:

• tuberculosis;
• pulmonary embolism (PE);
• tumor lesions;
• allergic reactions to medications;
• psittacosis;
• allergic pneumonitis;
• sarcoidosis;
• collagenosis.

The health care provider begins by examining the patient and interviewing his environment. The goal is to find out the background against which the disease has developed. The presence of concomitant diseases (cancer, tuberculosis, diabetes, HIV, treatment with glucocorticosteroids or cytostatics) is established, living conditions are assessed, contacts with sick people and animals are identified.

At the next stage, the doctor compares the information received about body temperature, chills, the presence of headaches, impaired consciousness, the nature of the cough, shortness of breath, rapid breathing, pain, the type of phlegm. In the differential diagnosis of pneumonia, it is important to take into account the patient's age.

The initial diagnosis and prescription of treatment is based on the results of the examination, and only after the analysis of blood and sputum, an X-ray examination, the therapist makes a final conclusion.

Differences between inflammation and other lung diseases

1. Differential diagnosis of pneumonia and tuberculosis

The course of some forms of tuberculosis in initial stage very similar to the clinical picture of bacterial pneumonia. However, it should be remembered that the onset of tuberculosis is almost asymptomatic. Patients complain of fatigue, slight malaise (as a result of intoxication), coughing, sweating. At this stage, on x-ray examination, lung damage is already evident. Experienced doctors say: "Tuberculosis is more visible than heard."

Bacterial pneumonia is characterized by a pronounced onset with chills, an increase in temperature above 38.5 degrees. The skin of such a patient is dry and hot, and perspiration is observed only at the time of the crisis. Sputum with pneumonia - with air bubbles, more viscous than with tuberculosis.

Tuberculosis on an X-ray image looks like clear rounded polymorphic foci, more often in the upper lobe. A blood test for pneumonia reveals pronounced leukocytosis, and for tuberculosis - lymphopenia and moderate leukocytosis. Microbiological examination of sputum reveals mycobacterium tuberculosis.

Only 5% of TB patients receive positive effect from treatment with broad-spectrum antibiotics. Therefore, if the symptoms of pneumonia in a person persist for more than 2 weeks, then the diagnosis should be clarified. This is probably tuberculosis. At the same time, in empiric therapy of pneumonia, it is not recommended to prescribe broad-spectrum anti-tuberculosis drugs.

1. Differential diagnosis of pneumonia and lung cancer

Cough, phlegm, pain and hemoptysis can accompany the growth of metastases in the pleura. Up to this point, lung cancer is asymptomatic, but it can be detected on an x-ray. In this case, peripheral cancer is located more often in the anterior upper lobes of the lung, its contours are radiant.

Cancer cells can invade other organs or appear in the lungs as metastases. For more details on the differences between acute pneumonia, tuberculosis and lung cancer, see Table 1.

Table 1. Differential diagnosis of pneumonia and tuberculosis.

Sign	Focal pneumonia	Peripheral lung cancer	Tuberculosis
Age	At any age, but more often in people under 50	More often in people over 50	Any age
Floor	Equally common in men and women	More common in male smokers	More often in men
Onset of the disease	Usually acute with fever	May be imperceptible or as the temperature rises	Acute, subacute with few symptoms
Cough	In the beginning it may not be	Often absent	Dry or coughing
Dyspnea	With a large lesion of the lung tissue	May be absent	With extensive damage to the lung tissue
Hemoptysis	Rarely	Rarely	Often
Chest pain	Occur when the pleura is involved	Possible	More often absent
Intoxication	Not expressed	Often not expressed	Pronounced, progressing continuously
Physical data	Expressed brightly: the nature of breathing changes and moist wheezing appears	Little or no	Little or no
Laboratory data	Leukocytosis, an increase in ESR, which decrease after the resolution of pneumonia	Moderate increase in ESR with normal amount leukocytes	Usually ESR and leukocyte count do not change
X-ray data	Sharply expressed, the lower lobes are more often affected, the focal shadows are homogeneous, the borders are vague, increased pulmonary pattern, enlargement of the roots of the lung	Initially, the tumor shadow is low-intensity with indistinct contours and "antennae"	Localization is more often in the upper lobe, the foci are polymorphic, have different ages with clear contours, there may be a "path" to the root and foci of seeding
Antibiotic effect	Expressed, reverse development of the process after 9-12 days	There is no or false positive dynamics, but changes during X-ray examination persist	Absent; radiological changes persist for a long time

Differential diagnosis of pneumonia and pulmonary embolism (PE) Prolonged bed rest after surgery, hip fractures, with atrial fibrillation can lead to thrombophlebitis of the lower extremities. The consequence is often pulmonary thromboembolism. In young women this problem sometimes occurs after taking oral contraceptives.

The characteristic features of PE, in addition to the background, are:

• cyanosis;
• shortness of breath;
• arterial hypotension;
• tachycardia.

When listening, the doctor detects a pleural friction noise and a weakening of breathing. X-rays show a triangular shadow, and perfusion radioisotope scans show ischemic "cold" zones. In this case, there is an acute overload of the right heart.

1. Differential diagnosis of pneumonia and eosinophilic infiltrate

When treated with glucocorticosteroids, infiltrates disappear after 10 days.

The nature of the pneumonia present will indicate its source. Pneumococcal acute pneumonia is accompanied by chills, high fever, headache... If germs enter the bloodstream, chills can be severe, especially in children. Elderly people do not have such a reaction.

For bacterial damage to the lungs, burning pains when breathing in the chest are characteristic. With a viral and mycoplasma infection, these symptoms are not observed, but a headache is expressed, a rash is possible.

The nature of the sputum:

• bacterial pneumonia - mucopurulent, thick;
• viral and mycoplasma - a small amount;
• lung abscess - purulent odor;
• pulmonary edema - profuse, frothy, pink;
• lobar pneumonia - rusty;
• bronchoalveolar cancer - salivary;
• bronchiectasis - profuse, purulent, with blood.

Bacterial pneumonia can be accompanied by liver damage, increased liver enzyme activity and increased blood urea levels.

In a blood test, the main indicator of the type of lung infection is the level of leukocytes. Leukocytosis is expressed in bacterial forms of pneumonia (more than 15 × 10 9 / l), with mycoplasma and viral, the indicator is almost unchanged.

In children

A number of techniques have been developed to make an accurate diagnosis of a pulmonary disease in a child. All of them take into account the age characteristics of patients, the etiology of pneumonia, factors contributing to its development, the forms of the course of the disease (pathogenesis).

Anatomical and physiological features of the child's body determine the tendency to develop pneumonia in early age, the possibility of developing into a chronic form and the severity of the course. An equally important role in the development of pneumonia is played by:

• hypothermia;
• poor child care;
• violation of hygiene rules;
• artificial feeding;
• unsanitary living conditions, incl. damp rooms;
• previously transferred infectious diseases.

The most likely pathogen in community-acquired pneumonia in children under 6 months of age there are viruses, staphylococci and gram-negative flora. Later - pneumococcus and H. influenzae type B. In adolescence, streptococcus is added. At nosocomial infection the source of infection for both adults and children is likely to be enterobacteria, E. coli, staphylococcus aureus, proteus, pseudomonas.

