Differential diagnosis of pneumonia (pneumonia). Pneumonia: complex and unresolved issues of diagnosis and treatment Differential diagnosis of community-acquired pneumonia

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) focal lesions of the respiratory parts of the lungs, different in etiology, pathogenesis, and morphological characteristics, with the presence of intra-alveolar exudation, manifested by a feverish reaction, intoxication, expressed to varying degrees, and detected by physical and x-ray examinations.

The most widespread classification is one that takes into account the conditions in which the disease developed, the characteristics of infection of the lung tissue, as well as the immunological reactivity of the body. Correct consideration of these factors makes it possible with a significant degree of probability to predict the etiology of the disease and, ultimately, to choose an adequate direction of 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 Physicians of the Ministry of Defense of the Russian Federation.

c) aspiration pneumonia;

d) pneumonia in persons with severe immune defects (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 division has nothing to do with the severity of the disease, and the main and only criterion for differentiation is the environment in which the pneumonia developed.

The term “community-acquired pneumonia” describes cases of acute illness that arose in a community-acquired

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

Diagnostics

Establishing a diagnosis of pneumonia is complicated by the fact that there is no specific clinical sign or combination of signs that can be relied upon reliably to suspect this diagnosis. Rather, the absence of any of the nonspecific symptoms or the absence of local steto-acoustic

Such 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 radiological data allows in some cases to make an assumption about a particular pathogen, but this information is of relative value;

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

“classic” signs of pneumonia (acute febrile onset, chest pain, etc.) may be absent, especially in weakened or elderly patients;

Approximately 25% of patients with VbP over the age of 65 years do not have fever, and leukocytosis is recorded only in 50-70%. In this case, symptoms can be represented by weakness, nausea, anorexia, abdominal pain, intellectual-mnestic disorders;

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

The most common radiological signs of pneumonia are

Suspicion of pneumonia should always arise 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 shadows appear in the projection of one or several segments;

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

Pleural effusion complicates the course of PBP in 10-25% of cases and is not of particular importance in predicting the etiology of the disease;

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

Reticulonodular infiltration in the basal parts of the lungs is characteristic of mycoplasma pneumonia (however, in 20% of cases it can be accompanied by focal confluent infiltration in the projection of several segments or even lobes).

Suspicion of pneumonia should always arise if the patient has a fever in combination with complaints of cough, shortness of breath, sputum production and/or chest pain. Patients suffering from pneumonia often complain of unmotivated weakness, fatigue, and severe sweating at night.

The information obtained during physical examination of patients with VBP depends on many factors, including the severity of the disease, the prevalence of pneumonic infiltration, age, and the presence of concomitant diseases. Classic objective signs of pneumonia are shortening (dullness) of the percussion tone over the affected area of ​​the lung, locally auscultated bronchial breathing, a focus of sonorous fine rales or inspiratory crepitus, increased bronchophony and vocal tremor. However, in some patients, objective signs of pneumonia may differ from typical ones or be absent altogether (in approximately 20% of patients).

Chest X-ray

This is the most important diagnostic test. Almost always, diagnosing VbP requires the detection of focal infiltrative changes in the lungs in combination with appropriate 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 that explain false-negative X-ray results in patients with pneumonia. These include dehydration (however, there is not enough data for this theory), deep neutropenia

niya, which makes it impossible to develop a localized acute inflammatory reaction in the lung tissue, early stages of the disease (it is believed that auscultation can recognize pneumonia even a 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 diagnostic problems arise that are associated with false-positive results of x-ray examination (see below).

The value of chest x-ray lies 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 radiograph (prevalence of infiltration, 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 antibacterial therapy.

Other studies

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

Standard research methods for patients with VbP who require hospitalization include biochemical blood tests, including functional tests of the liver and kidneys, as well as analysis of electrolyte levels.

In hospitalized patients with VbP, it is necessary to conduct microbiological studies: blood cultures twice (before prescribing antibiotics), 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 caused by 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 pO2 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 the laterogram of freely displaced fluid with a layer thickness of >1.0 cm), the study of pleural fluid should include counting leukocytes with a leukocyte formula, determining pH, lactate dehydrogenase activity, protein content, staining gram smears and

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

Possible causative agents of VbP depending on the conditions of its occurrence

Conditions of occurrence Probable pathogens

Alcoholism Chronic bronchitis/tobacco smoking Decompensated diabetes mellitus Staying in nursing homes Unsanitized oral cavity Influenza epidemic Massive aspiration Development of pneumonia due to bronchiectasis, cystic fibrosis Intravenous drug addiction Local bronchial obstruction (for example, lung cancer) Contact with air conditioners, humidifiers, etc. Outbreak of the disease in a community (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, P. cepacia, S. aureus 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, culture for aerobes, anaerobes and mycobacteria.

Diagnosis of VbP

The diagnosis of VBP is determined if the patient has radiologically confirmed focal infiltration of the 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 sputum;

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

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

If possible, one should strive for clinical and radiological confirmation of the diagnosis of VbP. In this case, it is necessary to take into account the likelihood of known syndrome-like diseases/pathological conditions.

The absence or unavailability of radiological confirmation of focal infiltration in the lungs makes the diagnosis of VbP inaccurate/uncertain. In this case, the diagnosis of the disease is based on taking into account the history, complaints and corresponding local symptoms.

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

Etiological diagnosis

It is obvious that the establishment of the fact of VbP, based on the results of physical and radiological examinations, can only be equated to a syndromic diagnosis, but it becomes nosological after the pathogen is identified. Unconditional evidence of the causal role of a microorganism in the development of pneumonia is its isolation from lung tissue, but the clinician has to trust the results of micro-organisms.

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 research methods are bacterioscopy with Gram staining and culture of sputum obtained by 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 not advisable (most likely the material represents the contents of the oral cavity). Detection in a smear of a significant number of gram-positive or gram-negative microorganisms with a typical morphology (gram-positive lanceolate diplococci - S. pneumoniae; accumulations of gram-positive cocci in the form of clusters - S. aureus, gram-negative coccobacilli - H. influenzae) can serve as a guide for

prescription of antibacterial therapy. The diagnostic value of the results of sputum examination can be assessed as high when a potential pathogen is isolated in 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 carried out taking into account clinical data.

