Pneumonia pathophysiology

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Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Philip Marcus, M.D., M.P.H.[2]

Overview

The symptoms of infectious pneumonia are caused by the invasion of the lungs by microorganisms and by the immune system's response to the infection. Although more than one hundred strains of microorganism can cause pneumonia, only a few are responsible for most cases. The most common causes of pneumonia are viruses and bacteria. Less common causes of infectious pneumonia are fungi and parasites. The detailed pathophysiology regarding each of these etiologic organisms has been detailed under the respective chapters. The symptoms of CAP are the result of both the invasion of the lungs by microorganisms and the immune system's response to the infection. The mechanisms of infection are quite different for viruses and the other microorganisms.

Pathophysiology

Microscopic Pathology

Viruses

• Viruses must invade cells in order to reproduce.
• Typically, a virus will reach the lungs by traveling in droplets through the mouth and nose with inhalation.
• There, the virus invades the cells lining the airways and the alveoli.
• This invasion often leads cell death either through direct killing by the virus or by self-destruction through apoptosis.
• Further damage to the lungs occurs when the immune system responds to the infection. White blood cells, in particular lymphocytes, are responsible for activating a variety of chemicals (cytokines) which cause leaking of fluid into the alveoli.
• The combination of cellular destruction and fluid-filled alveoli interrupts the transportation of oxygen into the bloodstream.
• In addition to the effects on the lungs, many viruses affect other organs and can lead to illness affecting many different bodily functions.
• Viruses also make the body more susceptible to bacterial infection; for this reason, bacterial pneumonia often complicates viral CAP.

Bacteria and fungi

• Bacteria and fungi also typically enter the lung with inhalation, though they can reach the lung through the bloodstream if other parts of the body are infected.
• Often, bacteria live in parts of the upper respiratory tract and are constantly being inhaled into the alveoli.
• Once inside the alveoli, bacteria and fungi travel into the spaces between the cells and also between adjacent alveoli through connecting pores.
• This invasion triggers the immune system to respond by sending white blood cells responsible for attacking microorganisms (neutrophils) to the lungs. The neutrophils engulf and kill the offending organisms but also release cytokines which result in a general activation of the immune system.
• This results in the fever, chills, and fatigue common in CAP. The neutrophils, bacteria, and fluid leaked from surrounding blood vessels fill the alveoli and result in impaired oxygen transportation.
• Bacteria often travel from the lung into the blood stream and can result in serious illness such as septic shock, in which there is low blood pressure leading to damage in multiple parts of the body including the brain, kidney, and heart.

Parasites

• In general, these parasites enter the body through the skin or by being swallowed.
• Once inside the body, these parasites travel to the lungs, most often through the blood. There, a similar combination of cellular destruction and immune response causes disruption of oxygen transportation.

Aspiration pneumonia pathophysiology

The location is often gravity dependent, and depends on the patient position. Generally the right middle and lower lung lobes are the most common sites of infiltrate formation due to the larger caliber and more vertical orientation of the right mainstem bronchus.

Patients who aspirate while standing can have bilateral lower lung lobe infiltrates. The right upper lobe is a common area of consolidation in alcoholics who aspirate in the prone position. Depending on the acidity of the aspirate, a chemical pneumonitis can develop, and bacterial pathogens (particularly anaerobic bacteria) may add to the inflammation.

Histopathological Findings in Aspiration Pneumonia

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Histopathological Findings

Lobar pneumonia

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Pneumocystis pneumonia

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Aspiration Pneumonia

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Aspiration pneumonia, infant

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Desquamative interstitial pneumonia

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Legionella pneumonia

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Measles pneumonia

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Abscess, bronchopneumonia

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