The differential diagnosis of pneumonia in children involves several types of classifications of pathology:

• By type, focal, segmental, croupous and interstitial acute are distinguished.
• By localization - in the lobe of the lung, in the segment, unilateral and bilateral.
• By type: community-acquired and nosocomial, perinatal, ventilator-associated, aspiration, immunodeficiency.
• By severity: light, moderate and severe with complications. In this case, complications are divided into pulmonary (pleurisy, pneumothorax) and extrapulmonary (cardiovascular failure, infectious toxic shock, disseminated intravascular coagulation syndrome, respiratory distress syndrome).

With all types of pneumonia in children, all the structural elements of the organ are involved in the process, gas exchange becomes difficult, the respiratory rate increases, pulmonary ventilation decreases with extreme need for oxygen. Pathology can affect the heart, which is forced to compensate for the lack of oxygen by increased intensity of contractions, followed by dystrophy of the heart muscle.

Oxygen deficiency causes metabolic disorders, blood acidification. Further, hypoxemia and hypoxia are observed. Cessation of oxygen assimilation externally manifests itself in a cyanosis of the face (hypoxemia) or an earthy gray color (hypoxia). Subsequent profound metabolic disorders can become irreversible and cause death.

The criteria for the diagnosis of acute pneumonia in children are:

1. With auscultation of the lungs, rapid breathing and an increase in heart rate against the background of apnea, moaning breathing pattern, blistering rales, bronchophonia.
2. An increase in temperature of more than 38 degrees for at least 3 days.
3. Dry cough, respiratory distress, voice tremors.
4. On X-rays, shadows in the form of lesions, darkening.
5. A blood test indicates leukocytosis, urine and feces without pathological abnormalities.

The signs of respiratory failure can be found in Table 2.

Table 2. Clinical and laboratory characteristics of respiratory failure in children with acute pneumonia (According to AF Tur, AF Tarasov, NP Shabalov, 1985).

DN step	Clinical characteristics	External respiration indicators	Blood gas composition, acid-base state (CBS)
I	There is no dyspnea at rest. Perioral cyanosis, intermittent, aggravated by anxiety. Pallor of the face, blood pressure - normal, less often - moderately increased. Ps: RR = 3.5-2.5: 1, tachycardia. Behavior unchanged, sometimes anxiety	The MO (respiratory minute volume) is increased, the RD (respiratory reserve) is decreased. VC (vital capacity of the lungs), DE (respiratory equivalent) increase in OD (breathing volume) slightly decreased	The gas composition of the blood at rest is unchanged or the blood oxygen saturation is moderately reduced (by 10%; pO2 = 8.67-10.00 kPa, however, when breathing oxygen, it approaches the norm. There are no natural changes in the CBS. Increase in the content of carbon dioxide in the blood.
II	Dyspnea at rest, breathing with the participation of accessory muscles, retraction of the intercostal spaces and the suprasternal fossa. Ps: RR = 2-1.5: 1, tachycardia. Perioral cyanosis of extremities, permanent, does not disappear when breathing oxygen, but is absent in the oxygen tent. Generalized pallor of the nail bed. HELL is increased. Behavior: lethargy, weakness, decreased muscle tone.	MOD increased. VC is reduced by more than 25-30%. RD and AP are reduced to 50% or less. DE is significantly increased, which indicates a pronounced decrease in oxygen utilization in the lungs.	Oxygen saturation of the blood is 70-85% (pO2 = 7.33-8.53 kPa. Hypercapnia (PCO2 higher than 6.0 kPa; blood pH - 7.34-7.25 (acidosis); base deficiency (BE) is increased). Plasma bicarbonate level is determined by the nature of acidosis.CBS depends on the state of hemodynamics
III	Dyspnea is pronounced (respiratory rate is more than 150% of the norm), irregular breathing, periodically bradypnoe, paradoxical breathing. Decrease or absence of respiratory noises on inspiration, blood pressure is reduced. Generalized cyanosis. Cyanosis of the lips, mucous membranes does not disappear when breathing oxygen. Generalized pallor, marbling. Behavior: lethargy, depressed consciousness, decreased skeletal muscle tone, coma, convulsions.	MOD is reduced, VC and AP are reduced by more than 50%, RD = 0	Blood oxygen saturation - less than 70% (pO2 below 5.33 kPa; decompensated acidosis (pH less than 7.2) BE greater than 6-8; hypercapnia (PCO2 greater than 9.87 kPa), bicarbonate and buffer bases (BE) lowered

For citation: Yu.K. Novikov Pneumonia: complex and unresolved issues of diagnosis and treatment // BC. 2004. No. 21. S. 1226

Pneumonia is an infectious lesion of the alveoli, accompanied by infiltration of inflammatory cells and exudation of the parenchyma, as a response to the introduction and proliferation of microorganisms, into sterile (normal) parts of the respiratory tract. The pneumonia section does not cover lung lesions in infectious diseases related to other nosological forms: plague, typhoid fever, tularemia, etc. If you follow the above definition for the diagnosis of pneumonia, then none of the criteria for the diagnosis can be objectively proven. Neither inflammation nor damage to the alveoli. And only by indirect data (determination of the pathogen in sputum or an increase in antibody titer in the blood), one can judge the infectious nature of lung damage. Direct evidence of inflammation in the pulmonary parenchyma and identification of the pathogen is possible only with a morphological study of the material obtained from a biopsy. The symptom complex, including cough with sputum and / or hemoptysis, chest pains usually with coughing and deep breathing, fever and symptoms of intoxication, is not characteristic only of pneumonia, but is detected in a number of other lung diseases. The most common are: - lung cancer; - thrombosis and pulmonary embolism; - pulmonary tuberculosis; - ARVI; - acute and infectious exacerbation of bronchitis; - pleurisy; - bronchiectasis; - acute forms of alveolitis; - pulmonary mycosis; - infectious diseases (typhus, tularemia, infectious hepatitis, etc.). The usual algorithm of clinical thinking provides for the solution (often unconscious) of the following questions when meeting a patient: - is the patient sick; - if sick, what organs and systems are involved in the process; - if the lungs are affected, then what is the nature of the lesion; - if pneumonia, then what is its etiology. Following this algorithm allows you to achieve maximum treatment efficiency. Differential diagnosis plays an important role in this.

Differential diagnosis for pneumonia Clinical and anamnestic criteria

Lungs' cancer

Belonging to the risk group: - men over 40; - smokers; - suffering from chronic bronchitis; - with a history of cancer; - have a family history of cancer. A typical picture of anamnesis, in addition to belonging to a risk group, includes a gradual onset of the disease, when symptoms of intoxication, bronchial obstruction, and tumor spread appear and increase: weakness, increasing fatigue, with time, weight loss, dynamics of cough syndrome - from dry hacking unproductive cough , cough with mucous or mucopurulent sputum streaked with blood to sputum like "raspberry jelly", hemoptysis, recurrent inflammation in the same areas of the lung, recurrent pleurisy, symptoms of compression of the superior vena cava. Extrapulmonary symptoms of lung cancer: indomitable skin itching, ichthyosis, drum fingers, progressive dementia, myopathic syndrome, Itsenko-Cushing's syndrome. It should be emphasized that despite a thorough clinical examination, it is not possible to identify a gradual onset of the disease and in 65% of cases the onset is regarded as acute - in the form of cancerous pneumonitis, paracancrotic pneumonia, and in fact, atelectasis-pneumonia in the zone of obturated bronchus.

