Consolidated lung

Characteristics
Infectious or non-infectious causes.
Infectious:
Incidence is increasing – due to an ageing population and the
increased prevalence of immunosuppression.
Community acquired – Streptococcus (>60%), Haemophilus, Mycoplasma,
Legionella and Chlamydia. Generally low mortality unless admission
required.
Hospital acquired – increasing Gram-negative infection. Higher
mortality rate than community-acquired pneumonias. Co-morbid
factors are important.
Pneumonia should always be considered in the elderly, the immunocompromised
and in pyrexia of unknown origin (PUO).
The prevalence of TB is increasing. Suspect it!
Non-infectious
Bronchoalveolar carcinoma.
Lymphoma.
Inflammatory conditions (Wegener’s granulomatosis).
Cryptogenic organising pneumonia.
Cardiac failure.
Sarcoid.
Always repeat imaging in cases of consolidation at an interval period
to confirm resolution. Failure to resolve should alert the clinician to a
non-infectious cause.
Clinical features
Productive cough, dyspnoea, pleuritic chest pain, myalgia and haemoptysis
may occur.
In the immunosuppressed patient, Pneumocystis may present with profound
hypoxia and little else on examination.
The young patient may present with vague symptoms such as headache,
abdominal pain or even diarrhoea. Confusion may be the only
sign in the elderly.
Examination may reveal coarse inspiratory crepitations. Bronchial
breathing with a dull percussion note is present in less than 25%.
Poor prognostic signs include – age>60, respiratory rate>30, profound
hypotension, acute confusion, urea>7 mmol/l and a markedly
low or raised white cell count.
Radiological features
May lag behind clinical onset and remain after resolution!
CXR
Lobar pneumonia – opacification of a lobe; usually Streptococcus.
Air bronchograms may be present.
Primary TB – right paratracheal (40%) and right hilar adenopathy
(60%) with consolidation in the mid or lower zones.
Post primary TB – ill-defined consolidation in the apical segments
which may cavitate.
Right middle and lower lobe pneumonia – loss of the outline
of the right heart border and the right hemidiaphragm silhouette
respectively.
Lingular segment pneumonia – loss of the outline of the left heart
border.
Left lower lobe consolidation – typically obliterates an arc of left
hemidiaphragm. Look ‘through the heart’ for loss of diaphragmatic
outline.
FOLLOW-UP IMAGING IN ADULTS ESSENTIAL.
FAILURE TO RESPOND TO ANTIBIOTICS MAY MEAN ANOTHER
DIAGNOSIS SHOULD BE CONSIDERED.
Differential diagnosis
Bronchoalveolar carcinoma.
Lymphoma.
Inflammatory conditions (Wegener’s granulomatosis).
Cryptogenic organising pneumonia.
Cardiac failure.
Sarcoid.
Management
Most patients can be discharged with appropriate oral antibiotics.
Give advice regarding deep breathing and coughing.
A NSAID may be of benefit in patients with pleuritic pain to enable
deep breathing and coughing.
Treat the unwell patient with high flow oxygen (remember the patient
with COPD is often dependent on their hypoxic drive to stimulate
respiration), IV fluids, IV antibiotics analgesia.
Follow-up imaging in adults.