the study of epidemiological characteristics, clinical manifestations of atypical pneumonia caused by bacteria in children

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH THE NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY PHAM THU HIEN THE STUDY OF EPIDEMIOLOGICAL CHARACTERISTICS, CLINICAL MANIFES

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH

THE NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY

PHAM THU HIEN

THE STUDY OF EPIDEMIOLOGICAL

CHARACTERISTICS, CLINICAL MANIFESTATIONS

OF ATYPICAL PNEUMONIA CAUSED BY BACTERIA

IN CHILDREN

Science: Epidemiology Code: 62 72 01 17

SUMMARY OF THE DOCTORAL DISSERTATION

HA NOI - 2014

2 The project was completed at the National Institute of Hygiene and Epidemiology

The scientific advisors:

Reviewer 1:

Reviewer 2:

Reviewer 3:

The dissertation will be defended at the meeting hall of the National Institute of Hygiene and Epidemiology

In… hours, …/… / 20…

The dissertation is available at:

1 The National Library

2 The National Institute of Hygiene and Epidemiology

LIST OF THE PUBLICATIONS BY THE

AUTHORS RELATED TO THE DISSERTATION

1 Pham Thu Hien, Dao Minh Tuan, Nguyen Phong Lan,

Phan Le Thanh Huong (2011), "The role of Mycoplasma

pneumoniae, Chlamydia pneumoniae, and Legionella

pneumophyla in community -acquired pneumonia in children:

preliminary results", Journal Journal preventive Medicine,

Vol XXI, No 7 ( 125 ), pp 62-69

2 Pham Thu Hien, Dao Minh Tuan, Nguyen Phong Lan,

Phan Le Thanh Huong( 2012 ) , " Causes, clinical features ,

clinical manifestations of atypical pneumonia in children " ,

Journal of Medical Research , episode 80 , No 3 A , pp

119-124

3 Pham Thu Hien, Dao Minh Tuan, Nguyen Phong Lan,

Phan Le Thanh Huong (2012), "Frequency , clinical

characteristics , subclinical pneumonia caused by

Mycoplasma pneumoniae, Chlamydia pneumoniae in

children ", Journal Journal preventive Medicine, Vol XXII,

No 6 (133), tr 31 - 38

4

LIST OF ABBREVIATIONS

C pneumoniae Chlamydia pneumoniae Chlamydia pneumoniae

ELISA enzyme-linked

immunosorbent assay

Kỹ thuật miễn dịch gắn men

IL Interleukin Interleukin INF Tumor necrosis factor Yếu tố hoại tử u

L pneumophila Legionella pneumophila Legionella pneumophila

M pneumoniae Mycoplasma pneumoniae Mycoplasma

pneumoniae

organisms

Pleuropneumonia like organisms

Real – time PCR Real –time polymerase

chain reaction

Phản ứng Real – time PCR

S pneumoniae Streptoccocus pneumoniae Streptoccocus

pneumoniae

VPKĐH (AP) Atypical pneumonia Viêm phổi không điển

hình

ABSTRACT OF THE DISSERTATION

1.Background

Atypical pneumonia is frequent in developing countries.However,

the studies about these conditions in developing countries, including

Vietnam are limited Forest (2007) reported that the incidence of

atypical pneumonia in the community-acquired pneumonia was 22 % in

the United States and 91% of those had been treated In Europe, the

incidence of atypical pneumonia was 28%, the rate of treatment was

74% In Latin America, the incidence of atypical pneumonia was 21%

and the rate of treatment was 57% In Asia / Africa, the incidence was

20%, the rate of treatment was 10%

The diagnostic methods for atypical pneumonia include: bacterial

culture in the special media, serology, and polymerase chain reaction

method Polymerase chain reaction method (PCR) has helped confirmed

and rapid diagnosis bacterial pathogens In Vietnam, PCR techniques are

available in only few hospitals in central and major medical centers Most

treatments have been done with empirical therapy that may result in

increasing in antibiotic resistant, and prolonged treatment time

Little is known about the epidemiology, clinical and laboratorial

manifestations of atypical pneumonia in children, including the diagnostic

techniques for bacterial causes of atypical pneumonia such as multiple

primers PCR (multiplex-PCR) and enzyme-linked immunosorbent assay

characteristics, clinical manifestations of atypical pneumonia caused by

bacteria in children” The study objectives were:

1 To d escribe the epidemiological characteristics, clinical manifestations

of atypical pneumonia caused by Mycoplasma pneumoniae, Chlamydia

pneumoniae, and Legionella pneumophila in children who were treated

at the National Hospital of Pediatrics in Hanoi, Vietnam from 07/2010

to 3/2012.