Pulmonary tuberculosis

Contact with a patient with tuberculosis. More often, even with a visible acute onset, there is a gradual increase in clinical symptoms. ... Relatively easily tolerated intoxication compared to a similar volume of damage to lung tissue of other etiology. ... Scant physical symptoms, inconsistent with significant R-logical changes. ... Dry cough, more often mucous than purulent, sputum. ... Isolated pleurisy, especially at a young age.

Infarction pneumonia with pulmonary embolism and pulmonary thrombosis History of lesion of the veins of the lower extremities and pelvis. More often, embologenous thrombosis is localized in the popliteal (20%), iliocaval segments. Veins of the upper extremities (8%) and heart cavities (2%) are less significant as causes of PE. It should be noted that only 40% of venous thrombosis clinic is preceded by pulmonary embolism. The development of the symptom complex of pneumonia (cough, hemoptysis, intoxication) is preceded by shortness of breath and chest pain, the severity of which depends on the caliber of the affected lung vessel. In pulmonary embolism, the presence of an embolism should not be confused. big circle, since through the open oval window with changed hemodynamics, the emboli enter the large circle.

Pain in pulmonary embolism:

Angina pectoris, infarction with concomitant damage to the coronary arteries; - bursting with increasing pressure in the pulmonary artery; - pleural with the development of infarction pneumonia with pleurisy; - in the right hypochondrium (abdominal) due to acute circulatory failure and stretching of the Glisson capsule of the liver.

Shortness of breath with PE:

Sudden; - not related to physical activity; - uncharacteristic orthopnea position; - shallow breathing.

Hemoptysis with pulmonary embolism:

On the second or third day after the development of infarction pneumonia.

Physical symptoms:

Wheezing, dullness, fever, intoxication, emphasis of the second tone on the pulmonary artery, swelling of the cervical veins - do not have specific features characteristic only of PE and are late signs... It should be noted that all symptoms associated with increased pressure in the pulmonary artery are found only in massive PE (50% vascular lesions).

Fibrosing alveolitis

The gradual but steady progression of shortness of breath, characteristic of interstitial lesions, does not cause difficulties in terms of differential diagnosis with pneumonia. The acute form (Libov desquamative pneumonia, Haman-Rich syndrome) has no significant clinical differences from bacterial pneumonia. Most often, after unsuccessful antibiotic treatment, the appointment of steroids with a pronounced positive effect suggests, and then using objective examination methods to prove the diagnosis of alveolitis.

For allergic exogenous alveolitis:

There is a connection with the allergen; - the elimination effect is noted; - the positive effect of corticosteroid treatment.

With toxic fibrosing alveolitis:

Communication with a toxic agent (drugs, occupational exposure to toxic substances).

Influenza and ARVI

The main difference from pneumonia is the absence of damage to the lung parenchyma and, accordingly, the absence of local physical symptoms. The symptoms of cough and intoxication are not specific. It should be borne in mind that ARVI, influenza are complicated by associated pneumonia. Physical symptoms in this case depend on the size of the pneumonic focus and the depth of its location from the surface. chest... Often only laboratory and X-ray methods can detect pneumonia (leukocytosis, shift of the formula to the left, increased ESR, infiltrative shadow, bacteriological examination of sputum).

Bronchitis and bronchiectasis

With bronchitis, there are no symptoms of local lung damage (wet wheezing, dullness, increased vocal tremor). To a lesser extent than in pneumonia, symptoms of intoxication are expressed. Shortness of breath with obstructive bronchitis is a nonspecific symptom, since up to 80% of cases of pneumonia are accompanied by obstructive changes in the FVD. The final diagnosis is established after laboratory and instrumental examination. With dysontogenetic bronchiectasis, the anamnesis is more often traced from childhood. With acquired - anamnesis of pneumonia, tuberculosis. A variety of physical symptoms (wheezing, moist, voiced, small-coarsely bubbly, dullness, etc.) depends on the prevalence of the process and the phase of inflammation. Cough, the amount of sputum cannot serve as objective symptoms of the diagnosis.

Hereditary-determined lung diseases

Violation of the main defense mechanisms (mucociliary transport in cystic fibrosis and ciliary insufficiency, immune defense in case of deficiency of immunoglobulin, especially immunoglobulin A, T-cell deficiency, pathology from macrophages) leads to damage to the lungs and bronchi, manifested mainly by the clinic of recurrent inflammation in the bronchopulmonary system (bronchitis, acquired bronchiectasis, pneumonia). And only laboratory and instrumental examination can reveal the root cause of nonspecific clinical symptoms.

Objective survey data

Pulmonary tuberculosis

X-ray Depending on the form of tuberculosis - focal shadow, infiltrate, infiltrate with decay, cavernous tuberculosis - a path to the root and an increase in root lymph nodes, old foci (petrification), with localization more often in I-III and VI segments, are characteristic. Tomography, including computer Clarification of the number, size of cavities, their walls, bronchial patency, the state of the lymph nodes of the root and mediastinum. Sputum analysis - lymphocytes, erythrocytes (with hemoptysis) Microscopy - tubercle bacilli Sputum culture - tubercle bacilli FBS - scars, fistulas, tubercles with damage to the bronchi Biopsy - tuberculous (caseous) granuloma Blood test Anemia - severe forms, leukocytosis, lymphocytosis, increased ESR Biochemical blood test Dysproteinemia, hypoalbuminemia in severe forms, hypoproteinemia Analysis of urine Nonspecific changes - protein, leukocytes In case of kidney damage, sowing of a tubercle bacillus. Lungs' cancerX-ray Decrease in airiness of lung tissue, atelectasis, infiltrates, focal formations. Tomography, including computer Narrowing of the bronchus or its complete obstruction, enlargement of the lymph nodes of the root. FBS - narrowing of the bronchus, plus tissue Lavage - atypical cells Biopsy - tumor tissue, cells Ultrasound - search for metastases or the main tumor, if metastases in the lungs (liver, kidneys, pancreas) Isotope research - search for metastases (liver bone) or tumors if metastases in the lungs. Fibrosing aulveolitesX-ray Dissemination in the middle and lower sections, "frosted glass", interstitial fibrosis, "cellular lung" CT scan - clarification of pathology FBS - nonspecific inflammatory changes Lavage - neutrophilia - ELISA, lymphocytosis - EAA Biopsy - desquamation, exudation (alveolitis), bronchiolitis, arteritis - ELISA, granulomas with EAA, arteritis with TFA, thickening of the basement membrane, body test - restrictive changes, impaired diffusion. Immunology An increase in IgG - ELISA, an increase in rheumatoid factor - ELISA, an increase in antipulmonary antibodies - ELISA, an increase in IgE - EAA, an increase in mucin antigen.