Seriously ill patients, including most hospitalized patients, should have two venous blood cultures (blood taken from different sites at least 10 minutes apart) before starting antibiotic therapy.

When collecting sputum, the following rules must be observed:

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

2. Before collecting sputum, you must thoroughly rinse your mouth with boiled water.

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

4. Sputum collection must be done in sterile containers.

5. The duration of sample storage at room temperature should not exceed 2 hours.

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Although it is important to obtain laboratory material before prescribing antibiotics, microbiological testing should not be a reason to delay antibacterial treatment. This especially applies to patients with severe disease.

Serological diagnosis

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

Currently, an enzyme-linked immunosorbent test for determining the specific soluble antigen of Legionella pneumophila (1st serotype) in urine in severe VbP has become widespread abroad. Od-

However, in our country, the use of this expensive method of rapid diagnosis of Legionella infection has not extended beyond individual clinical centers. Determination of Streptococcus pneumoniae antigen in urine is considered as a promising additional method, but the available data are insufficient to make clear recommendations.

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

Fiberoptic bronchoscopy with quantitative assessment of microbial contamination of the obtained material (“protected” brush biopsy, bronchoalveolar lavage) or other invasive diagnostic methods (transtracheal aspiration, transthoracic

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

Unfortunately, due to subjective and objective difficulties: incorrect collection of material or lack of sputum, errors in microbiological examination, the common practice of patients taking antibacterial drugs before seeing a doctor (for example, taking even one dose of a potentially effective antibiotic makes it unlikely that a pneumococcal culture is isolated) - in a large number of cases, the causative agent of pneumonia cannot be determined.

Issues of differential diagnosis will be discussed in the next issue of the journal.

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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 the 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 diagnosing pneumonia, then none of the diagnostic criteria 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) can one judge the infectious nature of the lung lesion. Direct evidence of inflammation in the pulmonary parenchyma and identification of the pathogen is possible only through morphological examination of the material obtained from a biopsy. The symptom complex, including cough with sputum and/or hemoptysis, chest pain usually with coughing and deep breathing, fever and symptoms of intoxication, is not characteristic only of pneumonia, but is also detected in a number of other lung diseases. The most common are: - lung cancer; - thrombosis and embolism of the pulmonary artery; - pulmonary tuberculosis; - ARVI; - acute and infectious exacerbation of bronchitis; - pleurisy; - bronchiectasis; - acute forms of alveolitis; - pulmonary mycosis; - infectious diseases (typhoid, tularemia, infectious hepatitis, etc.). The usual algorithm of clinical thinking involves solving (often unconsciously) 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, what is the nature of the lesion; - if pneumonia, what is its etiology. Following this algorithm allows you to achieve maximum treatment efficiency. Differential diagnosis plays an important role in this case.

Differential diagnosis for pneumonia Clinical and anamnestic criteria

Lungs' cancer

Belonging to the risk group: - men over 40 years old; - smokers; - suffering from chronic bronchitis; - having a history of cancer; - have a family history of cancer. A typical medical history, 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, and, over time, weight loss, dynamics of cough syndrome - from a dry hacking unproductive cough , cough with mucous or mucopurulent sputum streaked with blood to “raspberry jelly” type sputum, 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 itching of the skin, ichthyosis, “drum” fingers, progressive dementia, myopathic syndrome, Itsenko-Cushing syndrome. It should be emphasized that despite a thorough clinical examination, it is not possible to detect the gradual onset of the disease and in 65% of cases the onset is regarded as acute - in the form of cancerous pneumonitis, paracancrosis pneumonia, and in fact, atelectasis-pneumonia in the area of ​​the obstructed bronchus.

Pulmonary tuberculosis

Contact with a patient with tuberculosis. More often, even with a visible acute onset, a gradual increase in clinical symptoms is observed. . Relatively easily tolerated intoxication compared to a similar volume of damage to lung tissue of other etiologies. . Poor physical symptoms that do not correspond to 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 artery thrombosis History of damage to the veins of the lower extremities and pelvis. Most often, embologenic thrombosis is localized in the popliteal (20%) or ocaval segments. The veins of the upper extremities (8%) and the cavity of the heart (2%) are less significant as causes of pulmonary embolism. It should be noted that only in 40% of cases is the clinical picture of venous thrombosis 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 size of the affected pulmonary vessel. In case of pulmonary embolism, one should not be embarrassed by the presence of an embolism in the systemic circle, since through the patent oval window, with changed hemodynamics, the emboli enter the systemic circle.

Pain with pulmonary embolism:

Angina, infarction with concomitant damage to the coronary arteries; - bursting with increased 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 Glissonian capsule of the liver.

Shortness of breath with pulmonary embolism:

Sudden; - not related to physical activity; - the position of orthopnea is not typical; - shallow breathing.

Hemoptysis with pulmonary embolism:

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

Physical symptoms:

Wheezing, dullness, increased body temperature, intoxication, emphasis of the second tone on the pulmonary artery, swelling of the neck 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 occur only with massive pulmonary embolism (50% vascular damage).

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 (desquamative Liebow's pneumonia, Haman-Rich syndrome) has no significant clinical differences from bacterial pneumonia. Most often, after unsuccessful treatment with antibiotics, the prescription of steroids with a pronounced positive effect allows us to assume, and then using objective examination methods to prove the diagnosis of alveolitis.

For allergic exogenous alveolitis:

There is a connection with the allergen; - there is an elimination effect; - positive effect of treatment with corticosteroids.

For toxic fibrosing alveolitis:

Association with a toxic agent (medicines, occupational exposure to toxic substances).

