Pneumonia

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For other uses, see Pneumonia (disambiguation).

Pneumonia
Classification and external resources

A chest X-ray showing a very prominent wedgeshaped bacterial pneumonia in the right lung.
J12, J13, J14, J15, J16, J17, J18,
ICD-10
P23
ICD-9
480-486, 770.0
DiseasesDB
10166
MedlinePlus
000145
eMedicine
topic list
MeSH
D011014
Pneumonia is an inflammatory condition of the lungespecially affecting the microscopic
air sacs (alveoli)associated with fever, chest symptoms, and a lack of air space
(consolidation) on a chest X-ray.[1][2] Pneumonia is typically caused by an infection but there
are a number of other causes.[1] Infectious agents include: bacteria, viruses, fungi, and
parasites.[3]
Typical symptoms include cough, chest pain, fever, and difficulty breathing.[4] Diagnostic
tools include x-rays and examination of the sputum. Vaccines to prevent certain types of
pneumonia are available. Treatment depends on the underlying cause. Presumed bacterial
pneumonia is treated with antibiotics.
Although pneumonia was regarded by William Osler in the 19th century as "the captain of the
men of death", the advent of antibiotic therapy and vaccines in the 20th century have seen
radical improvements in survival outcomes. Nevertheless, in the third world, and among the
very old, the very young and the chronically ill, pneumonia remains a leading cause of death.
[5]

Contents

1 Classification

2 Signs and symptoms

3 Cause
o 3.1 Bacteria
o 3.2 Viruses
o 3.3 Fungi
o 3.4 Parasites
o 3.5 Idiopathic

4 Pathophysiology
o 4.1 Viral
o 4.2 Bacterial

5 Diagnosis
o 5.1 Imaging
o 5.2 Microbiology
o 5.3 Differential diagnosis

6 Prevention
o 6.1 Vaccination
o 6.2 Environmental
o 6.3 Other

7 Management
o 7.1 Bacterial
o 7.2 Viral
o 7.3 Aspiration

8 Prognosis
o 8.1 Clinical prediction rules
o 8.2 Pleural effusion, empyema, and abscess
o 8.3 Respiratory and circulatory failure

9 Epidemiology
o 9.1 Children

10 History

11 Society and culture

12 References

13 External links

Classification
Main article: Classification of pneumonia
Pneumonitis refers to lung inflammation; pneumonia refers to pneumonitis, usually due to
infection but sometimes non infectious, that has the additional feature of pulmonary
consolidation.[6] Pneumonia can be classified in several ways. It is most commonly classified
by where or how it was acquired (community-acquired, aspiration, healthcare-associated,
hospital-acquired, and ventilator-associated pneumonia),[7] but may also be classified by the
area of lung affected (lobar pneumonia, bronchial pneumonia and acute interstitial
pneumonia),[7] or by the causative organism.[8] Pneumonia in children may additionally be
classified based on signs and symptoms as non-severe, severe, or very severe.[9]

Signs and symptoms

Main symptoms of infectious pneumonia

People with infectious pneumonia often have a productive cough, fever accompanied by
shaking chills, shortness of breath, sharp or stabbing chest pain during deep breaths,
confusion, and an increased respiratory rate.[10] In the elderly, confusion may be the most
prominent symptom.[10] The typical symptoms in children under five are fever, cough, and
fast or difficult breathing.[11] Fever, however, is not very specific, as it occurs in many other
common illnesses, and may be absent in those with severe disease or malnutrition. In
addition, a cough is frequently absent in children less than 2 months old.[11] More severe
symptoms may include: central cyanosis, decreased thirst, convulsions, persistent vomiting,
Symptoms frequency in pneumonia[12]
Symptom
Frequency
Cough
7991%
Fatigue
90%
Fever
7175%
Shortness of breath
6775%
Sputum
6065%
Chest pain
3949%
[11]
or a decreased level of consciousness.
Some causes of pneumonia are associated with classic, but non-specific, clinical
characteristics. Pneumonia caused by Legionella may occur with abdominal pain, diarrhea, or
confusion,[13] while pneumonia caused by Streptococcus pneumoniae is associated with rusty
colored sputum,[14] and pneumonia caused by Klebsiella may have bloody sputum often
described as "currant jelly".[12]
Physical examination may sometimes reveal low blood pressure, a high heart rate, or a low
oxygen saturation. Examination of the chest may be normal, but may show decreased chest
expansion on the affected side. Harsh breath sounds from the larger airways that are
transmitted through the inflamed lung are termed bronchial breathing, and are heard on
auscultation with a stethoscope. Rales (or crackles) may be heard over the affected area
during inspiration. Percussion may be dulled over the affected lung, and increased, rather
than decreased, vocal resonance distinguishes pneumonia from a pleural effusion.[10]
Struggling to breathe, confusion, and blue-tinged skin are signs of a medical emergency.