Congenital pathology

X-ray see bronchitis Immunology IgA or other Ig deficiency, T cell deficiency, macrophage deficiency Sweat analysis - increase in chlorides Genetic research - identification of the gene for cystic fibrosis.

SARS and flu

X-ray - ENT norm - laryngitis, pharyngitis, rhinitis Sputum analysis - neutrophils, columnar epithelium Blood test - lymphocytosis.

Bronchiectasis

X-ray Strengthening, deformation of the pulmonary pattern, depending on the prevalence. Cellularity of the pulmonary pattern in the later stages. Tomography Expansion and deformation of the bronchi (saccular, cylindrical) FBS - indirect signs of bronchiectasis and bronchitis Lavage - macrophages, neutrophils, bacteria Sputum - the same sputum culture - pneumotropic pathogens, more often Gr + and Gr - flora, in credits> 10 CFU / ml Bronchography - saccular bronchiectasis, cylindrical Blood test - nonspecific inflammation Biochemical analysis blood - depending on the severity and duration: hypoproteinemia, hypoalbuminemia, dysgammaglobulinemia. Analysis of urine - nonspecific changes With prolonged course - changes for amyloidosis of the nephrotic syndrome.

Bronchitis

X-ray Strengthening the pulmonary pattern Tomography - too FBS - hyperemia, swelling of the mucous membrane, sputum. Diffuse lesion. Lavage - neutrophils, macrophages Biopsy - metaplasia in chronic bronchitis Sputum culture - non-specific counting CFU / ml of non-specific flora Sputum analysis - macrophages, neutrophils Serology - increased titers of antibodies to pneumotropic pathogens FVD - obstructive type Immunology - various variants of immunological, secondary insufficiency.

TELA

X-ray Non-specific infiltrative shadows Tomogram Does not bear additional information for the diagnosis of PE FBS - contraindicated ECG - symptoms of overload with massive PE (more than 50% of the vessels) SI QIII (neg.) T in V 1 V 2 Perfusion lung scan Focal decrease in isotope accumulation - 100% reliability of the diagnosis in the absence of changes in the R-gram. 15% of errors in cancer, tuberculosis, abscess. Angiopulmonography Defective filling of blood vessels, breakage or depletion of blood vessels, delay in filling phases are signs of Westermark. Doppler ultrasonography of veins Search for embologenous thrombosis Phlebography - the same Blood test Anemia with massive lesions, leukocytosis, left shift, increased ESR Blood chemistry Bilirubinemia with massive lesion Analysis of urine Nonspecific changes, protein, leukocytes, oligo-anuria - in shock.

Clinical criteria for pneumonia

Patients complain of: - dry or sputum cough, hemoptysis, chest pain; - fever above 38 °, intoxication. Physical data Crepitation, small bubbling rales, dullness of percussion sound, increased vocal tremor. Objective diagnostic criteria To determine the diagnosis, the following studies are prescribed: - X-ray of the chest organs in two projections is shown with an incomplete set of clinical symptoms; - microbiological examination: Gram smear staining, sputum culture with quantitative determination of CFU / ml and antibiotic sensitivity; - clinical blood test. The listed methods are sufficient for the diagnosis of pneumonia at the outpatient stage and with an uncomplicated typical course of pneumonia in a hospital.

Additional research methods

X-ray tomography, CT scan are prescribed for the defeat of the upper lobes, lymph nodes, mediastinum, decrease in the volume of the lobe, suspected abscess formation with ineffectiveness of adequate antibiotic therapy. Microbiological examination of sputum, pleural fluid, urine and blood, including mycological examination, is advisable in case of continuing febrile state, suspected sepsis, tuberculosis, superinfection, AIDS. Serological research - determination of antibodies to fungi, mycoplasma, chlamydia and legionella, cytomegalovirus - is indicated for an atypical course of pneumonia in the risk group for alcoholics, drug addicts, with immunodeficiency (including AIDS), and for the elderly. A biochemical blood test is prescribed for severe pneumonia with manifestations of renal, liver failure, in patients with chronic diseases, decompensation of diabetes mellitus. Cyto- and histological examination are carried out at risk for lung cancer in smokers after 40 years, in patients with chronic bronchitis and a family history of cancer. Bronchological examination: diagnostic bronchoscopy is performed in the absence of an effect from adequate therapy for pneumonia, if lung cancer is suspected in the risk group, foreign body, including during aspiration in patients with loss of consciousness, if necessary, biopsy. Therapeutic bronchoscopy is performed during abscess formation to ensure drainage. Ultrasound procedure heart and organs abdominal cavity is carried out with suspicion of sepsis, bacterial endocarditis. Pulmonary isotope scans and pulmonary angiography are indicated for suspected pulmonary embolism (PE). Additional methods included in the examination plan, in fact, allow for differential diagnosis and are carried out in a hospital, where the patient is hospitalized depending on the severity of the condition and / or with an atypical course of the disease that requires a diagnostic search.

Determining the severity of pneumonia is one of the key points in the diagnosis and is in the first place before the doctor after determining the nosological form. Subsequent actions (determination of indications for hospitalization, in which department) depend on the severity of the condition.

Hospitalization criteria

Hospitalization of patients with pneumonia is indicated in the presence of the following factors: - age over 70 years; - concomitant chronic diseases (chronic obstructive pulmonary disease, congestive heart failure, chronic hepatitis, chronic nephritis, diabetes mellitus, alcoholism or substance abuse, immunodeficiency); - ineffective ambulatory treatment in three days; - confusion or decreased consciousness; - possible aspiration; - the number of breaths is more than 30 per minute; - unstable hemodynamics; - septic shock; - infectious metastases; - multi-lobe lesion; - exudative pleurisy; - abscess formation; - leukopenia less than 4000 / ml or leukocytosis more than 20,000; - anemia: hemoglobin less than 9 g / ml; - renal failure (urea more than 7 mmol); - social testimony.

Indications for intensive care- Respiratory failure - PO2 / FiO2<250 (<200 при ХОБЛ), признаки утомления диафрагмы, необходимость в механической вентиляции; - Недостаточность кровообращения - шок (систолическое АД<90 мм рт.ст., диастолическое АД<60 мм рт.ст.), необходимость введения вазоконстрикторов чаще, чем через 4 часа, диурез < 20 мл/ч; - Острая почечная недостаточность и необходимость диализа; - Синдром диссеминированного внутрисосудистого свертывания; - Менингит; - Кома.

Antibacterial therapy

Lactam antibiotics

Most? -lactam drugs concentration in the lung parenchyma is less than in the blood. Almost all drugs enter the sputum at a concentration much lower than in the bronchial mucosa. Moreover, many causative agents of respiratory diseases ( H. influenzae, Moraxella catarrhalis, Streptococcus spp.) are located precisely in the lumen of the bronchi or in the mucous membrane, therefore, large doses of drugs are required for successful treatment. Uh? -lactam drugs, the concentration in the liquid covering the epithelium of the lower respiratory tract is greater than in sputum, bronchial secretions. However, after concentration? β-lactam drug will exceed the MIC of the pathogen, a further increase in concentration is meaningless, since the effectiveness of these drugs depends mainly on the time during which the concentration of the antibiotic exceeds the MIC. ? β-lactam drugs in high doses retain their effectiveness against pneumococci with intermediate sensitivity, in contrast to macrolides and fluoroquinolones.