Flu and ARVI

The main difference from pneumonia is the absence of damage to the lung parenchyma and, accordingly, the absence of local physical symptoms. Symptoms of cough and intoxication are not specific. It should be borne in mind that acute respiratory viral infections and 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 of the chest. Often only laboratory and radiological 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 (moist rales, dullness, increased vocal tremors). To a lesser extent than with pneumonia, symptoms of intoxication are expressed. Dyspnea in obstructive bronchitis is a nonspecific symptom, since up to 80% of cases of pneumonia are accompanied by obstructive changes in respiratory function. The final diagnosis is established after laboratory and instrumental examination. In dysontogenetic bronchiectasis, the history is often traced back to childhood. If acquired - a history of pneumonia, tuberculosis. A variety of physical symptoms (wheezing, moist, ringing, small-large blistering, dullness, etc.) depend on the extent of the process and the phase of inflammation. Cough and the amount of sputum cannot serve as objective symptoms of diagnosis.

Hereditary-determined lung diseases

Violation of the main defense mechanisms (mucociliary transport in cystic fibrosis and ciliary insufficiency, immune defense in immunoglobulin deficiency, especially immunoglobulin A, T-cell deficiency, macrophage pathology) 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 allows us to identify the root cause of nonspecific clinical symptoms.

Data from objective examination methods

Pulmonary tuberculosis

Radiography Depending on the form of tuberculosis - focal shadow, infiltrate, infiltrate with decay, cavernous tuberculosis - a path to the root and enlargement of the lymph nodes of the root, old foci (petrificates), with localization often in segments I-III and VI are characteristic. Tomography, including computer clarification of the number, size of cavities, their walls, bronchial patency, condition of the lymph nodes of the root and mediastinum. Sputum analysis - lymphocytes, erythrocytes (for hemoptysis) Microscopy - tubercle bacilli Sputum culture - tubercle bacilli FBS - scars, fistulas, tubercles with damage to the bronchi Biopsy - tuberculous (caseous) granuloma Blood analysis 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, culture of tuberculosis bacillus. Lungs' cancerRadiography Decreased airiness of the lung tissue, atelectasis, infiltrates, focal formations. Tomography, including computed tomography Narrowing of the bronchus or its complete obstruction, enlargement of the root lymph nodes. FBS - narrowing of the bronchus, plus tissue Lavage - atypical cells Biopsy - tumor tissue, cells Ultrasound - search for metastases or the main tumor, if metastases are in the lungs (liver, kidneys, pancreas) Isotope studies - search for metastases (liver bones) or tumors, if metastases are in the lungs. Fibrosing avulveolitisRadiography Dissemination in the middle and lower sections, ground glass, interstitial fibrosis, honeycomb 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 Increased IgG - ELISA, increased rheumatoid factor - ELISA, increased antipulmonary antibodies - ELISA, increased IgE - EAA, increased mucin antigen.

Congenital pathology

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

ARVI and influenza

Radiography - ENT norm - laryngitis, pharyngitis, rhinitis Sputum analysis - neutrophils, columnar epithelium Blood analysis - lymphocytosis.

Bronchiectasis

Radiography Strengthening, deformation of the pulmonary pattern depending on the prevalence. Cellularity of the pulmonary pattern in the late 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, most often Gr+ and Gr- flora, titers > 10 CFU/ml Bronchography - bronchiectasis, saccular, cylindrical Blood analysis - nonspecific inflammation Blood chemistry - depending on the severity and duration: hypoproteinemia, hypoalbuminemia, disgammaglobulinemia. Analysis of urine - nonspecific changes With a long course - changes for amyloidosis nephrotic syndrome.

Bronchitis

Radiography Strengthening the pulmonary pattern Tomography - Same FBS - hyperemia, swelling of the mucous membrane, sputum. Diffuse damage. Lavage - neutrophils, macrophages Biopsy - metaplasia in chronic bronchitis Sputum culture - nonspecific count of CFU/ml of nonspecific flora Sputum analysis - macrophages, neutrophils Serology - increase in antibody titers to pneumotropic pathogens FVD - obstructive type Immunology - various variants of immunological, secondary deficiency.

TELA

X-ray Infiltrative shadows without specificity Tomogram Does not provide additional information for the diagnosis of pulmonary embolism FBS - contraindicated ECG - symptoms of overload with massive pulmonary embolism (more than 50% of vessels) SI QIII (neg.) T in V 1 V 2 Lung perfusion scan A focal decrease in isotope accumulation is 100% certainty of diagnosis in the absence of changes in the R-gram. 15% errors in cancer, tuberculosis, abscess. Angiopulmonography Defect in the filling of blood vessels, breakage or depletion of blood vessels, delayed filling phases are signs of Westermarck. Dopplerography of veins Search for embologenic thrombosis Phlebography - the same Blood analysis Anemia with massive lesions, leukocytosis, shift to the left, increased ESR Blood chemistry Bilirubinemia with massive lesions Analysis of urine Nonspecific changes, protein, leukocytes, oligo-anuria - in shock.

Clinical criteria for pneumonia

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

Additional research methods

X-ray tomography and computed tomography are prescribed for damage to the upper lobes, lymph nodes, mediastinum, a decrease in the volume of the lobe, suspected abscess formation when adequate antibacterial therapy is ineffective. Microbiological examination of sputum, pleural fluid, urine and blood, including mycological examination, is advisable in case of ongoing febrile condition, suspicion of sepsis, tuberculosis, superinfection, AIDS. Serological testing - determination of antibodies to fungi, mycoplasma, chlamydia and legionella, cytomegalovirus - is indicated for atypical pneumonia in the risk group of alcoholics, drug addicts, immunodeficiency (including AIDS), and the elderly. A biochemical blood test is prescribed for severe pneumonia with manifestations of renal and liver failure, in patients with chronic diseases, and decompensated diabetes mellitus. Cyto- and histological studies are carried out in the risk group for lung cancer in smokers over 40 years of age, in patients with chronic bronchitis and a family history of cancer. Bronchological examination: diagnostic bronchoscopy is carried out in the absence of effect from adequate therapy for pneumonia, if lung cancer is suspected in a risk group, if there is a foreign body, including during aspiration in patients with loss of consciousness, if a biopsy is necessary. Therapeutic bronchoscopy is performed for abscess formation to ensure drainage. An ultrasound examination of the heart and abdominal organs is performed if sepsis or bacterial endocarditis is suspected. Isotope scanning of the lungs and angiopulmonography 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 in case of an atypical course of the disease that requires a diagnostic search.

