Pneumonia

肺 炎

BRONCHOPNEUMONIA

支气管肺炎

It may occur in previously normal lungs or be superimposed on underlying bronchitis or other respiratory disease, e. g. bronchiectasis or carcinoma. It is preceded by bronchial infection and is commonest in children (measles and whooping cough) and the elderly (chronic bronchitis and hypostatic pneumonia in debilitated patients in bed). In normal adults it may follow respiratory viral infections.

可以发生在原来正常的肺，亦可在原有支气管 炎或其他呼吸道疾病(例如支气管扩张症或肺癌)的 基础上再发生本病。发病之前有支气管感染，这在儿童(麻疹及百日咳)及老年人(慢性支气管炎及卧 床不起者的体位性肺炎)最常见。在正常成年人可 在呼吸道病毒感染之后发生。

Clinical presentation

临床表现

The history is initially often of acute bronchitis. Fever and malaise develop with a cough producing infected (yellow or green) sputum. On examination, coarse crepitations may be areas of consolidation with dullness to percussion, increased vocal resonance and bronchial breathing.

病史上常以急性支气管炎发病，出现发热，不 适，并咳脓痰(黄或绿色)。体检有粗的水泡音，部分肺野可能有实变，叩诊实音，语音共振增强，并有支气管性呼吸音。

Investigation

检查

Diagnosis is confirmed on chest X-ray. Blood cultures should be sent. Sputum should be sent for culture and Gram stain before starting antibiotics. These should not be withheld until sensitivities are available.

胸部X线检查可确诊。应送血培养，在开始抗 生素治疗之前应送痰培养及革兰染色检查，但不必 等敏感试验的结果出来后再行治疗

Management Haemophilus influenzae and Streptococcus pneumoniae are the most common organisms but other bacteria (e.g. klebsiella and staphylococcus) may be responsible. Initial therapy involves the use of: (1) Oxygen--28% in the presence of respiratory chronic failure. (2) Antibiotics - erythromycin, amoxicillin or trimethoprim in the first instance. (3) Physiotherapy.

处理 最常见的致病菌是流感嗜血杆菌及肺炎链球菌，但亦可由其他细菌(例如克雷白杆菌及葡 萄球菌)引起。开始时可用以下方法治疗：(1)氧气，有慢性呼吸衰竭出现时可给氧(28％)。(2)抗生素， 最先可用红霉素，羟氨苄青霉素或甲氧苄氨嘧啶。 (3)理疗。

Important predisposing causes should be considered including diabetes mellitus and carcinoma of the bronchus. Complications include lung abscess, pleural effusion and empyema.

应考虑重要的诱发因素，包括糖尿病及支气管 癌。合并症有肺脓肿，胸腔积液及脓胸。

LOBAR PNEUMONIA

大叶性肺炎

This has become less common since the advent of penicillin.

自从青霉素问世以后，大叶肺炎已不常见。

Clinical presentation

临床表现

The onset is sudden with cough, rusty sputum, marked fever and rigors. There are signs of consolidation if a large area of lung is involved. Vesicles of herpes simplex occur around the lips. Chest X-ray shows consolidation in lobar distribution. Cerebral abscess is a rare complication. The pneumococcus is particularly dangerous to the splenectomised patient.医学全.在.线www.lindalemus.com

突然发病，咳嗽、咳铁锈痰，高热及寒颤。如果一大片肺被侵犯则有实变征。唇部可发生单纯疱疹。胸部X线检查见有呈大叶性分布的实变阴影。脑脓肿是较少见的合并症。对脾切除患者，肺炎双球菌(感染)是特别危险的。

Management

处理

The organism most frequently cultured from sputum and blood is S. pneumoniae (pneumococcus) and this responds to i. m. crystalline penicillin (1-2 million units 6-hourly) which is the drug of first choice.

从血及痰中培养出的细菌最常见的是肺炎双球 菌，肌内注射青霉素有效(100～200万uq6h)，故作为首选药物。

NB Lobar consolidation, particularly with loss of volume on chest X-ray, may indicate an underlying bronchial obstruction, e. g. neoplasm, foreign body.

注意 大叶实变，特别是X线检查有肺不张，可能提示有潜在支气管阻塞性疾患(例如新生物，异物)。

OTHER BACTERIAL PNEUMONIAS

其他细菌性肺炎

Klebsiella pneumoniac (Fried!~nder's). This is rare and often opportunistic in patients with leukaemia, lymphomas or on steroids. The history is of sudden prostration, fever, rigors and cough with blood-stained viscous sputum. The chest X-ray 'shows patchy areas of consolidation, often involving the upper lobe. The mortality is high (40%) and subsequent respiratory disability common.

克雷白杆菌肺炎 罕见，偶可发生于白血病，淋巴瘤或激素治疗的患者。患者病情突然恶化，发热，寒颤，咳嗽并有带血的粘痰。胸部X线可见片块状实变区常累及上叶。死亡率高(占40％)。患者在以后常有呼吸功能异常。

The bacillus is not penicillin or ampicillin sensitive. It responds to streptomycin, chloramphenicol and with some strains, tetracyclines. Lung abscess and bronchiectasis are common complications.