2 To identify the factors associated with the severity of atypical

pneumonia in children

6

2 New contribution to the science

- This project was the first study to identify the prevalence of atypical

pneumophila,co-infection rate of pneumonia in hospitalized children

- The study has identified several factors associated with severity of atypical pneumonia Co-infection with bacteria and viruses was the related factors for severe atypical pneumonia

characteristics of atypical pneumonia, atypical pneumonia co-infection

in children

3 Practical value of the subject

characteristics of atypical pneumonia to draw specific symptoms which suggesting early clinical diagnosis, help clinicians quickly optimal decision the choice of antibiotic therapy and have a more comprehensive view of the causes of pneumonia in children

microorganisms which cause respiratory infections in children, and to guide treatment and prevention strategies

- Microbiological diagnostic techniques based on molecular biology (only

in a few specialized laboratories) will be confirmed and efficient which can be replicated in the laboratory of clinical microbiology

4 The structure of the dissertation

The dissertation consists of 128 pages including: Background and objectives: 2 pages; Literature review: 34 pages; Methods: 18 pages; Results: 34 pages; Discussion: 37 pages; Conclusion: 2 pages, and recommendation: 1 page There are 29 tables and 20 figures, 228 references including 22 in Vietnamese, 206 documents in foreign languages

Chapter 1 OVERVIEW 1.1 Introduction

been recognized from the dairy failed to sulfonamides or penicillin used

pneumoniae pneumonia or pneumococcal (pneumococci). The failure

to respond to antimicrobial therapy has been thought as "atypical"

(atypical) This term, along with "Walking around pneumonia" is used

broadly to refer to respiratory disease caused by M pneumoniae in

humans Then other agents cause similar clinical picture was included

pneumophila

1.2 Epidemiological characteristics of atypical pneumonia caused by

Mycoplasma pneumoniae, and Legionella pneumophila

Mycoplasma pneumoniae

Disease appears in all countries, however studies about the disease

mostly have been carried out in the United States, Europe and Japan

In the U.S, infection caused byM pneumoniaeaccounts for 15-20% of

all community-acquired pneumonia.Especially in the summer time, M

Pneumonia can reach up to 50% of all community-acquired pneumonia

During 2010 to 2012, an outbreak of M pneumoniae infection

happened in some Asian countries A multicenter study in Asia in 2005

found that M pneumoniae was an important cause of the community

acquired pneumonia, which accounted for 22.3%

Disease occurs in people of all ages, predominant in the age group

from 5-9 years old

Disease can occur throughout the year, and the peak during the

period from late summer to early fall

The bacteria can live everywhere in nature, transmitted from

person to person via the respiratory tract The average Incubation period

is 3 weeks.After suffering from this disease, an immune survived about

4 years Immunology temporary and recurence

1.3.2 Epidemiology characteristics of Chlamydia pneumoniae

pneumonia

C p neumoniae infection distributes over the world A study

from 10 different regions of the world showed a higher frequency in

tropical populations In the U.S and many other countries, the

sero-prevalence ofC pneumoniaeinfection was of 50% of total population

Estimated number of cases of pneumonia caused byC pneumoniaein

the United States is 300,000 cases per year Globally, prevalence of

pneumonia caused by C pneumoniae from 4337 patients was 8% in

8

North America, 7% in Europe, 6% in Latin America and 5% in Asia Forest (2007)

The disease affects both genders and all age groups Disease occurs throughout the year, and gets its peak during summer time

Infectious reservoir is humans, and it is transmitted through respiratory secretions directly exposed to coughing, sneezing After suffering from this disease, patients have an immune temporarily and recurrent frequently.Disease cycle every 4 - 8 years

1.3.3 Epidemiological characteristics of Legionella pneumophila pneumonia

Legionella disease occurs worldwide The majority of cases

disease been identified in tropical countries In the U.S., about

Legionella infection were 5,907 cases in 2007 and 5,960 cases in 2008

Most patients exposed to L pneumophila but no symptoms The risk increase in an older people Children after ages 4 rare occurs

pneumonia due to L pneumophila.