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

Criteria for hospitalization

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 outpatient treatment for three days; - confusion or decreased consciousness; - possible aspiration; - number of respirations more than 30 per minute; - unstable hemodynamics; - septic shock; - infectious metastases; - multilobar 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 indications.

Indications for intensive therapy- 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

The majority? -lactam drugs concentration in the lung parenchyma is less than in the blood. Almost all drugs enter the sputum in concentrations much lower than in the bronchial mucosa. At the same time, many pathogens of respiratory diseases ( H. influenzae, Moraxella catarrhalis, Streptococcus spp.) are located precisely in the lumen of the bronchi or in the mucous membrane, so successful treatment requires large doses of drugs. U? -lactam drugs concentration in the fluid covering the epithelium of the lower respiratory tract is greater than in sputum and bronchial secretions. However, after the concentration? -lactam drug exceeds the MIC of the pathogen, further increase in concentration becomes meaningless, since the effectiveness of these drugs depends mainly on the time during which the concentration of the antibiotic exceeds the MIC. ? -lactam agents 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 ability, they accumulate better in 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 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 epithelial cells better than the liquid on the epithelial surface. Azithromycin after a single oral dose of 500 mg reaches a concentration in the fluid lining the epithelium that is 17.5 times greater 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? -lactam drugs practically do not penetrate intracellularly; macrolides are able to accumulate in macrophages in 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 epithelial fluid is very high. The effectiveness of drugs in this group is determined by both duration of action and concentration. Since the mid-90s, respiratory fluoroquinolones (levofloxacin, sparfloxacin) have taken a strong place in antibiotic selection algorithms (ABPs), built on the principles of evidence-based medicine (recommendations of the Society of Infectious Diseases, USA, 1998; guidelines of the American Thoracic Society, 2001; recommendations of the British Thoracic Society, 2001) But at the same time, it must be noted that the cost of respiratory fluoroquinolones is significantly higher than the cost of antibacterial drugs used in routine practice. In addition, the ban on the use of drugs in this group for the treatment of children and pregnant women remains.

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

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is a pulmonary infection that developed two or more days after the patient was admitted to the hospital, in the absence of signs of the disease at the time of hospitalization. Manifestations of nosocomial pneumonia are similar to those of other forms of pneumonia: fever, cough with sputum, tachypnea, leukocytosis, infiltrative changes in the lungs, etc., but may be mild and erased. Diagnosis is based on clinical, physical, radiological and laboratory criteria. Treatment of nosocomial pneumonia includes adequate antibiotic therapy, sanitation of the respiratory tract (lavage, inhalation, physiotherapy), and infusion therapy.

ICD-10

J18 Pneumonia without specifying the pathogen

General information

Hospital-acquired (nosocomial, nosocomial) pneumonia is a hospital-acquired lower respiratory tract infection, the symptoms of which develop no earlier than 48 hours after the patient’s admission to a hospital. Nosocomial pneumonia is one of the three most common hospital-acquired infections, second in prevalence only to wound infections and urinary tract infections. Nosocomial pneumonia develops in 0.5-1% of patients treated in hospitals, and in patients in intensive care units it occurs 5-10 times more often. The mortality rate for nosocomial pneumonia is extremely high - from 10-20% to 70-80% (depending on the type of pathogen and the severity of the patient’s background condition).

Causes

The main role in the etiology of nosocomial bacterial pneumonia belongs to gram-negative flora (Pseudomonas aeruginosa, Klebsiella, Escherichia coli, Proteus, Serration, etc.) - these bacteria are found in the secretions of the respiratory tract in 50-70% of cases. In 15-30% of patients, the leading pathogen is methicillin-resistant Staphylococcus aureus. Due to various adaptive mechanisms, these bacteria develop resistance to most known antibacterial agents. Anaerobes (bacteriodes, fusobacteria, etc.) are the etiological agents of 10-30% of nosocomial pneumonias. Approximately 4% of patients develop Legionella pneumonia - as a rule, it occurs as a massive outbreak in hospitals, caused by Legionella contamination of air conditioning and water supply systems.

Nosocomial lower respiratory tract infections caused by viruses are diagnosed much less frequently than bacterial pneumonia. Among the causative agents of nosocomial viral pneumonia, the leading role belongs to influenza A and B viruses, the RS virus, and in patients with weakened immunity – cytomegalovirus.

Common risk factors for infectious complications of the respiratory tract are long-term hospitalization, hypokinesia, uncontrolled antibiotic therapy, and old and senile age. The severity of the patient’s condition, caused by concomitant COPD, the postoperative period, trauma, blood loss, shock, immunosuppression, coma, etc., is of significant importance. Medical manipulations can contribute to the colonization of the lower respiratory tract with microbial flora: endotracheal intubation and reintubation, tracheostomy, bronchoscopy, bronchography, etc. The main routes for pathogenic microflora to enter the respiratory tract are aspiration of secretions from the oropharynx or stomach contents, and hematogenous spread of infection from distant foci.

Ventilator-associated pneumonia occurs in patients on mechanical ventilation; Moreover, every day spent on mechanical breathing increases the risk of developing hospital-acquired pneumonia by 1%. Postoperative, or congestive pneumonia, develops in immobilized patients who have undergone severe surgical interventions, mainly in the thoracic and abdominal cavities. In this case, the background for the development of pulmonary infection is a violation of the drainage function of the bronchi and hypoventilation. The aspiration mechanism of nosocomial pneumonia is typical for patients with cerebrovascular disorders who have impaired cough and swallowing reflexes; in this case, the pathogenic effect is exerted not only by infectious agents, but also by the aggressive nature of the gastric aspirate.