Cause

Pneumonia is due primarily to infections, with less common causes including irritants and the
unknown. Although more than one hundred strains of microorganisms can cause pneumonia,
only a few are responsible for most cases. The most common types of infectious agents are
viruses and bacteria, with its being less commonly due to fungi or parasites. Mixed infections
with both viruses and bacteria may occur in up to 45% of infections in children and 15% of
infections in adults.[15] A causative agent is not isolated in approximately half of cases despite
careful testing.[16] The term pneumonia is sometimes more broadly applied to inflammation of
the lung (for example caused by autoimmune disease, chemical burns or drug reactions),
however this is more accurately referred to as pneumonitis.[17][18]

Bacteria
Main article: Bacterial pneumonia

The bacterium Streptococcus pneumoniae, a common cause of pneumonia, imaged by an

electron microscope
Bacteria are the most common cause of community acquired pneumonia, with Streptococcus
pneumoniae isolated in nearly 50% of cases.[7][19] Other commonly isolated bacteria include:
Haemophilus influenzae in 20%, Chlamydophila pneumoniae in 13%, Mycoplasma
pneumoniae in 3%,[7] Staphylococcus aureus, Moraxella catarrhalis, Legionella pneumophila
and gram-negative bacilli.[16]
Risk factors for infection depend on the organism involved.[16] Alcoholism is associated with
Streptococcus pneumoniae, anaerobic organisms, and Mycobacterium tuberculosis, smoking
is associated with Streptococcus pneumoniae, Haemophilus influenzae, Moraxella
catarrhalis, and Legionella pneumophila, exposure to bird with Chlamydia psittaci, farm
animals with Coxiella burnetti, aspiration of stomach contents with anaerobes, and cystic
fibrosis with Pseudomonas aeruginosa and Staphylococcus aureus.[16] Streptococcus
pneumoniae is more common in the winter.[16]

Viruses
Main article: Viral pneumonia
In adults, viruses account for approximately a third of pneumonia cases.[15] Commonly
implicated agents include: rhinoviruses,[15]coronaviruses,[15] influenza virus,[20] respiratory
syncytial virus (RSV),[20] adenovirus,[20] and parainfluenza.[20] Herpes simplex virus is a rare
cause of pneumonia, except in newborns. People with weakened immune systems are at
increased risk of pneumonia caused by cytomegalovirus (CMV).

Fungi
Main article: Fungal pneumonia
Fungal pneumonia is uncommon,[16] but it may occur in individuals with weakened immune
systems due to AIDS, immunosuppressive drugs, or other medical problems. The
pathophysiology of pneumonia caused by fungi is similar to that of bacterial pneumonia.
Fungal pneumonia is most often caused by Histoplasma capsulatum, blastomyces,
Cryptococcus neoformans, Pneumocystis jiroveci, and Coccidioides immitis. Histoplasmosis
is most common in the Mississippi River basin, and coccidioidomycosis is most common in
the southwestern United States.[16]

Parasites
Main article: Parasitic pneumonia
A variety of parasites can affect the lungs. These parasites typically enter the body through
the skin or the mouth. Once inside the body, they travel to the lungs, usually through the
blood. In parasitic pneumonia, as with other kinds of pneumonia, a combination of cellular
destruction and immune response causes disruption of oxygen transportation. One type of
white blood cell, the eosinophil, responds vigorously to parasite infection. Eosinophils in the
lungs can lead to eosinophilic pneumonia, thus complicating the underlying parasitic
pneumonia. The most common parasites causing pneumonia are Toxoplasma gondii,
Strongyloides stercoralis, and Ascariasis.