Legionella live everywhere, special in the aquatic environment, the disease transmitte through tiny droplets of water vapor Disease is not transmitted from person to person Incubation period 2 -10 days Re-infection occurs in immunocompromised people

1.4 The clinical features, laboratory manifestations and treatment

of pneumonia caused by M pneumoniae, C pneumoniae and L.

pneumophila

1.4.1 The clinical features of pneumonia caused by M pneumoniae,

C pneumoniae, L pneumophila

M pneumoniae, C pneumoniaeis causative agents of pneumonia with the various degree of severity Majority of patients appear with mild illness and self-recover.Few patients progress to severe condition, acute respiratory failure and death

The common pulmonary manifestations are: eardrum inflammation, rash, urticaria, pleurisy, thrombocytopenia, meningitis, and mild anemia

The extrapulmonary manifestations are rare: hemolytic anemia, coagulation disorders, thrombosis, pulmonary abscess, pneumothorax, burnout syndrome, pericarditis, myocarditis, Stevens Johnson syndrome,

neurological manifestations: meningitis, encephalitis, mental disorders,

Guillain – Barre syndromes, cerebellar ataxia, the brainstem, like polio

L pneumophila causes two distinct disease entities: pneumonia

and Pontiac fever.Pontiac fever is usually mild, patients may have fever,

may have clinical manifestations including abnormalities in the central

nervous system (headache, mental confusion, encephalopathy, coma),

cardiac abnormalities(relatively slow heart rate), gastrointestinal

manifestations (target diarrhea, abdominal pain), liver damage (liver

enzymes) and kidney(microscopic hematuria, increased creatinine),

electrolyte abnormalities (assuming m and decreased serum sodium

phosphate)

Extrapulmonary manifestations of Legionella can present with the

damage in spleen, liver, kidney, heart, bone and bone marrow, joints,

inguinal lymph nodes, nervous and digestive tract

1.4.2. Laboratory manifestations of pneumonia caused by M.

pneumoniae, C pneumoniae and L pneumophila

Chest X-ray (CXR):

Radiographic manifestations of atypical pneumonia can be

extremely variable and can mimic with a wide variety of lung diseases

The inflammatory response causes interstitial mononuclear cell

inflammation that may be manifested radiographically as diffuse,

reticular infiltrates of bronchopneumonia in the perihilar regions or

lower lobes, usually with a unilateral distribution, and hilar adenopathy

Bilateral involvement may occur in about 20% of cases

Bacteriological tests

- Blood culture: L pneumophila can be isolated from blood

culture with low sensitivity

- Gram stain: L pneumophila start gram paler color when dyed.M.

pneumoniaeresults because bacteria do not have cell walls so they do not

color when dyed

Respiratory secretions culture: by using a special medium (PPLO

pneumoniae;BCYE environment - Buffered Charcoal Yeast Extract Agar

10

detect L pneumophila culture) L pneumohila usually grows after 3-5 days, M pneumoniaeusually results after 7-21 days later

Serological method s: the methods are: complement fixation technique

(Complement Fixation - CF), immunofluorescence technique (Immuno Fluorescence Assay - IFA), Enzyme-linked immunosorbent technique

(Enzyme Immuno Assay - EIA), particle agglutination technique

(partical Agglutination - PA).

Antigen detection methods:

The tests include direct immunofluorescence, free electrolyte cell convection, infiltration and immune enzyme immunoassay

PCR (Polymerase Chain Reaction) PCR is a continuous chain reaction, including many successive cycles, each cycle consisting of three phases: denaturation phase; annealing stage; synthesis stage PCR primers to test multiple

simultaneous detection of atypical pathogens such as C pneumoniae,

M pneumoniae, L pneumophila Results showed that Multiplex - PCR assay is sensitive, useful, cheap and quick assay diagnosis for

patients pneumonia

pneumoniae and L pneumophila

M pneumoniae bacterium do not has wall, C pneumoniae,

L p neumophila are intracellular bacteria therefore all antibiotics belong to beta-lactam groups are not effective They are sensitive to the macrolide antibiotics such as erythromycin, clarythromycin, azithromicin, tetracycline and quinolones However, tetracycline is not indicated for children under 8 years of age and quinolone not indicated for children