Classification

According to the timing of occurrence, hospital infection is divided into early and late. Nosocomial pneumonia is considered early if it occurs within the first 5 days after admission to the hospital. As a rule, it is caused by pathogens that were present in the patient’s body even before hospitalization (St. аureus, St. pneumoniae, H. influenzae and other representatives of the microflora of the upper respiratory tract). Typically, these pathogens show sensitivity to traditional antibiotics, and pneumonia itself proceeds more favorably.

Late nosocomial pneumonia manifests itself after 5 or more days of hospital treatment. Its development is caused by hospital strains themselves (methicillin-resistant St. aureus, Acinetobacter spp., P. aeruginosa, Enterobacteriaceae, etc.), exhibiting highly virulent properties and multiresistance to antimicrobial drugs. The course and prognosis of late nosocomial pneumonia are very serious.

Taking into account the causative factors, there are 3 forms of nosocomial respiratory tract infection:

• postoperative or congestive pneumonia

At the same time, quite often different forms are layered on top of each other, further aggravating the course of hospital-acquired pneumonia and increasing the risk of death.

Symptoms of hospital-acquired pneumonia

A feature of the course of nosocomial pneumonia is the blurring of symptoms, which makes recognition of a pulmonary infection difficult. First of all, this is explained by the general severity of the patients’ condition associated with the underlying disease, surgery, old age, coma, etc.

However, in some cases, hospital-acquired pneumonia can be suspected based on clinical data: a new episode of fever, an increase in the amount of sputum/tracheal aspirate or a change in their nature (viscosity, color, odor, etc.). Patients may complain of the appearance or worsening of cough, shortness of breath, and chest pain. In patients who are in a serious or unconscious state, attention should be paid to hyperthermia, increased heart rate, tachycardia, and signs of hypoxemia. The criteria for a severe infectious process in the lungs are signs of severe respiratory (RR > 30/min.) and cardiovascular failure (HR > 125/min., blood pressure

Diagnostics

A complete diagnostic examination for suspected nosocomial pneumonia is based on a combination of clinical, physical, instrumental (lung X-ray, chest CT), laboratory methods (CBC, biochemical and gas composition of blood, sputum culture).

To make an appropriate diagnosis, pulmonologists are guided by recommended criteria, including: fever above 38.3°C, increased bronchial secretion, purulent sputum or bronchial secretions, cough, tachypnea, bronchial breathing, moist rales, inspiratory crepitus. The fact of nosocomial pneumonia is confirmed by radiological signs (the appearance of fresh infiltrates in the lung tissue) and laboratory data (leukocytosis >12.0x10 9 /l, band shift >10%, arterial hypoxemia Pa02

In order to verify the probable causative agents of nosocomial pneumonia and determine antibiotic sensitivity, a microbiological study of the secretion of the tracheobronchial tree is carried out. For this purpose, not only samples of freely expectorated sputum are used, but also tracheal aspirate and bronchial lavage water. Along with cultural isolation of the pathogen, PCR research is widely used.

Treatment of nosocomial pneumonia

The difficulty of treating nosocomial pneumonia lies in the multiresistance of pathogens to antimicrobial drugs and the severity of the general condition of patients. In almost all cases, initial antibiotic therapy is empirical, that is, it begins even before microbiological identification of the pathogen. After establishing the etiology of nosocomial pneumonia, the drug can be replaced with a more effective one against the identified microorganism.

The drugs of choice for nosocomial pneumonia caused by E. Coli and K. pneumoniae are III-IV generation cephalosporins, inhibitor-protected penicillins, and fluoroquinolones. Pseudomonas aeruginosa is sensitive to a combination of III-IV generation cephalosporins (or carbapenems) with aminoglycosides. If hospital strains are represented by St. aureus, the prescription of cefazolin, oxacillin, amoxicillin with clavulanic acid, etc. is required. For the treatment of pulmonary aspergillosis, voriconazole or caspofungin is used.

In the initial period, the intravenous route of administration of the drug is preferable; later, with positive dynamics, a transition to intramuscular injections or oral administration is possible. The duration of antibiotic therapy in patients with nosocomial pneumonia is 14-21 days. The effectiveness of etiotropic therapy is assessed based on the dynamics of clinical, laboratory and radiological parameters.

In addition to systemic antibiotic therapy, for nosocomial pneumonia, important attention is paid to the sanitation of the respiratory tract: bronchoalveolar lavage, inhalation therapy, tracheal aspiration. Patients are shown an active motor regimen: frequent changes of position and sitting up in bed, exercise therapy, breathing exercises, etc. Additionally, detoxification and symptomatic therapy is carried out (infusions of solutions, administration and administration of bronchodilators, mucolytics, antipyretics). To prevent deep vein thrombosis, heparin or wearing compression stockings is prescribed; To prevent stress gastric ulcers, H2 blockers and proton pump inhibitors are used. In patients with severe septic manifestations, administration of intravenous immunoglobulins may be indicated.

Prognosis and prevention

Clinical outcomes of nosocomial pneumonia include resolution, improvement, treatment failure, relapse, and death. Nosocomial pneumonia is the main cause of mortality in the structure of nosocomial infections. This is explained by the difficulty of its timely diagnosis, especially in elderly, weakened patients, and patients in a comatose state.

Prevention of nosocomial pneumonia is based on a complex of medical and epidemiological measures: treatment of concomitant foci of infection, compliance with the sanitary and hygienic regime and infection control in health care facilities, and prevention of the transfer of pathogens by medical staff during endoscopic procedures. Early postoperative activation of patients and stimulation of expectoration of sputum are extremely important; seriously ill patients need adequate toileting of the oropharynx and constant aspiration of tracheal secretions.