Idiopathic
Main article: Idiopathic interstitial pneumonia
Idiopathic interstitial pneumonia or noninfectious pneumonia[21] are a class of diffuse lung
diseases. They include: diffuse alveolar damage, organizing pneumonia, nonspecific
interstitial pneumonia, lymphocytic interstitial pneumonia, desquamative interstitial
pneumonia, respiratory bronchiolitis interstitial lung disease, and usual interstitial pneumonia.
[22]

Pathophysiology

Pneumonia fills the lung's alveoli with fluid, hindering oxygenation. The alveolus on the left
is normal, whereas the one on the right is full of fluid from pneumonia.
Pneumonia frequently starts as an upper respiratory tract infection that moves into the lower
respiratory tract.[23]

Viral
Viruses invade cells in order to reproduce. Typically, a virus reaches the lungs when airborne
droplets are inhaled through the mouth or nose. Once in the lungs, the virus invades the cells
lining the airways and alveoli. This invasion often leads to cell death, either from damage to
the cell by the virus or from a protective process called apoptosis in which the infected cell
destroys itself before it can be used as a conduit for virus reproduction. When the immune
system responds to the viral infection, even more lung damage occurs. White blood cells,
mainly lymphocytes, activate certain chemical cytokines that allow fluid to leak into the
alveoli. This combination of cell destruction and fluid-filled alveoli interrupts the normal
transportation of oxygen into the bloodstream.
As well as damaging the lungs, many viruses affect other organs and thus disrupt many body
functions. Viruses can also make the body more susceptible to other bacterial infections; in
this way bacterial pneumonia can arise as a co-morbid condition.[20]

Bacterial
Bacteria typically enter the lung when airborne droplets are inhaled, but can also reach the
lung through the bloodstream when there is an infection in another part of the body. Many
bacteria live in parts of the upper respiratory tract, such as the nose, mouth, and sinuses, and
can easily be inhaled into the alveoli. Once inside, bacteria may invade the spaces between
cells and between alveoli through connecting pores. This invasion triggers the immune
system to send neutrophils, a type of defensive white blood cell, to the lungs. The neutrophils
engulf and kill the offending organisms, and also release cytokines, causing a general
activation of the immune system. This leads to the fever, chills, and fatigue common in
bacterial and fungal pneumonia. The neutrophils, bacteria, and fluid from surrounding blood
vessels fill the alveoli and interrupt normal oxygen transportation.

Diagnosis
Crackles
Crackles heard in the lungs of a person with pneumonia using a stethoscope.
Problems listening to this file? See media help.

Pneumonia is typically diagnosed based on a combination of physical signs and a chest Xray.[24] Confirming the underlying cause can be difficult, however, with no definitive test able
to distinguish between bacterial and not-bacterial origin.[15][24] The World Health Organization
has defined pneumonia in children clinically based on either a cough or difficulty breathing
and a rapid respiratory rate, chest indrawing, or a decreased level of consciousness.[25] A rapid
respiratory rate is defined as greater than 60 breaths per minute in children under 2 months
old, 50 breaths per minute in children two months to one year old, or greater than 40 breaths
per minute in children one to five years old.[25] In children, an increased respiratory rate and
lower chest indrawing are more sensitive than hearing chest crackles with a stethoscope.[11]
In adults, investigations are in general not needed in mild cases[26] as if all vital signs and
auscultation are normal the risk of pneumonia is very low.[27] In those requiring admission to
a hospital, pulse oximetry, chest radiography, and blood tests including a complete blood
count, serum electrolytes, C-reactive protein, and possibly liver function tests are
recommended.[26] The diagnosis of influenza-like illness can be made based on the presenting
signs and symptoms however verification of an influenza infection requires testing.[28] Thus
treatment is frequently based on the presence of influenza in the community or a rapid
influenza test.[28]