Macrolides Macrolides are highly lipophilic, which ensures their high concentration in the tissues and fluids of the respiratory tract. Due to their high diffusion capacity, they accumulate better in the lung tissue, reaching higher concentrations there than in plasma.

Azithromycin (Hemomycin) has approximately the same properties, while its concentration in serum is usually difficult to determine, and in the lung tissue it remains at a very high level for 48-96 hours after a single administration. In general, the concentration of new macrolides in the bronchial mucosa is 5-30 times higher than the serum concentration. Macrolides penetrate better into the epithelial cells than into the liquid on the surface of the epithelium. Azithromycin after a single oral administration at a dose of 500 mg reaches a concentration in the epithelium lining fluid that is 17.5 times higher than the MIC90 for S. Pneumoniae... To combat intracellular pathogens ( Legionella spp., C. pneumoniae) of particular importance is the concentration that antibacterial agents reach in alveolar macrophages. While highly ionized? β-lactam drugs practically do not penetrate intracellularly, macrolides are able to accumulate in macrophages at a concentration that is many times higher than their concentration in the extracellular space.

Fluoroquinolones Fluoroquinolones accumulate in the bronchial mucosa at approximately the same concentration as in plasma. The concentration of fluoroquinolones in the epithelial fluid is very high. The effectiveness of drugs in this group is determined by both the duration of action and the concentration. Since the mid-90s, respiratory fluoroquinolones (levofloxacin, sparfloxacin) have taken a firm place in antibiotic selection algorithms (ABP) based on the principles of evidence-based medicine (recommendations of the Society for Infectious Diseases, USA, 1998; guidelines of the American Thoracic Society, 2001; recommendations of the British Thoracic Society, 2001) But along with this, it must be stated that the cost of respiratory fluoroquinolones is significantly higher than the cost of ABPs used in routine practice. In addition, the ban on the use of drugs of this group for the treatment of children and pregnant women remains.

Aminoglycosides Aminoglycosides show approximately the same tissue and plasma concentrations. When comparing the concentration of gentamicin in bronchial secretions on a biological model with intramuscular multiple, intramuscular single and intravenous bolus administration, the concentration of gentamicin in the bronchi reached the MIC level only with intravenous bolus administration. Aminoglycosides slowly accumulate in macrophages (ribosomes), but at the same time it loses its activity. In the study of vancomycin, it was shown that this antibiotic in the liquid covering the epithelium of the lower respiratory tract reaches the MIC90 value for the majority of Gy + - pathogens of respiratory infections. When conducting empirical antibiotic therapy, it seems rational to use combinations of drugs, which enhances the antimicrobial effect and allows you to fight a wider range of potential pathogens. It should be noted that the existing opinion about the inadmissibility of combining drugs with bacteriostatic and bactericidal action has been revised in relation to combinations of macrolides with cephalosporins. Tables 1-3 show the approach to the choice of an antibiotic in various clinical situations, depending on the age and condition of the patient, the severity of pneumonia.

Literature
1. Chuchalin A.G. Pneumonia. - M., 2002.
2. A pragmatice guidlines for the managemant of community acquired
pneumonia in adults (in Process Citation). Clin. Inf. Dis. - 2000.
- Vol.31. - P.347.
3. Bartlett J. Management of Respiratory Tract Infections. -
Lippincott W. et Wilkins, 2001.
4. Brevis R.A.L. Lecture notes on respiratory diseases. - Blackwell
scientific publications, 1985.
5. Empiric Treatment of Community-acquired Pneumonia: ATS and IDSA
Guidelines American Thorac. Soc. - 2001.
6. Fein A. et al. Diagnosis and management of pneumonia and other
respiratory infections. - Professional Communications inc., 1999.
7. Inglis T.J.J. Clinical Microbiology. - Churchil Livingston, 1997.
8. Management of adult community-acquired lower respiratory tract
infections. Erohtan Study on Community Acquired Pneumonia (ESOCAP)
committee / Chairmen: Huchon G., Woodhead M. - 1999.
9. Mandel L.A. Community-acquired pneumonia. Etiology, epidemiology
and treatment. Chest. - 1995. - Vol.81. - P. 357.
10. Pneumonia. Ed. by A. Torres and M. Woodhead. - Eropian Respiratory
Monograph., 1997
11.Pulmonary Differential Diagnosis. Harold Zaskon. W.B.Saunders,
2000.
12. Bartlett JG, Gorbach SL, Tally FP, et al. Bacteriology and treatment
of primary lung abscess. Am Rev Respir Dis. 1974; 109: 510-518.
13. Huxley EJ, Viroslav J, Gray WR, et al. Pharyngeal aspiration in
normal adults and patients with depressed consciousness. Am J Med.
1978;64:564-568.
14. Driks MR, Craven DE, Celli BR, et al. Nosocomial pneumonia in
intubated patients given sucralfate as compared with antacids or histamine
type 2 blockers. N Engl J Med. 1987; 317: 1376-1382.
15. Tryba M. Risk of acute stress bleeding and nosocomial pneumonia
in ventilated intensive care unit patients: Sucralfate versus
antacids. Am J Med. 1987; 83 (Suppl 3B): 117-124.
16. Bartlett JG, Finegold SM. Anaerobic infections of the lung and
pleural space. Am Rev Respir Dis. 1974; 110: 56-77.
17. Finegold SM. Anaerobic Bacteria in Human Disease. New York:
Academic Press; 1977.
18. Bartlett JG, Finegold SM. Anaerobic pleuropulmonary infections.
Medicine (Baltimore). 1972; 51: 413-450.

Various diseases affecting the respiratory system are very similar to each other, have a high likelihood of complications, and pose a health hazard. Differential diagnosis of pneumonia allows you to establish the cause that provoked the inflammatory process, which makes it possible to make the treatment as competent and productive as possible.

The differential diagnosis of pneumonia is established on the basis of a research method, which involves the step-by-step exclusion of diseases with similar symptoms. In the process of research, the doctor must collect the maximum possible amount of reliable information regarding the lifestyle, reactions and individual characteristics of the patient's body.

Differential diagnosis is carried out according to the following algorithm:

• First, symptoms are identified, on the basis of which the most likely diagnoses are selected.
• After collecting diagnoses, a detailed description of the disease is made and the leading variant is determined.
• The third stage involves comparing the most appropriate diagnoses. To exclude a probable option, the diagnostician must make a deliberate analysis of all the information received.

Differential diagnosis should be carried out in cases when the patient suffers from any lung diseases, or he has signs of various concomitant ailments of the respiratory tract and other organs that can distort the symptoms and significantly complicate the diagnosis process.

Features of the course of the disease

Pneumonia is an acute focal infiltrative disease that affects the lung tissue and covers both individual areas and various segments, including the entire organ. Most often, the onset of the disease is provoked by hemophilic sticks, pneumococci and intracellular bacteria (such as legionella, mycoplasma and). Pneumonia is diagnosed according to instrumental and laboratory criteria, which include the following signs:

• the presence of pleural noises;
• dull percussion sounds in certain areas;
• increased tremor of the vocal cords;
• pain syndrome localized in the chest area;
• the presence of a wet or dry cough;
• intoxication;
• a feverish condition accompanied by a high body temperature.