Pulmonary tuberculosis

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

Analysis of anamnesis data

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

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

Analysis of data from external examination of patients

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

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

Analysis of physical data obtained during examination of the lungs

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

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

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

Setting up tuberculin tests

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

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

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

Microbiological diagnosis of tuberculosis

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

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

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

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

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

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

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

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

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

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

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

Focal pulmonary tuberculosis

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

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

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

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

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

Infiltrative pulmonary tuberculosis

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

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

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

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

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

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

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

Caseous pneumonia

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

Miliary pulmonary tuberculosis

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

Disseminated pulmonary tuberculosis

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

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

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

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

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

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

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

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

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

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

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

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

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

Exudative pleurisy

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

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

Pulmonary infarction

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

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

Lungs' cancer

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

Analysis of anamnesis data

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

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

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

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

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

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

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

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

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

Bronchoscopy

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

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

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

Cytological examination of sputum

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

Cytological examination of pleural exudate

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

Needle biopsy of palpable peripheral lymph nodes

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

Immunological diagnostic methods

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

Transthoracic puncture

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

Acute appendicitis

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

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

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

Cardiogenic pulmonary edema

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

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

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

Pneumonitis in systemic vasculitis and diffuse connective tissue diseases

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

Etiological diagnosis

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

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

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

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

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

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

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

How is differential diagnosis of pneumonia carried out?

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

What is characteristic of pneumonia?

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

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

Is there a difference between pneumonia and bronchitis?

Differences between diseases:

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

How is the differential diagnosis made?

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

• fluorography;
• X-ray.

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

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

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

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

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

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

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

What types of pneumonia are there?

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

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

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

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

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

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

A table that your doctor will familiarize you with can provide more detailed information about the differentiation of pneumonia.

How can you quickly cure pneumonia?

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

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

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

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

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

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

Diagnosis of pneumonia in children

Laboratory diagnosis of pneumonia

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

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

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

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

Instrumental methods for diagnosing pneumonia

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

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

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

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

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

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

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

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

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

Differential diagnosis of pneumonia in a child

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

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

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

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

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

What is pulmonary tuberculosis: differential diagnosis and clinical picture

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

Characteristics of pulmonary tuberculosis

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

• aerosol;
• fecal-oral;
• contact;
• vertical.

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

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

Clinical symptoms

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

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

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

Diagnostic measures

Today, the diagnosis of pulmonary tuberculosis involves:

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

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

Differential diagnosis

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

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

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

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

Tuberculosis and other diseases

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

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

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

Difference between caseous and lobar pneumonia

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

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

Successful treatment of any pathology is impossible without a complete examination. A number of diseases require comparative analysis to more accurately clarify the picture. In this sense, differential diagnosis of pneumonia is necessary to exclude similar symptoms, and ultimately determine the only correct diagnosis and prescribe a therapeutic course. The technique allows you to avoid incorrect treatment and incorrect dosages of drugs, prevents complications and side effects associated with erroneous examination, which is especially important for diseases in children. Detailed information about pneumonia is available

Diagnostic methods

The process of differential testing of pathologies is carried out according to the elimination scheme, that is, at first the symptoms are grouped, then excluded in small groups until the real clinical picture is formed. Diagnostics is carried out in several stages:

• Primary data are summarized under the general syndrome, and on their basis a list of possible pathologies is formed
• A graph of symptoms, the general condition of the patient, changes in his well-being is studied in detail and a chart is drawn up, taking into account various factors
• A comparative analysis is carried out according to the list, including the clinical picture, accompanying signs and their features. Another graph of similar and different values ​​is drawn up
• The symptoms are compared and their belonging to the original disease is determined
• The specialist finds third-party signs that are not related to this pathology
• Diseases whose clinical picture does not fit into the overall picture are excluded
• Based on the final information, a diagnosis is established and treatment is prescribed.

As for the general examination methods, in this case they are identical to traditional analyzes and testing of the patient:

• Listening to the patient's complaints, collecting anamnesis, checking the medical record for past pathologies
• Auscultation and percussion
• General inspection
• Biochemical tests
• X-ray
• Electrocardiogram
• Ultrasonography
• Magnetic resonance and computed tomography
• Bronchoscopy
• Spirometry.

The collected and analyzed anamnesis allows us to obtain a reliable picture, including the causes of the disease in children and adults, and frequently recurring symptoms. The doctor also identifies other disorders in the body. The initial examination does not provide complete data, since the patient’s assessment of his own well-being is almost always subjective. Small children generally cannot tell where it hurts.

Differentiation of pneumonia

Pathologies of the respiratory system have the same clinical picture, especially in the first stages of development. Many analyzes and tests take time to carry out, and in the case of acute cases, every minute matters, especially for children. Patients often turn to doctors when processes become threatening.

Poorly treatable pneumonia may turn out to be tuberculosis or mask oncological pathologies. In addition, there is some similarity of symptoms with heart failure, thromboembolism, and vasculitis. First of all, differentiation is established between different types of pneumonia in children and adults. Visual data on symptoms and causes are shown in the table:

Type of pathogen that caused pneumonia	Etiological factor	Clinical picture	Temperature	Complications
Pneumococci	Chronic lung pathologies, community infections	Begins with an acute manifestation, cough with rusty sputum	38-40 0 C, fever	Pleurisy, abscess, empyema
Mycoplasmas	Preschool children, adults during seasonal influenza epidemics	Gradual development, runny nose, sore throat, cough, myocarditis, anemia	Low-grade fever	Lung tissue infiltrates, erythema, skin rash, meningitis, encephalitis
Influenza	Chronic obstruction, heart failure, smoking, old age, children under 6 years of age	Flank pain, persistent cough with purulent discharge, cyanosis	Absent or low-grade	Meningitis, arthritis, septicemia, epiglottitis
Legionella	Staying in the air conditioner area or near open water bodies, immunodeficiency syndrome	Acute onset and severe course, cough with sputum, headaches and joint pain, hemoptysis is rare	Fever, chills, maximum readings	Lesions of the digestive system, toxic shock
Chlamydia	Intrapartum infection in children under 6 months, transmission of infection by birds	Rhinitis, laryngitis, weakness, myalgia, dry cough, scanty sputum	38-39 0 C	Otitis, reactive arthritis, atherosclerosis, sarcoidosis
Staphylococcus	Children of the neonatal period, surgical interventions, drug addiction, alcoholism	Severe course, painful cough, shortness of breath, intoxication	39-40 0 C	Pneumosclerosis, sepsis, endocarditis
Bacteroides, actinomycetes	Invasive procedures, surgeries, open wounds, insect and animal bites	Intoxication, nausea, headache, tachycardia, hypotension, cyanosis. Purulent sputum in cough	Fever, chills, 38-39 0 C	Failure and dysfunction of all systems, sepsis, death
Klebsiella	Diabetes mellitus, hepatic cirrhosis	Acute onset, pain in the side, jaundice, dry cough and hemoptysis	39-40 0 C	Vascular thrombosis, fibrosis, infarction
Escherechia and Protea	Pyelonephritis, epicystoma, elderly people	Severe cough, severe course with abscesses, hypotension	High performance	Pleural empyema
Pseudomonas	Weakened children, adults with reduced immunity. Transmitted by aerosol, food and contact	Persistent, wet cough with purulent sputum, oxygen deficiency, cyanosis, shortness of breath	Low-grade fever	Meningitis, pyelonephritis, osteomyelitis
Fungi	Chemotherapy for cancer patients. Taking antibiotics, immunosuppressants	Weakness, myalgia, dry cough, pulmonary hemorrhage	Low-grade fever gives way to high levels	Thrombosis, hemorrhagic infarction, abscesses
Pneumocysts	Malignant tumors, immunodeficiency syndrome	Gradual development, cyanosis, frothy sputum, anorexia	Spasmodic	Pneumothorax, pleurisy, impaired gas exchange, death
Viruses	Young children, elderly and frail people	Pharyngitis, rhinitis, swollen lymph nodes, frequent cough with moist rales	Fluctuations during the day	Otitis, encephalitis, meningitis, empyema

Since most symptoms have a similar pattern, the main principle of diagnosis is bacterial culture. When collecting anamnesis, the doctor must reflect the following points:

• Etiological factors
• Presence of background pathologies
• Prevalence and characteristics of pneumonia foci
• Severity
• Stage of development
• Possible complications and risks of their occurrence.

In each specific case, the type of pathogen is indicated. If such data are not available or it takes time to obtain them, the reasons, available results of radiographs, bronchoscopy and spirometry are described. If there is a lack of information, an empirical treatment regimen should be prescribed, which is adjusted as the diagnosis is completed.

If there is an underlying disease, the pediatrician or therapist describes its symptoms, features of the course and impact on the patient’s condition. Therapy is based on the specific interaction and combination of different drugs and antibiotics. This fact is most important, since associated pneumonia can become protracted or lead to irreversible consequences.

Differentiation with other diseases

When examining a patient, the doctor faces two tasks. The first is to limit pulmonary inflammation from other diseases of the respiratory system. The second is the definition of extrapulmonary pathologies by symptoms from the respiratory system. Each of these principles has specific distinctive features:

With tuberculosis

The most common mistakes are made when comparing these two diseases. According to research, infection with mycobacteria is complicated by influenza or pneumonia. Exacerbation of tuberculosis is similar to the manifestations of pneumonia - a dry cough, pale skin, low-grade fever.

Sometimes the inflammatory process is accompanied by positive tuberculin tests, which further complicates the diagnosis. However, differentiation plays an important role, since most physiotherapy methods that are used for pneumonia are unacceptable for tuberculosis. The formation of infiltrates may be accompanied by nonspecific changes - hyperemia, hyperreaction, lymphostasis. This creates favorable conditions for viruses to attach to mycobacteria.

When analyzing the patient’s condition, the main question arises - how does developing catarrh affect the course of existing tuberculosis. Typically, the clinical picture of the formation of cavities and caseous formations is similar. In both cases, an acute onset is detected, a cough with pain, sputum with bloody discharge. An X-ray examination shows that the affected area is enlarged and there are characteristic changes.

The difference consists of a number of factors: with tuberculosis, the shadows are heterogeneous and compacted, areas of clearing coincide with the seeded foci. Therapeutic regimens effective for pneumonia do not produce results within more than three days. A massive proliferation of mycobacteria is found in the sputum. Also, the limitation allows you to determine the biochemical test. With tuberculosis, an increase in leukocyte elements is detected in the blood, which are reduced in pneumonia.

With bronchitis

Pathology most often begins to develop as a result of respiratory viral infections or simultaneously with them. The main symptom is coughing attacks, first dry, then with sputum production. Increases in temperature are short-term in nature, it rises within 2-3 days, then remains within the subfebrile range. The sound does not change during percussion; wheezing is observed during auscultation. The pulmonary pattern is enhanced, but there is no infiltration.

When differentiating pneumonia and bronchitis, there are two main mistakes: when the first disease is interpreted as an exacerbation of the second. In addition, patients with pneumonia who smoke may exhibit the characteristic pattern of chronic smoker's bronchitis. In most cases, pulmonary inflammation is more severe. It is predominantly bacteriological in nature, while bronchitis is pulmonary. The difficulty arises when the origin of both pathologies is the same, but in such cases confirmation will be based on additional examinations.

With the flu

Misdiagnosis when compared with respiratory pathologies is not uncommon. During a pandemic, it is especially difficult to limit pulmonary inflammation and influenza. First of all, the specifics of the clinical picture should be taken into account:

• Respiratory lesions begin acutely, the temperature is high, a runny nose is added, the cough is dry, the sputum is clear and non-viscous. Sore throat, red eyes, swollen face.
• With the flu, the patient complains of joint pain and aches, severe weakness, and fever with high temperatures. Catarrhal signs, which are absent at first, appear after 3-4 days.
• Pneumonia can develop either slowly or suddenly. The patient suffers from shortness of breath, loses appetite, and loses weight sharply. The cough is frequent, the discharge is viscous, purulent or bloody. There is pain in the chest area.

Often, pulmonary inflammation is a complication after influenza or respiratory infections. In this case, they can develop as a result of direct viral damage or due to the penetration of bacteria as a secondary factor. The examination reveals tissue compaction, foci of infiltration, and individual areas of destruction.