本菌对青霉素及氨苄青霉素不敏感，用链霉素、氯霉素有效。有些菌株用四环素有效。常合并肺脓肿及支气管扩张症。

Staphylococcal pneumonia This produces widespread infection with abscess formation. It occurs in patients with underlying disease which prevents normal response to infection, e.g. chronic leukaemia. Hodgkln's disease, cystic fibrosis, and patients on steroid therapy. It may complicate influenzal pneumonia and this makes it relatively common during epidemics of influenza. The organism may not be penicillin sensitive, so flucloxacillin is the drug of choice. Lung abscess, empyema and subsequent bronchlectasis are relatively common complications.

葡萄球菌肺炎 它引起广泛的感染和形成脓肿。常发生在有潜在疾患的病人，因为这些病妨碍了他们对感染的正常反应，例如慢性白血病、何杰金病、囊性纤维化，以及激素治疗的病人都常发生。可以并发流感肺炎，因而在流感流行时较常见。本菌可能对青霉素不敏感，因而可选用氟氯苯唑青霉素治疗。较常见的合并症有肺脓肿、脓胸及随后发生的支气管扩张症。

LEGIONNAIRE'S DISEASE

军 团 病

This was first described ill a group of American army veterans (legionnaires). It begins as an influenza-like illness with fever, malaise and myalgia and proceeds with cough (little sputum). dyspnoea and sometimes severe anoxia, marked confusion and coma. Diarrhoea and vomiting are common and renal failure may develop. Examination shows consolidation which usually affects one or both lung bases. Radiological changes may persist for more than 2 months after the acute illness. The bacterium is the Gramnegative bacillus Legionella pneumophila and the diagnosis confirmed by a rising antibody titre.

本病首先报道是在一组美国陆军退伍军人中发生。发病时好似流感，有发热、乏力及肌痛，以后发生咳嗽(痰少)、气急。有时严重缺氧，显著的精神错乱及昏迷。常有腹泻及呕吐，且可发展为肾功 能衰竭。检查可见实变，常波及一侧或双侧肺底部。X线改变在急性病变后可持续2个月以上。本病由革兰阴性的需气军团杆菌所引起，抗体滴定度升高可确定诊断。医学全.在线提供

Erythromycin or tetracycline are the antibiotics of choice but the mortality remains high (20%).

可选用红霉素或四环素治疗，但死亡率仍高 (占20％)。

NB Legionnaire's disease (and Mycoplasma pneumoniae or psittacosis) should be suspected in all patients who develop atypical pneumonia which does not respond to standard antibiotics especially after travel away from home—often to the Mediterranean.

注意 凡患有非典型肺炎而对标准的抗生素治疗无效，特别是离家出外旅行的患者——通常是到地中海地区，应疑患军团病(及肺炎支原体肺炎或鹦鹉病)。

RECURRENT BACTERIAL PNEUMONIA

复发性细菌性肺炎

In the absence of chronic bronchitis, recurrent pneumonia arouses the suspicion of: (1) Bronchial carcinoma preventing drainage of infected areas of the lung. (2) Bronchiectasis (including fibrocystic disease). (3) Achalasia of the cardia, 25% of which present as chest disease; pharyngeal pouch and neuromuscular disease of the oesophagus, e. g. bulbar palsy, (4) Hypogammaglobulinaemia and myeloma.

如果患者没有慢性支气管炎而再发生肺炎，应考虑：(1)支气管癌妨碍了肺感染部位的引流。(2)支气管扩张症(包括纤维囊性疾病)。(3)胃贲门松弛不良患者，25％表现为胸部疾患，咽袋及食管的神经肌肉病(例如延髓麻痹)。(4)低γ-球蛋白血症及骨髓瘤。

VIRAL PNEUMONIA

病毒性肺炎

The most common virus producing pneumonia in children in this country and the USA is the respiratory syncytial virus (so called as it is a respiratory virus which produces syncytium formation when grown in tissue culture). The agent is not responsive to antibiotics and it may be indistinguishable from acute bacterial bronchitis or bronchiolitis in children and infants. The presence of an associated skin rash supports the likelihood of RSV infection.

在英美的儿童中，最常见的肺炎病毒为呼吸道合胞病毒(之所以用这个名称是因为该病毒在组织培养时可以形成合胞体)。本病用抗生素无效。在婴儿及儿童患者，与急性细菌性支气管炎或细支气管炎不易区别。如果患者同时出现皮疹，则支持呼吸道合胞病毒感染。

Acute virus pneumonia in adults is very rare and occurs during epidemics of influenza A (Asian' flu). The picture is of rapid and progressive dyspnoea. Death may occur within hours from acute haemorrhagic disease of the lungs. The most common cause of pneumonia during epidemics of influenza results from secondary bacterial infection, the most serious being staphylococcal pneumonia. The viruses of measles, chickenpox, and herpes zoster may directly affect the lung. The diagnosis is confirmed by a rise in specific antibody titre.