Pneumonia is confirmed by a number of additional studies that reveal the presence of sputum in the analyzes, darkening in the lung tissue, accelerated ESR and other negative changes.

Differentiating pneumonia and lung cancer

Differential diagnosis of pneumonia includes a number of tests to identify cancerous lesions of the middle and small bronchi. The clinical picture combines various signs, among which the following are worth highlighting:

• shortness of breath, accompanied by hemoptysis;
• pain in the chest area;
• fever and cough.

With obstructive bronchitis, an increase in sputum in volume is observed in a similar way, as well as an increase in shortness of breath and an increase in coughing attacks. However, this symptomatology occurs mainly at the initial stages, indicating that the local process has managed to spread to the surrounding tissues. Some of the main signs of a cancerous lesion are:

• Pain syndrome in the shoulder region, which indicates the growth of cancer in the region of the cervico-brachial plexus.
• Constricted pupil, confirming that the sympathetic ganglion is involved.
• If metastases involve nerve nodes, difficulty swallowing is observed.

According to the results of laboratory studies, with pneumonia, a strong increase in the level of leukocytes and ESR can be observed. There is a noticeable increase in the roots of the lungs, and the affected area has a uniform appearance, while the edges look blurry. In cancer, the reaction to antibiotics is most often absent, the level of leukocytes is within normal limits, the ESR is not greatly increased.

Differentiation of tuberculosis and pneumonia

The symptoms of tuberculosis and bacterial pneumonia have very similar manifestations, since both diagnoses are bacterial damage to the lung tissue. Tuberculosis can provoke an inflammatory process in the lungs when other pathogens are added to Koch's bacillus. You can distinguish this ailment from pneumonia by the following features:

• The onset of the disease is usually accompanied by acute attacks of dry cough and fever.
• Tuberculosis is accompanied by severe and permanently progressive intoxication of the body.
• Pain in the chest area is rare.
• Shortness of breath occurs when the internal tissues of the lungs are severely damaged.
• There is no reaction of the body to antibiotic treatment.

In tuberculosis, changes in respiratory function are rare. Laboratory tests show ESR and leukocyte counts within normal limits. The x-ray shows changes affecting the upper lobes and having clear contours.

The advanced forms of bronchitis have a number of similar symptoms to pneumonia. If the focus of an infectious lesion passes to the alveoli from the bronchi, one disease may well spill over into another. The doctor should first of all pay attention to such signs as: the presence of purulent mucus in the sputum, cough, fever.

Under the age of two, it manifests itself in the form of crepitus, small bubbling rales and increased deformation of the vascular pattern. Bronchiolitis has a number of features in common with pneumonia, but it can be distinguished by the absence of infiltration, hard breathing and percussion sound, which has a boxy shade.

The course of pneumonia and lung abscess

Lung abscess often occurs after pneumonia. Signs of an abscess being formed may not be visible on an x-ray, which greatly complicates the diagnosis. The most common manifestations of an abscess are weakened respiratory function, temperature jumps and severe pain in the affected area.

Pulmonary embolism can be easily confused with pneumonia, but PE is accompanied by signs of lung tissue damage, severe shortness of breath, tachycardia and cyanosis, as well as a 15–25% decrease in blood pressure. Differential diagnosis of pneumonia in the presence of thromboembolism is based on a detailed study of the test results and the history of previous diseases of the lungs and other internal organs.

PE often develops after surgery, abuse of hormonal contraceptives and other medications. Can provoke pneumonia and oppression of lung tissue.

Etiology of pneumonia and pleurisy

can develop as an independent disease, or be caused by the transferred pneumonia. As a result of the disease, pleural fluid sweats out into the area that delimits the pleural sheets with the lungs.

It is problematic to detect the disease through standard diagnostic methods, since clear signs of pleurisy are most often absent. An x-ray of the lungs shows lesions that periodically change their own dislocation, which is not observed in the case of pneumonia. If present, or patients usually suffer from rapid weight loss and prolonged coughing, which is accompanied by coughing up blood.

Echinococcosis

This pathology is expressed in the form of the formation of a specific cyst in the lungs. Over a long period, the lesion can proceed without obvious signs, but subsequently the patient begins to be bothered by:

• permanent feeling of weakness;
• nausea;
• high fatigue.

The echinococcal bladder, increasing in size, leads to squeezing of adjacent tissues, which leads to shortness of breath, pain syndrome localized in the chest region, and coughing up blood.

A large cyst provokes external deformation, in which difficulties with respiratory function are observed in the affected part. If it breaks through the tissue of the bronchi, the patient suffers from, accompanied by the release of translucent, cloudy sputum.

Fibrosing alveolitis is a pathological process in which the respiratory vesicles are damaged. The disease begins gradually, people who work in hazardous industries and people who smoke are most susceptible to it. The main symptoms of the disease are the presence of shortness of breath and cough, accompanied by a small amount of sputum, lethargy, increased fatigue and pain syndrome localized in the chest area.

Fibrosing alveolitis is accompanied by symptoms such as crepitus. X-ray allows you to determine the position and dimensions of small-focal shadows, usually localized in the region of the lower lobes.

Differential diagnosis of pneumonia is carried out for various systemic diseases that have an autoimmune nature. With this ailment, the formation of pulmonary infiltration occurs, in which the upper parts of the respiratory tract and other internal organs are affected. The first signs are expressed in the form of fatigue and weakness, after which the patient is worried about the pain syndrome localized in the joints and muscles. The pathological process in the lungs is accompanied by:

• shortness of breath;
• coughing up blood;
• tracheitis;
• pharyngitis;
• sinusitis;
• chronic rhinitis.

Systemic lung disease provokes the occurrence of cutaneous vasculitis, polyneuritis, nephritis and stomatitis. X-ray can reveal the presence of nodular opacities, pleural effusion, and massive or focal infiltration. The disease is accompanied by damage to the upper respiratory tract, joint and muscle pain, as well as fatigue and weakness.

In the lungs, foci of infiltration occur, which are identified with the help. In most cases, the disease provoked by roundworms proceeds without pronounced symptoms, however, many patients have: cough with yellow sputum, profuse night sweats, headache, malaise and other signs.

Differential diagnosis of pneumonia in such cases is carried out with pulmonary infarction, pneumonia and tuberculosis. In the clinical picture, a latent onset is observed, after which there is a constant increase in dry cough, accompanied by a small amount of sputum. Functional examination of the lungs usually demonstrates the presence of obstructive changes.

Clarification of the diagnosis

The primary diagnosis of pneumonia is based on a chest x-ray. Since some types of pneumonia do not show radiological changes at the initial stages of development, it is necessary to differentiate pneumonia based on the results of complex studies.

Computed tomography of the lungs is prescribed in cases when, according to the results of ultrasound and radiography, it was not possible to obtain enough information to establish the correct diagnosis and assess the risks of complications.

This analytical method allows you to establish the presence of initial infiltrative deviations, when the radiography is not yet able to provide the necessary information to make the most likely verdict. Thus, it is possible to identify the disease at any stage only with the help of differential diagnosis.