under 15 years of age

1.5 Studies of atypical pneumonia, severe atypical pneumonia in children and related factors

1.5.1 Current research on atypical pneumonia in children

1.5.1.1 In the World

pneumoniae encountered in the upper respiratory tract and lower

pneumophila causes severe disease in adults, it occurs rarely in

children under 4 years of age

1.5.1.2 In Vietnam

Some research interest in disease incidence and clinical features of

pneumonia caused byM pneumoniaamong hospitalized children in some

provinces of Vietnam only Molecular biology techniques are deployed in

some centers, large hospitals nearly

1.5.2 Studies of severe atypical pneumonia and related factors

1.5.2.1 Etiological bacteria

Pneumonia caused by L.pneumophila that disease is second,

followed by pneumococcal pneumonia requiring intensive treatment

For people with normal immune systems, the mortality rate is usually in

the range of 10-15%

1.5.2.2 Coinfection status

Co-infection status was considered as aggravating factors in

community-acquired pneumonia in adults has been demonstrated by

Gutiérrez: pleural effusion, atelectasis, septic shock, hypoxemia

requiring mechanical ventilation, death in patients with pneumonia due

to coinfected patients higher than agent patients (OR = 2.84, 95% CI

1.24 to 6.54, p = 0,02)

1.5.2.3 Accompanying diseases

Studies in adults show that with diseases such as asthma, chronic

obstructive pulmonary disease, malignancies, cardiovascular, diabetes,

immunosuppression are factors that increase the severity of the disease

1.5.2.4 Specific treatment late

Specific treatment late is emphasized associated with significant

mortality in adults suffer from pneumonia caused by L pneumophila

According to Gacouin A., duration of illness before admission to the

ICU for more than 5 days (OR 7:46, 95% CI 1.17 to 47.6) were risk

factors for mortality of L pneumophila pneumonia

1.5.2.5 Extrapulmonary manifestations

Atypical pneumonia with severe extrapulmonary manifestations

such as neurologic manifestations, hemolytic, heart disease,

12

polyarthritis, skin lesions, electrolyte disorders, multiple organ failure related to status severe, even fatal

1.5.2.6 The other factors

Concerning the situation of severe atypical pneumonia, such as the

relationship between bacterial load, drug resistance of M pneumoniae

to macrolides, leucocytosis, lung injury 2 sides, pleural effusion, increased levels of LDH, ALT, AST, and decreased blood protid; increased IL6, TNF, respiratory failure, mechanical ventilation, Lower serum sodium <136 mEq / l, Paco 2 / FiO 2 <130 ureanemia > 30 mg / dl,albuminemia decreased, multiple organ failure, requiring mechanical ventilation, complications of lung abscess, wall chemistry, effusion related lung deterioration, mortality of the disease

Chapter 2 METHODS

2.1 Study subjects

- Patients with pneumonia caused by different microbial agents, aged from 12 months to 15 years old who were treated at the Respiratory Department of the National Hospital of Paediatrics from 7/2010 to 3/2012

- Patients with atypical pneumonia due to at least one of the three

studied bacteria: M pneumoniae, C pneumoniae và L pneumophila,

aged from 12 months to 15 years old who were treated at the Respiratory Department of the National Hospital of Paediatrics from 7/2010 to 3/2012, referred to “ atypical bacterial pneumonia”

- Patients with atypical pneumonia due to at least one of the three

studied bacteria: M pneumoniae, C pneumoniae và L pneumophila,

were diagnosed severe atypical pneumonia

2.2 Inclusion criteria 2.2.1 Case definition

- Pneumonia were diagnosed by using the WHO's criteria: cough,

fever, tachypnea, infiltration on chest radiograph

2.2.2 Atypical bacterial pneumonia case

- Patients were diagnosed with pneumonia

-Three bacteria M pneumoniae, C pneumoniae and L pneumophila were confirmed by Multiplex PCR in bronchial secretions

or nasopharyngeal or throat swab positive for the three studied bacterias, or ELISA: double the serum samples were positive for one of three studied bacterias