Imaging

CT of the chest demonstrating right sided pneumonia (left side of the image).
A chest radiograph is frequently used in diagnosis.[11] In people with mild disease, imaging is
needed only in those with potential complications, those who have not improved with
treatment, or those in which the cause in uncertain.[11][26] If a person is sufficiently sick to
require hospitalization, a chest radiograph is recommended.[26] Findings do not always
correlate with severity of disease and do not reliably distinguish between bacterial infection
and viral infection.[11]
X-ray signs of bacterial community acquired pneumonia classically show lung consolidation
of one lung segmental lobe.[7] However, radiographic findings may be variable, especially in
other types of pneumonia.[7] Aspiration pneumonia may present with bilateral opacities

primarily in the bases of the lungs and on the right side.[7] Radiographs of viral pneumonia
cases may appear normal, hyper-inflated, have bilateral patchy areas, or present similar to
bacterial pneumonia with lobar consolidation.[7] A CT scan can give additional information in
indeterminate cases.[7]
Radiologic findings often lag behind clinical findings, especially in the presence of
dehydration, thus many clinicians make a diagnosis of "clinical pneumonia" on the basis of
history and crackles on examination.[29] This lag is more often remarked in Pneumocystis
carinii pneumonia, where chest radiograph findings may be normal in 10-39% of patients.[30]

Microbiology
For people managed in the community figuring out the causative agent is not cost effective,
and typically does not alter management.[11] For those not responsive to treatment, sputum
culture should be considered, and culture for Mycobacterium tuberculosis should be carried
out in those with a chronic productive cough.[26] Testing for other specific organisms may be
recommended during outbreaks, for public health reasons.[26] In those who are hospitalized
for severe disease both sputum and blood cultures are recommended.[26] Viral infections can
be confirmed via detection of either the virus or its antigens with culture or polymerase chain
reaction (PCR) among other techniques.[15] With routine microbiological testing a causative
agent is determined in only 15% of cases.[10]

Differential diagnosis
Several diseases can present similar to pneumonia, including: chronic obstructive pulmonary
disease (COPD), asthma, pulmonary edema, bronchiectasis, lung cancer, and pulmonary
emboli.[10] Unlike pneumonia, asthma and COPD typically present with wheezing, pulmonary
edema presents with an abnormal electrocardiogram, cancer and bronchiectasis present with a
cough of longer duration, and pulmonary emboli presents with acute onset sharp chest pain
and shortness of breath.[10]

Prevention
Prevention includes vaccination, environmental measures, and appropriately treating other
diseases.[11]

Vaccination
Vaccination is effective for preventing certain bacterial and viral pneumonias in both children
and adults.
Influenza vaccines are modestly effective against influenza A and B.[15][31] The Center for
Disease Control and Prevention (CDC) recommends that everyone 6 months and older get
yearly vaccination.[32] When an influenza outbreak is occurring, medications such as
amantadine, rimantadine, zanamivir, and oseltamivir can help prevent influenza.[33][34]
Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae have good
evidence to support their use.[23] Vaccinating children against Streptococcus pneumoniae has
also led to a decreased incidence of these infections in adults, because many adults acquire

infections from children. A vaccine against Streptococcus pneumoniae is also available for
adults, and has been found to decrease the risk of invasive pneumococcal disease.[35]

Environmental
Reducing indoor air pollution is recommended[11] as is smoking cessation.[26]

Other
Appropriately treating underlying illnesses (such as AIDS) can decrease a person's risk of
pneumonia.
There are several ways to prevent pneumonia in newborn infants. Testing pregnant women
for Group B Streptococcus and Chlamydia trachomatis, and giving antibiotic treatment, if
needed, reduces pneumonia in infants. Suctioning the mouth and throat of infants with
meconium-stained amniotic fluid decreases the rate of aspiration pneumonia.