Community-acquired pneumonia: diagnosis and differential diagnosis

A.I. Sinopalnikov

The collective term "pneumonia" is usually used to designate a group of acute infectious (mainly bacterial nature) focal lesions of the respiratory parts of the lungs with different degrees of etiology, pathogenesis, morphological characteristics of focal lesions of the respiratory parts of the lungs with the presence of intraalveolar exudation, manifested in varying degrees of febrile reaction, intoxication and detected during physical and radiological studies.

The most widespread classification is taking into account the conditions in which the disease developed, the features of infection of the lung tissue, as well as the immunological reactivity of the organism. Correct consideration of these factors allows predicting the etiology of the disease with a significant degree of probability and, ultimately, choosing an adequate direction for empirical antimicrobial chemotherapy. In accordance with this classification, the following types of pneumonia are distinguished:

a) community-acquired (acquired outside a medical institution) pneumonia (synonyms: home, outpatient);

b) nosocomial (acquired in a medical institution) pneumonia (synonyms: hospital, nosocomial);

Alexander Igorevich Sinopalnikov - Professor, Head of the Department of Pulmonology with a course of phthisiology at the State Institute for Advanced Training of Doctors of the Ministry of Defense of the Russian Federation.

c) aspiration pneumonia;

d) pneumonia in persons with severe immunosuppression (congenital immunodeficiency, HIV infection, iatrogenic immunosuppression).

The most practically significant is the division of pneumonia into community-acquired and nosocomial. It must be emphasized that such a subdivision has nothing to do with the severity of the course of the disease, and the main and only criterion for differentiation is the environment in which pneumonia developed.

The term “community-acquired pneumonia” describes cases of acute illness occurring in community-acquired

conditions, accompanied by symptoms of lower respiratory tract infection (fever, cough with sputum, possibly purulent, chest pain, shortness of breath) and radiographic evidence of “fresh” focal-in-infiltrative changes in the lungs in the absence of an obvious diagnostic alternative.

Diagnostics

The diagnosis of pneumonia is complicated by the fact that there is no specific clinical sign or combination of signs that can be reliably relied on if this diagnosis is suspected. Rather, the absence of any of the nonspecific symptoms or the absence of local stetho-acoustic

These changes in the lungs make the diagnosis of pneumonia less likely.

In general, the key clinical and radiological signs of community-acquired pneumonia (CAP) can be formulated as follows:

Analysis of clinical features and X-ray data allows in some cases to make an assumption about a particular pathogen, but this information is of relative value;

Sudden onset, febrile fever, tremendous chills, pleural chest pains, lobar infiltration are characteristic of Streptococcus pneumoniae (it is often possible to isolate pneumococcus from the blood), partly for Legionella spp., Less often for other pathogens. On the contrary, this picture is absolutely not typical for Mycoplasma pneumoniae and Chlamy-dophila (Chlamydia) pneumoniae;

“Classic” signs of pneumonia (acute febrile onset, chest pains, etc.) may be absent, especially in weak or elderly patients;

Approximately 25% of CAP patients over the age of 65 years have no fever, and leukocytosis is recorded only in 50-70%. In this case, symptoms can be represented by weakness, nausea, anorexia, abdominal pain, intellectual and mental disorders;

Late diagnosis and delay in starting antibiotic therapy lead to a worse prognosis: mortality among patients over 65 reaches 10-25%;

The most common X-ray signs of pneumonia are

Pneumonia should always be suspected if the patient has a fever in combination with complaints of cough, shortness of breath, sputum production and / or chest pain.

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focal blackouts appear in the projection of one or more segments;

In cases of lobar infiltration, the phenomenon of "air bronchogram" is visualized in 33% of patients;

Pleural effusion complicates the course of CAP in 10-25% of cases and is not particularly important in predicting the etiology of the disease;

The formation of cavities of destruction in the lungs is not typical for pneumococcal, mycoplasma and chlamydial pneumonia, but rather testifies in favor of staphylococcal infection, aerobic gram-negative pathogens of the intestinal group and anaerobes;

Reticulo-nodular infiltration in the basal parts of the lungs is characteristic of mycoplasma pneumonia (however, in 20% of cases it may be accompanied by focal-confluent infiltration in the projection of several segments or even a lobe).

Pneumonia should always be suspected if the patient has a fever in combination with complaints of cough, shortness of breath, sputum production and / or chest pain. Patients with pneumonia often complain of unmotivated weakness, fatigue, and heavy sweating at night.

The information obtained from physical examination of patients with CAP depends on many factors, including the severity of the disease, the prevalence of pneumonic infiltration, age, and the presence of comorbidities. The classical objective signs of pneumonia are the shortening (dullness) of the percussion tone over the affected area of ​​the lung, locally audible bronchial breathing, the focus of sonorous small bubbling rales or inspiratory crepitus, increased bronchophonia and vocal tremor. However, in some patients, objective signs of pneumonia may differ from typical ones or be absent altogether (in about 20% of patients).

Chest x-ray

This is the most important diagnostic test. Almost always, the diagnosis of CAP requires the detection of focal infiltrative changes in the lungs in combination with the corresponding symptoms. And although there is an opinion that steto-acoustic signs of focal infiltration usually coincide with radiographic data, numerous studies have shown their low sensitivity and specificity in the diagnosis of pneumonia.

There are several reasons for false negative x-ray results in patients with pneumonia. These include dehydration (however, there is not enough data for this theory), deep neutro-

the development of a localized acute inflammatory reaction in the lung tissue, early stages of the disease (it is believed that pneumonia can be recognized by auscultation one day before the appearance of infiltration on the radiograph) and, finally, cases of pneumonia caused by Pneumocystis carinii in HIV-infected patients (in 10-20% of patients there are no radiological changes).

Sometimes there are diagnostic problems associated with false positive x-ray results (see below).

The value of chest x-ray is not only in verifying the diagnosis of pneumonia (as a rule, in the presence of appropriate clinical signs), assessing the dynamics of the process and the completeness of recovery. Changes on the roentgenogram (the prevalence of infiltration, the presence or absence of pleural effusion, destruction) correspond to the severity of the disease and serve as a kind of “guide” in the choice of antibiotic therapy.

Other studies

A complete blood count is the standard diagnostic test. Obviously, neither the total number of leukocytes in the peripheral blood, nor the leukocyte formula make it possible to speak with certainty about the potential causative agent of pneumonia. However, leukocytosis of more than 10-12 x 109 / L indicates a high likelihood of bacterial infection, and leukopenia below 3 x 109 / L or leukocytosis above 25 x 109 / L are unfavorable prognostic signs.

Biochemical blood tests, including liver and kidney function tests, and electrolyte analysis are also standard methods of investigation in patients with CAP requiring hospitalization.

In hospitalized patients with CAP, microbiological studies are mandatory: blood cultures twice (before antibiotics are prescribed), in the presence of a productive cough - bacterioscopy of a Gram stained sputum smear and its culture (see below).