2.2.3 Severe atypical pneumonia case

Children were diagnosed with severe atypical pneumonia entitled to

classify pneumonia and WHO standards and the Association of

Pediatric Infection of the America

- Patients with atypical pneumonia due to at least one of the

three studied bacteria

- The severity of pneumonia was determined by the criteria for

severe pneumonia of the American Association of Pediatric Infection

a One or more major signs: required mechanical ventilation; sepsis

b Or at least two of the following signs: tachypnea, apnea,

consciousness disorders; hypotension; pleural effusion, SpO2 <90%

with room air and Pao 2 / FiO 2 ratio < 250; many pulmonary infiltrates

2.2.4 Exclusion criteria:

- Typical pneumonia

- Co-infection cases of pneumonia will not be considered for the

clinical characteristics, laboratory manifestations

- Hospital- acquired pneumonia

- Patient s’ families without agreed to participate in the study

2 3 Methodology

2.3.1 Study Design: epidemiology descriptive case series and analysis

study

™ Sample sizes for objective 1: WHO calculated by estimating the

percentage - a group

2 2

/ 1

) (

) 1 (

ε

α

p p p

Z

−

where n is the minimum sample size, Z (1 - α / 2) is the coefficient of

reliability, corresponding to 95% confidence level we have Z (1 - α / 2) = 1.96 p

dependence incidence of pneumonia by M pneumoniae, C

pneumoniae, L pneumophila, estimated in prospective studies on the

incidence of atypical pneumonia in hospital (in this study the rate of p

= 18% = 0.18) q = 1-p = 1-.18 = 0.82; p.ε accuracy desired sample, choose

ε = 0.16 A required minimum sample size was 718 patients We did

enrolled 722 patients for this study

14

™ Sample sizes for objective 2

The purpose of the study is to describe a case series and combine with the analytic study to identify factors associated with severe atypical pneumonia cases, we used all cases diagnosed with atypical pneumonia (215 patients) that occurred during the study period (7/2010

- 3/2012), among them, 97 cases were clasified as severe atypical pneumonia

2.3.2 Sampling method:

™ Source of patients:

Children from 12 months to 15 years, with an initial diagnosis of pneumonia, treatment in National Hospital of Pediatrics from the local different provinces

™ Sampling method fore objective 1:

A convenient sampling technique, as a rule, chose one patient from

2 patients ( k=3),according to data pneumonia in hospitalized patients in the preceding year divided by the total study minimum sample size was calculated) apply to case series research, prospective, longitudinal follow-up

technique, take the whole 215 atypical pneumonia patients were selected by criteria subjects for the study objective 1 From 215 cases with atypical pneumonia, we selected 97 cases with severe atypical pneuonia and 118 non- severe atypical pneumonia cases We

conducted a comparative analysis to determine the factors associated with severe atypical pneumonia among patients who were treated at the National Hospital of Pediatrics The data collection was performed duringthe study, but thefinal analysiswas carried out only at the end

of the study when all clinical, liboratorial andmicrobiology data was collected for all patients

2.4 Study variables

2.4.1 Study variable for objective 1

™ Epidermiological data collection

Demographic data: name, age, sex, location, education, information

family

Epidemiological factors: geography, season, habitat, level of income History: obstetrics, development, immunization, disease history

™ Clinical data collection: by interviewing parents and/or by physical

examination

™ Laboratory data collection

The laboratory tests included blood specimens for counting

leukocyte (WBC), C-reactive protein (CRP), IL6 and for the detection

of IgM, IgA, IgG, IgE antibody and IgM antibody against M

pneumoniae, C pneumoniae and L pneumophila.Throat

swabs/bronchial exudates were used for detection of M pneumoniae, C

pneumoniae and L pneumophila specific DNA by multiplex PCR In

addition, RT-PCR was applied to determine the presence of co –

infections involving other viral respiratory pathogens such as

Adenovirus, Respiratory Syncytial Virus (RSV), Rhinovirus, Influenza

A & B(RNA extraction using Qiamp Viral RNA Mini kit, RT-PCR

using Kit SuperSckip III One- Step Kit [Invitrogen]

2.4.2 Study variable for objective 2

Factors associated with severe atypical pneumonia: time from

onset to admission, antibiotic use before admission, signs, clinical

symptoms, WBC, CPR, IL6, IgA, IgM, IgG, IGE antibody, coinfected

status with severity of disease

2.5 Data analysis

Statistical analysis was performed using Stata.10, SPSS.13,

Epidata 3.1

Chapter 3 RESULTS 3.1 Epidemiological characteristics of Atypical bacterial

pneumonia in children.