Management
Typically, oral antibiotics, rest, simple analgesics, and fluids suffice for complete resolution.
[26]
However, those with other medical conditions, the elderly, or those with significant trouble
CURB-65
Symptom
Points
Confusion
1
Urea>7 mmol/l
1
Respiratory rate>30
1
SBP<90mmHg, DBP<60mmHg
1
Age>=65
1
breathing may require more advanced care. If the symptoms worsen, the pneumonia does not
improve with home treatment, or complications occur, hospitalization may be required.[26]
Worldwide, approximately 713% of cases in children result in hospitalization[11] while in the
developed world between 22 and 42% of adults with community-acquired pneumonia are
admitted.[26] The CURB-65 score is useful for determining the need for admission in adults.[26]
If the score is 0 or 1 people can typically be managed at home, if it is 2 a short hospital stay
or close follow up is needed, if it is 35 hospitalization is recommended.[26] In children those
with respiratory distress or oxygen saturations of less than 90% should be hospitalized.[36] The
utility of chest physiotherapy in pneumonia has not yet been determined.[37] Over-the-counter
cough medicine has not been found to be effective.[38]

Bacterial
Antibiotics improve outcomes in those with bacterial pneumonia.[39] Antibiotic choice
depends initially on the characteristics of the person affected, such as age, underlying health,
and the location the infection was acquired. In the UK, empiric treatment with amoxicillin is
recommended as the first line for community-acquired pneumonia, with doxycycline or
clarithromycin as alternatives.[26] In North America, where the "atypical" forms of
community-acquired pneumonia are more common, macrolides (such as azithromycin), and
doxycycline have displaced amoxicillin as first-line outpatient treatment in adults.[19][40] In

children with mild or moderate symptoms amoxicillin remains the first line.[36] The use of
fluoroquinolones in uncomplicated cases is discouraged due to concerns about side effects
and resistance.[19] The duration of treatment has traditionally been seven to ten days, but
increasing evidence suggests that short courses (three to five days) are similarly effective.[41]
Antibiotics recommended for hospital-acquired pneumonia include third- and fourthgeneration cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, and
vancomycin.[42] These antibiotics, often given intravenously, may be used in combination.

Viral
Neuraminidase inhibitors may be used to treat viral pneumonia caused by influenza viruses
(influenza A and influenza B).[15] No specific antiviral medications are recommended for
other types of community acquired viral pneumonias including SARS coronavirus,
adenovirus, hantavirus, and parainfluenza virus.[15] Influenza A may be treated with
rimantadine or amantadine, while influenza A or B may be treated with oseltamivir,
zanamivir or peramivir.[15] These are of most benefit if they are started within 48 hours of the
onset of symptoms.[15] Many strains of H5N1 influenza A, also known as avian influenza or
"bird flu," have shown resistance to rimantadine and amantadine.[15] The use of antibiotics in
viral pneumonia is recommended by some experts as it is impossible to rule out a
complicating bacterial infection.[15] The British Thoracic Society recommends that antibiotics
be withheld in those with mild disease.[15] The use of corticosteroids is controversial.[15]

Aspiration
In general, aspiration pneumonitis is treated conservatively with antibiotics indicated only for
aspiration pneumonia.[43] The choice of antibiotic will depend on several factors, including the
suspected causative organism and whether pneumonia was acquired in the community or
developed in a hospital setting. Common options include clindamycin, a combination of a
beta-lactam antibiotic and metronidazole, or an aminoglycoside.[44] Corticosteroids are
commonly used in aspiration pneumonia, but there is no evidence to support their
effectiveness.[44]

Prognosis
With treatment, most types of bacterial pneumonia can be cleared within two to four weeks[45]
and mortality is very low.[15] Viral pneumonia may last longer, and mycoplasmal pneumonia
may take four to six weeks to resolve completely.[45] The eventual outcome of an episode of
pneumonia depends on how ill the person is when he or she was first diagnosed.[45] Before the
advent of antibiotics mortality was typically 30% for hospitalized patients.[16]
In the United States, about 5% of those diagnosed with pneumococcal pneumonia will die. In
cases where the pneumonia progresses to blood infection, just over 20% will die.[46]
The death rate (or mortality) also depends on the underlying cause of the pneumonia.
Pneumonia caused by Mycoplasma, for instance, is associated with lower mortality. However,
about half of the people who develop methicillin-resistant Staphylococcus aureus (MRSA)
pneumonia while on a ventilator will die.[47] In regions of the world without advanced health
care systems, pneumonia is even more deadly. Limited access to clinics and hospitals, limited
access to x-rays, limited antibiotic choices, and inability to diagnose and treat underlying