In patients with symptoms of respiratory failure due to widespread pneumonic infiltration, massive pleural effusion, the development of pneumonia against the background of chronic obstructive pulmonary disease, it is necessary to determine arterial blood gases. In this case, hypoxemia with a decrease in the pO_ level below 60 mm Hg. Art. prognostically unfavorable and indicates the need to place the patient in the intensive care unit.

In the presence of pleural effusion and conditions for safe pleural puncture (visualization on a laterogram of freely displaceable fluid with a layer thickness> 1.0 cm), the study of pleural fluid should include counting leukocytes with a leukocyte formula, determining pH, lactate dehydrogenase activity, protein content, staining strokes on Gram and on

The absence or inaccessibility of radiographic confirmation of focal infiltration in the lungs makes the diagnosis of pneumonia inaccurate / uncertain.

Probable causative agents of PFS, depending on the conditions of its occurrence

Conditions of occurrence Possible pathogens

Alcoholism Chronic bronchitis / tobacco smoking Decompensated diabetes mellitus Staying in nursing homes Non-sanitized oral cavity Influenza epidemic Massive aspiration Development of pneumonia against the background of bronchiectasis, cystic fibrosis Intravenous drug addiction Local bronchial obstruction (for example, lung cancer) Contact with air conditioners, humidifiers An outbreak of the disease in a team (schoolchildren, military personnel) S. pneumoniae, anaerobes, aerobic enterobacteria (Klebsiella pneumoniae, etc.) S. pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Legionella spp. S. pneumoniae, Staphylococcus aureus S. pneumoniae, Enterobacteriaceae, H. influenzae, S. aureus, Chlamydophila pneumoniae, anaerobes Anaerobes S. pneumoniae, S. aureus, Streptococcus pyogenes, H. influenzae Anaerobes Pseudomonas aeruginosa, a P. cepacia, S. S. aureus, anaerobes Anaerobes Legionella pneumophila S. pneumoniae, Mycoplasma pneumoniae, Chlamydophila pneumoniae

no Bartlett J.G. Management of Respiratory Tract Infections. Philadelphia, 1999. Mandell L.A. et al. // Clin. Infect. Dis. 2000. V. 31. P 383.

acid-fast bacteria, sowing on aerobes, anaerobes and mycobacteria.

Diagnosing CAP

The diagnosis of CAP is definite if the patient has radiologically confirmed focal infiltration of lung tissue and at least two clinical signs from among the following:

a) acute fever at the onset of the disease (body temperature> 38.0 ° C);

b) cough with phlegm;

c) physical signs (focus of crepitus and / or fine bubbling rales, hard bronchial breathing, shortening of percussion sound);

d) leukocytosis> 10 x 109 / l and / or stab shift (> 10%).

If possible, you should strive for clinical and radiological confirmation of the diagnosis of CAP. In this case, it is necessary to take into account the likelihood of known syndromic diseases / pathological conditions.

The absence or inaccessibility of radiographic confirmation of focal infiltration in the lungs makes the diagnosis of CAP inaccurate / uncertain. In this case, the diagnosis of the disease is based on taking into account the data of the anamnesis, complaints and corresponding local symptoms.

If, when examining a patient with fever, complaints of cough, shortness of breath, sputum and / or chest pain, X-ray examination is unavailable and there are no local stetho-acoustic symptoms, then the assumption of PFS becomes unlikely.

Etiological diagnosis

Obviously, the establishment of the fact of PFS, based on the results of physical and X-ray studies, can only be equated to a syndromic diagnosis, but it becomes nosological after the pathogen is identified. Unconditional evidence of the causal role of the microorganism in the development of pneumonia is its isolation from the lung tissue, however, the clinician has to rely on the results of micro-

biological blood tests (positive in 6-10% of cases), pleural fluid, sputum (possible contamination of bronchial secretions when passing through the oropharynx) or immunoserological tests, as well as anamnestic data (table).

Standard methods studies are bacterioscopy with Gram stain and culture of sputum obtained with deep coughing. Before starting a microbiological study, it is necessary to stain the smear according to Gram. If there are less than 25 leukocytes and more than 10 epithelial cells in the smear, further examination is impractical (most likely the material is the contents of the oral cavity). The detection in a smear of a significant number of gram-positive or gram-negative microorganisms with typical morphology (gram-positive lanceolate diplococci - S. pneumoniae; clusters of gram-positive cocci in the form of clusters - S. aureus, gram-negative coccobacilli - H. influenzae) can serve as a guide for

the appointment of antibiotic therapy. The diagnostic value of sputum test results can be assessed as high when a potential pathogen is isolated at a concentration of more than 105 CFU / ml (CFU - colony forming units).

Obviously, the interpretation of the results of bacterioscopy and sputum culture should be based on clinical evidence.

Seriously ill patients, including the majority of hospitalized patients, should be cultured twice before antibiotic therapy (blood is taken from different places with an interval of at least 10 minutes).

When collecting sputum, the following rules must be observed

1. Sputum is collected before meals, if possible before the start of antibiotic therapy.

2. Before collecting sputum, rinse the mouth thoroughly with boiled water.

3. The patient is instructed to receive the contents of the lower respiratory tract, and not the oronopharynx.

4. Collection of sputum should be done in sterile containers.

5. Duration of storage of samples at room temperature should not exceed 2 hours.

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While it is important to obtain laboratory material prior to antibiotic prescribing, microbiological testing should not delay antibiotic treatment. This is especially true for patients with a severe course of the disease.

Serological diagnostics

infections of Mycoplasma pneumoniae, Chlamydophila (Chlamydia) pneumoniae and Legionella are not considered among the mandatory research methods, because, taking into account the repeated sampling of blood serum in the acute period and during the period of convalescence (a few weeks after the onset of the disease), this is not a clinical, but an epidemiological level diagnostics.

Currently, the enzyme immunoassay for the determination of the specific soluble antigen of Legionella pneumophila (serotype 1) in urine with severe CAP has become widespread abroad. Od-

However, in our country, the use of this expensive method of express diagnostics of legionella infection has not gone beyond the framework of individual clinical centers. Determination of Streptococcus pneumoniae antigen in urine is considered as a promising additional method, but the available data are insufficient to give unambiguous recommendations.

The polymerase chain reaction (PCR) method is developing very quickly and seems to be promising for the diagnosis of such causative agents of CpD as C. pneumoniae and M. pneumoniae. However, this method cannot yet be recommended for widespread clinical practice.

Fibrobronchoscopy with a quantitative assessment of the microbial contamination of the obtained material (“protected” brush biopsy, bronchoalveolar lavage) or other methods of invasive diagnostics (transtracheal aspiration, transthoracal-

biopsy, etc.) are reserved for individual cases: pneumonia in patients with immunosuppression, suspected pulmonary tuberculosis in the absence of productive cough, obstructive pneumonitis in lung cancer or aspiration of a foreign body, etc.

Unfortunately, due to subjective and objective difficulties: incorrect sampling of material or absence of sputum, errors in conducting a microbiological study, a common practice of receiving patients antibacterial drugs before going to the doctor (for example, taking even one dose of a potentially effective antibiotic makes it unlikely that a culture of pneumococcus is isolated) - in a large number of cases, the causative agent of pneumonia cannot be identified.

Differential diagnostics will be discussed in the next issue of the journal.

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