成人的病毒性肺炎极罕见，有时在A型流行性感冒(亚洲型流感)流行时发生。临床表现为迅速发生气急，并进行性加重。可能因急性肺出血性疾病而在数小时内死亡。在流感流行时发生的肺炎，最常见的病因是继发性细菌感染，最严重的是葡萄球菌性肺炎。麻疹、水痘及疱疹病毒可直接侵犯肺。特异性抗体滴定度升高可确定诊断。

MYCOPLASMA PNEUMONIA

肺炎支原体肺炎

This is caused by Mycoplasma pneumoniae, the only mycoplasma definitely pathcgenic to man. The clinical picture resembles bacterial pneumonia although cough and sputum are absent in one-third of cases.

病因为肺炎支原体，是能使人致病的唯一支原体。临床表现类似细菌性肺炎，但l／3患者可不咳、无痰。

Respiratory symptoms and signs and. X-ray changes (patchy consolidation with small effusions) are usually preceded by several days of flu-like symptoms. Polyarthritis occurs and may persist for months. Malaise and fatigue may persist long after the acute illness is over. The diagnosis is confirmed by a rise of specific antibody titre, the presence of cold agglutinins and antibodies to Mycoplasma in the serum and/or isolation of the organism. Tetracycline (0.5--1.0gqds) is the antibiotic choice. Psittacosis and ornithosis (Bedsoniae) may cause a similar picture and also respond to tetracycline, though diarrhea is commoner.

在出现呼吸道症状及X线征状的前几天常有流感样症状。X线表现为片块状实变及小量积液。可有多发性关节炎，并持续数月。不适及疲乏在急性期后可持续甚久。如特异性抗体滴定度升高，血清中存在冷凝集素，支原体抗体或分离出支原体(或同时出现后两者)，可确诊为本病。可选用四环素治疗(每次0．6一1．0g，每日4次)。鹦鹉热及鸟病毒病(衣原体属)的临床表现与之相同。用四环素亦有效，但腹泻较常见。

OPPORTUNISTIC INFECTION OF THE LUNGS

机遇性肺部感染

This is seen in immunosuppressed patients usually on steroids, azathioprine, or cytotoxic agents following transplantation or for leukaemia or lymphoma. The range of organisms found is very wide and includes bacteria (Pseudomonas M. tuberculosis, E. coli), fungi (Aspergillus, Monilia, Cryptococcus). Viruses (Cytomegalo-Virus. Herpes zoster) and Pneumocystis carinii. It is important to attempt to isolate the organism from the sputum and to carry out blood culture, endobronchial brush biopsy, and/or percutaneous lung biopsy. Treatment should not be delayed, because the prognosis is very poor.

在免疫受到抑制的病人可发生此病，患者因移植、白血病或淋巴瘤而常应用激素、硫唑嘌呤或细胞毒类药物治疗者。致病微生物的范围很广泛，包括细菌(假单胞菌属、结核杆菌，大肠杆菌)，真菌(曲霉属、念珠菌属、隐球菌属)，病毒(巨细胞病毒、疱疹病毒)及卡氏肺囊虫。努力从痰中分离出致病的微生物极为重要，送血培养，支气管刷洗活检，及(或)经皮穿刺作肺活检。治疗必须及时，因为本病预后差。

ASPIRATION PNEUMONIA

吸入性肺炎

There are two main varieties differentiated from each other by the type of fluid aspirated and the circumstances in which it occurs.

根据吸入的液体及得病的情况主要可分成两大类。

Aspiration of gastric contents may produce a severe chemical pneumonitis with considerable pulmonary oedema and bronchospasm (Mendelson's syndrome). The acute respiratory distress and shock can be rapidly fatal and very difficult to treat. It tends to occur in states of reduced consciousness such as general anaesthesia, drunks, and when gastric lavage (for drug overdose) has been performed inexpertly.

吸入胃内容可以产生严重的化学性肺炎，有相当程度的肺水肿及支气管痉挛(Mendelson’s综合征)。急性呼吸困难及休克可迅速致死，很难治疗。意识模糊时易于发生，例如全麻、醉酒，以及由不熟练者洗胃(因药物过量)时均易发生。

Aspiration of bacteria from the oropharynx may follow dental anaesthesia and can occur in bulbar palsies. The bacteria, apart from bacteroides, are nearly all penicillin sensitive and crystalline penicillin with metronidazole are the antibiotics of choice initially until sensitivities are known. Recurrent episodes occur in some oesophageal diseases includinghiatus hernia, stricture, achalasia of the cardia, and in patients with diverticula or pharyngeal pouch.

自口咽中吸入细菌可在牙科麻醉时发生，亦可在延髓麻痹时发生。除类杆菌感染以外，吸入的细菌差不多都对青霉素敏感，在获悉细菌药敏试验报告之前，可先选用青霉素及灭滴灵治疗。某些食管病患者可以并发此病，例如膈疝，狭窄、贲门松弛不良以及食管憩室或咽袋患者.