conditions inevitably lead to higher rates of death from pneumonia. For these reasons, the
majority of deaths in children under five due to pneumococcal disease occur in developing
countries.[48]
Adenovirus can cause severe necrotizing pneumonia in which all or part of a lung has
increased translucency radiographically, which is called Swyer-James Syndrome.[49] Severe
adenovirus pneumonia also may result in bronchiolitis obliterans, a subacute inflammatory
process in which the small airways are replaced by scar tissue, resulting in a reduction in lung
volume and lung compliance.[49] Sometimes pneumonia can lead to additional complications.
Complications are more frequently associated with bacterial pneumonia than with viral
pneumonia. The most important complications include respiratory and circulatory failure and
pleural effusions, empyema or abscesses.

Clinical prediction rules

Clinical prediction rules have been developed to more objectively prognosticate outcomes in
pneumonia. Although these rules are often used in deciding whether or not to hospitalize the
person, they were derived simply to inform on prognosis; neither index was designed or
tested as guide to determine whether the person would benefit by hospital admission.

Pneumonia severity index (or PORT Score)[50] online calculator

CURB-65 score, which takes into account the severity of symptoms, any underlying
diseases, and age[51] online calculator

Pleural effusion, empyema, and abscess

A pleural effusion as seen on chest x-ray. The A arrow indicates fluid layering in the right
chest. The B arrow indicates the width of the right lung. The volume of the lung is reduced
because of the collection of fluid around the lung.
In pneumonia, a collection of fluid (pleural effusion) often forms in the space that surrounds
the lung (the pleural cavity). Occasionally, microorganisms will infect this fluid, causing what
is called an empyema. To distinguish an empyema from the more common simple
parapneumonic effusion, the fluid is collected with a needle (thoracentesis), and examined. If
this shows evidence of empyema, complete drainage of the fluid may be necessary, often
requiring a chest tube. In severe cases of empyema, surgery may be needed. If the infected
fluid is not drained, the infection may persist, because antibiotics do not penetrate well into

the pleural cavity. If the fluid is sterile, it need be drained only if it is causing symptoms or
remains unresolved.
Rarely, bacteria in the lung will form a pocket of infected fluid called a lung abscess. Lung
abscesses can usually be seen with a chest X-ray or chest CT scan. Abscesses typically occur
in aspiration pneumonia, and often contain several types of bacteria. Antibiotics are usually
adequate to treat a lung abscess, but sometimes the abscess must be drained by a surgeon or
radiologist.

Respiratory and circulatory failure

Because pneumonia affects the lungs, people with pneumonia often have difficulty breathing,
sometimes to the point where mechanical assistance is required. Non-invasive breathing
assistance may be helpful, such as with a bi-level positive airway pressure machine. In other
cases, placement of an endotracheal tube (breathing tube) may be necessary, and a ventilator
may be used to help the person breathe.
Pneumonia can also cause respiratory failure by triggering acute respiratory distress
syndrome (ARDS), which results from a combination of infection and inflammatory
response. The lungs quickly fill with fluid and become very stiff. This stiffness, combined
with severe difficulties extracting oxygen due to the alveolar fluid, creates a need for
mechanical ventilation.
Sepsis and septic shock are potential complications of pneumonia. Sepsis occurs when
microorganisms enter the bloodstream and the immune system responds by secreting
cytokines. Sepsis most often occurs with bacterial pneumonia; Streptococcus pneumoniae is
the most common cause. Individuals with sepsis or septic shock need hospitalization in an
intensive care unit. They often require intravenous fluids and medications to help keep their
blood pressure up. Sepsis can cause liver, kidney, and heart damage, among other problems,
and it is often fatal.

