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Key Concepts

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  • The etiology and clinical manifestations of pneumonia depend on the environment where the disease is acquired and the host characteristics.

  • Treatment of pneumonia is based on an assessment of place of therapy (outpatient, hospital ward, or ICU), the presence of coexisting cardiopulmonary diseases, and the presence of modifying factors.

  • Although prompt initiation of antibiotics is critical in patients with nosocomial pneumonia, all patients with suspected pneumonia should have a sampling done of lower respiratory tract secretions to better guide the therapy.

  • Lung abscess should be managed initially with appropriate medical therapy and/or percutaneous drainage.

  • Owing to the presence of branching hyphae, infections due to actinomycosis and nocardiosis may be mistaken for fungal infections. It is important to make the distinction because actinomycotic infections do not respond to antifungal therapy but rather to antibiotics.

  • Surgical consultation is regularly requested for the diagnosis and treatment of pulmonary complications of the endemic mycoses: Histoplasma capsulatum, Blastomyces dermatitidis and Coccidioidomycosis immitis, and the yeast Cryptococcus neoformans. All resemble pulmonary malignancies.

  • Histoplasmosis causes pericarditis, mediastinal fibrosis, and mediastinal granuloma, which can cause entrapment of vascular structures, the esophagus, and the trachea.

  • Coccidioidomycosis can cause both spontaneous pneumothorax associated with effusion and thin-walled cavities that can become superinfected with tuberculosis and aspergillosis.

  • Cryptococcosis can result in organ damage from tissue distortion secondary to an expanding fungal burden.

  • Most patients with pulmonary aspergillosis have either impaired immunity or underlying preexisting chronic lung disease. Aspergillomas may develop in preexisting cavities. Surgery is indicated for complications of the disease, such as massive hemoptysis.

  • Surgery has largely been supplanted by multiple-regimen medical therapy for tuberculous and nontuberculous mycobacterial infections. There is still a role for pulmonary resection in multidrug-resistant infection, cavitary lesions, and lung destruction.

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Pneumonia and Lung Abscess

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Lower respiratory tract infections are important in the practice of the thoracic surgeon because their complications may require surgical intervention and they may complicate thoracic surgical procedures.

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Pneumonia

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Pneumonia is an infection of the lower respiratory tract that involves the terminal airways: respiratory bronchioles, alveolar ducts, and alveoli. The infection develops when the sterility of the tracheobronchial tree is breached by the introduction of a virulent pathogen or a defect in the host immunologic defense. Symptoms of acute lower respiratory infection may include fever or hypothermia, rigors, sweats, new cough with or without sputum production or change in color of respiratory secretions in a patient with chronic cough, chest discomfort, or shortness of breath. Most patients also have nonspecific symptoms, such as fatigue, myalgias, abdominal pain, anorexia, and headache.

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Despite advancements in the diagnosis and treatment of pneumonia in the past century, it is listed by the Centers for Disease Control and Prevention as the sixth leading cause of death in the United States and the leading cause of death from infectious diseases.1 Contemporary management of pneumonia is based on whether the infection was ...

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