With pleurisy

Massive inflammatory damage to the respiratory system resembles pleural changes, especially when both processes occur in the lower lobe areas. Painful sensations in the chest are characteristic of both pathologies. Some patients complain of discomfort when coughing. But there are a number of symptoms that are fundamentally different. Exudative pleurisy is characterized by a special sign - the sound of pleura rubbing during breathing.

After the first stage of development with a specific clinical picture, the following series of symptoms occurs. This is a more acute pain than with pneumonia, which intensifies when bending and turning. The temperature is normal or slightly elevated, the cough is dry, and sputum is difficult to produce. An x-ray is considered the most reliable examination method, but if the effusion volume is less than 300 ml, confirmation by puncture is required, which helps not only to determine the amount of fluid, but also its composition. The same method is suitable for differentiation from pneumonia. In addition, the data of biochemical analysis are important.

With atelectasis

Damage to the lungs with tissue collapse and impaired gas exchange may also have similar symptoms to pneumonia. Respiratory failure, cyanosis, shortness of breath. Chest pain is associated with impaired gas exchange. The collapsed area creates a favorable environment for the development of infection. The etiological factors of atelectasis are blockages and compressions associated with injuries, aspirations, destructive tissue changes, and surfactant deficiency. This is the main difference from pneumonia.

The initial clinical picture is identical: with atelectasis, cyanosis, shortness of breath, and cough are also observed. Typically dry. As the condition worsens and respiratory failure develops, the risk of death increases. The temperature is rising. If an infection develops against the background of a collapsed lung. This indicates the onset of pneumonia with abscess formation. In this case, intoxication and sputum are added, often with bloody spots due to damage to blood vessels and increased pressure in the pulmonary circulation.

With cancer

The initial manifestations of oncological formations do not differ from the inflammatory process in the lungs. Just a few years ago, the rate of misdiagnosis was 70%. If pneumonia is suspected, the doctor prescribes antibiotics. If the drugs do not bring results after two weeks of use, it is necessary to urgently examine the patient for the development of malignant neoplasms. Differentiation lies in early diagnosis, since with cancer the signs are initially scant, only in the later stages they become pronounced.

When metastasis begins and the tumor grows into the pleural tissue, the clinical picture becomes clear. The patient develops pain and coughs with sputum and blood clots. An X-ray image makes it especially clear to see the progression of the pathology. Later, characteristic joint pain appears, especially at night. With all open signs, the temperature rarely rises; it remains low-grade throughout the disease.

With other pathologies

It is often necessary to distinguish between pulmonary inflammation and dysfunction of the heart and blood vessels, which lead to stagnation in the respiratory system and proliferation of connective tissue. Like pneumonia, hepostasis is accompanied by shortness of breath, wheezing and percussion sounds. Since cardiac failure is characterized by hypothermia, the patient's condition gradually worsens.

With collagenosis and rheumatoid arthritis, a person also suffers from similar symptoms. At the same time, the data from auscultation and X-ray examination are identical - increased pulmonary shadows, the presence of infiltrates. The difference is that antibacterial therapy for collagenosis is ineffective, but when taking glucocorticosteroids, positive dynamics are noted. In addition, there is practically no sputum, no changes in the position of the diaphragm, and bilateral atelectasis.

During a heart attack, the lungs are affected due to thrombosis affecting the adjacent arteries. The pathology develops after phlebitis of the lower extremities and varicose veins. In addition, people with myocardial dysfunction, vasculitis, and ischemia are susceptible to the disease. The main symptom is pain, which intensifies when turning the torso, coughing, sneezing, or laughing. Many patients develop serous pleural lesions against the background of a heart attack.

Sudden attacks of shortness of breath, even suffocation, are characteristic of thromboembolism. Diagnosis and differentiation are based on a preliminary examination of thrombophlebitis, diseases associated with vascular damage. The blockage is not related to bacterial etiology; the pathogen may act as a subsequent factor, since in the area. Closed by a blood clot, microcirculation is disrupted, which creates conditions for the penetration and growth of pathogens. For such patients, isotope scanning of the respiratory organs and angiopulmonography of the system are performed.

To visually compare the principles of differentiation, you can use the table, which displays the characteristic signs and causes of the four main pathologies:

Symptoms	Pneumonia	Tuberculosis	Cancer	Flu. Respiratory diseases
Etiological factors	Hypothermia, weakened immunity, frequent colds	Chronic lung diseases, bad habits, low social level	Predisposition, bronchial obstruction, smoking, alcoholism, low immunity	Seasonal epidemics, weak body defense mechanism
Patient age	Any	Most often from 25 to 40 years	Mostly over 50 years of age	Any
First stage of development	Spicy	Asymptomatic, sometimes acute	Gradual	Spicy
Cough	Dry, hemoptysis is rare, sputum depends on the type of pathogen	Moderate, purulent sputum, hemoptysis in special forms	Constant, severe, hemoptysis progresses to bleeding	First dry, then wet. Sputum is clear
Painful sensations in the chest	Moderate	Rare	Growing	Short-term
Temperature	39-40 0 C	38 0 C	37.5 0 C	39-40 0 C
Dyspnea	Moderate, short-term	In advanced stages or absent	Increasing	Absent
Weight loss	Rarely	In some forms	Progressive	Not typical
Intoxication	Depending on the pathogen	Moderate	Strong, especially in the last stages and after chemotherapy	Can not be
Sputum test	Depending on the pathogen	Mycobacteria	Cancer cells	Viruses and bacteria are not detected
Auscultation	Wheezing is strong and moist	Wheezing in the upper areas. Weakly expressed	Intense wheezing	Weakly expressed
Percussion	Short sound	Short sound	Dullness	Clear lung sound
Tests for tuberculin	Moderately positive	Hyperergic	Negative	Not carried out

Differential diagnosis is a technique necessary to distinguish between several types of pathologies with the same symptoms. It plays an important role in determining therapeutic regimens, especially in cases where bacteria are capable of exhibiting resistance. Thanks to these methods of examination, it became possible for the early detection of not only pneumonia, but also tuberculosis, atelectasis, cancer, and empyema. The techniques are aimed at accelerating recovery, improving the condition of patients with irreversible disorders and preventing death for people at risk.