Epidemiology
Main article: Epidemiology of pneumonia

Age-standardized death from lower respiratory tract infections per 100,000 inhabitants in
2004.[52]
no data
3500-4200
<100
4200-4900
100-700
4900-5600
700-1400
5600-6300
1400-2100
6300-7000
2100-2800
>7000
2800-3500

Pneumonia is a common illness affecting approximately 450 million people a year and
occurring in all parts of the world.[15] It is a major cause of death among all age groups
resulting in 4 million deaths (7% of the world's yearly total).[15][39] Rates are greatest in
children less than five, and adults older than 75 years of age.[15] It occurs about five times
more frequently in the developing world versus the developed world.[15] Viral pneumonia
accounts for about 200 million cases.[15]

Children
In 2008 pneumonia occurred in approximately 156 million children (151 million in the
developing world and 5 million in the developed world).[15] It resulted in 1.6 million deaths,
or 2834% of all deaths in those under five years of age, of which 95% occurred in the
developing world.[11][15] Countries with the greatest burden of disease include: India
(43 million), China (21 million) and Pakistan (10 million).[53] It is the leading cause of death
among children in low income countries.[15][39] Many of these deaths occur in the newborn
period. The World Health Organization estimates that one in three newborn infant deaths are
due to pneumonia.[54] Approximately half of these deaths are theoretically preventable, as they
are caused by the bacteria for which an effective vaccine is available.[55]

History

WPA poster, 1936/1937

Pneumonia has been a common disease throughout human history.[56] The symptoms were
described by Hippocrates (c. 460 BC 370 BC):[56] "Peripneumonia, and pleuritic affections,
are to be thus observed: If the fever be acute, and if there be pains on either side, or in both,
and if expiration be if cough be present, and the sputa expectorated be of a blond or livid
color, or likewise thin, frothy, and florid, or having any other character different from the
common... When pneumonia is at its height, the case is beyond remedy if he is not purged,
and it is bad if he has dyspnoea, and urine that is thin and acrid, and if sweats come out about

the neck and head, for such sweats are bad, as proceeding from the suffocation, rales, and the
violence of the disease which is obtaining the upper hand."[57] However, Hippocrates referred
to pneumonia as a disease "named by the ancients." He also reported the results of surgical
drainage of empyemas. Maimonides (11351204 AD) observed "The basic symptoms that
occur in pneumonia and that are never lacking are as follows: acute fever, sticking pleuritic
pain in the side, short rapid breaths, serrated pulse and cough."[58] This clinical description is
quite similar to those found in modern textbooks, and it reflected the extent of medical
knowledge through the Middle Ages into the 19th century.
Bacteria were first seen in the airways of individuals who died from pneumonia by Edwin
Klebs in 1875.[59] Initial work identifying the two common bacterial causes Streptococcus
pneumoniae and Klebsiella pneumoniae was performed by Carl Friedlnder[60] and Albert
Frnkel[61] in 1882 and 1884, respectively. Friedlnder's initial work introduced the Gram
stain, a fundamental laboratory test still used today to identify and categorize bacteria.
Christian Gram's paper describing the procedure in 1884 helped differentiate the two different
bacteria, and showed that pneumonia could be caused by more than one microorganism.[62]
Sir William Osler, known as "the father of modern medicine," appreciated the death and
disability cause by pneumonia, describing it as the "captain of the men of death" in 1918, as it
had overtaken tuberculosis as one of the leading causes of death in this time. This phrase was
originally coined by John Bunyan in reference to "consumption" (tuberculosis).[63][64] Osler
also described pneumonia as "the old man's friend" as death was often quick and painless
when there were many slower more painful ways to die.[16]
Several developments in the 1900s improved the outcome for those with pneumonia. With the
advent of penicillin and other antibiotics, modern surgical techniques, and intensive care in
the twentieth century, mortality from pneumonia, which had approached 30%, dropped
precipitously in the developed world. Vaccination of infants against Haemophilus influenzae
type B began in 1988 and led to a dramatic decline in cases shortly thereafter.[65] Vaccination
against Streptococcus pneumoniae in adults began in 1977, and in children in 2000, resulting
in a similar decline.[66]

Society and culture

See also: List of notable pneumonia cases
Because of the combination of a very high burden of disease in developing countries and a
relatively low awareness of the disease in industrialized countries, the global health
community has declared November 12 to be World Pneumonia Day, a day for concerned
citizens and policy makers to take action against the disease.[67]

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External links