3.1.1 General epidemiological characteristics of atypical pneumonia

Table 3.1 The rate of common pneumonia

Rate%

Typical pneumonia caused by bacteria 82 11.35

Pneumonia caused by typical bacteria co-

infection with virus

Pneumonia with unknown etiology 331 45.84

Table 3.1.shows the overall incidence of atypical pneumonia was

29.8% of the total pneumonia

16

Table 3.2 Classification of atypical pneumonia

Classification of atypical pneumonia

The number

Atypical pneumonia

In group

144 67

10

atypical pneumonia Outside

Atypical pneumonia + typical bacterial pneumonia

38 17.67

Atypical pneumonia + viral pneumonia

19

8.84

Atypicalpneumonia + typical pneumonia + viral pneumonia

4

1.86

Table 3.2shows the co-infection rate was 33%, which co-infected with typical pneumonia and viral pneumonia accounted for 28.37%

Table 3.3 classify of pneumonia cases by agent bacterial atypical pneumonia (data not shown here): it found that M pneumoniae

was the most predominant among community acquired pneumonia in 26.3%; C pneumoniae and L.pneumophila detected with low rate (3.7%, 1.8%)

4,63

17,67 8,84 1,86

54.24

7.5

2.56

22.33

4.19

35.7

0

10

20

30

40

50

60

Under 2 yrs >2-5yrs >5-10 yrs >10yrs

typical pneumonia Atypical pneumonia

Chart 3.1. Age distribution of typical pneumonia and atypical

pneumonia

Chart 3.1 shows that the proportion of children aged greater than 5 years

old with atypical pneumonia was 23.3% But among 215 patients with

atypical pneumonia The incidence of children aged higher in the group

under 5 years old The age variables were significantly difference (p

< 0.001)

There was no difference in gender distribution among children with

atypical pneumonia (data not shown)

Chart 3.3 Seasonal distribution of atypical pneumonia

Atypical pneumonia occurs throughout all seasons, more frequent

during spring-summer seasons than Auturm - Winter season There was

statistically significant difference with p = 0.003 (χ2test)

Spring Summer Auturm Winter

18

Table 3.11 Factors associated with co-infection

Characteristics Adjusted OR 95% CI p

Age

>2 years - 5 years old 0.79 0.39 1.58 0.50

Gender

Family economic conditions

Method of birth

Asthma

Nutritional status

Overweight and

Test fit the Hosmer-Lemeshow test pattern n = 215, p = 0.8619

Table3:11 shows the relationship between co – infected status and each of variables, including age, gender, family economic

Except for Caesarean section, the other variables were not significantly associated with co - infection (OR = 2.12, p = 0.037)

3.1 Table 2 The functional symptoms of hospitalized atypical

pneumonia patients (data not presented here): signs d yspnea in

coinfected atypical pneumonia outside group higher statistical

significance compared with atypical pneumonia in group (p <0,05).

63.64

77.05

16.39

67.21

54.1

8.2 55.84

0

20

40

60

80

100

Moist ure Cra ccl es ronchy ra les interc ost al

trac tion consol idat ion pl eura l infusion pneumot horax

Atypical pneumonia in group coinfection aty pical pneumonia outside groups

Chart 3.7 Physical symptoms in the lungs of atypical pneumonia

patients

Examination finding moisture and crackles among coinfected

atypical pneumonia outside group higher statistical significance

compared than atypical pneumonia in group (p <0.05) (Figure 3.7)

Increased work of breathing signs among coinfected atypical

pneumonia outside group higher statistical significance compared than

atypical pneumonia in group (p <0.001)

50.754.1

35 21.3

9.1 9.8

5.2 14.8 0

10

20

30

40

50

60

Parchy infiltration consolidation Interstitial

infiltration

pleuro -pneumonia Atypical pneumonia in group

Coinfected atypical pneumonia outside group

Chart 3:10 Chest X-ray characteristics of the study subjects

Lobar consolidation with coinfected atypical pneumonia outside

group was significantly lower compared to the atypical pneumonia in

pneumonia outside group as higher statistical significance than the

atypical pneumonia in group (p = 0,05)

20

3.1.3 Characteristics of atypical pneumonia analyzed by bacterial pathogens

Table 3:18 functional symptoms of atypical simple pneumonia

Clinical

Atypical

M pneumoniae

Atypical

L pneumophila

Atypical

C pneumoniae

n = 29

%

Table 3:19 Physical symptoms of atypical simple pneumonia

Clinical

Atypical

M pneumoniae

Atypical

L neumophila

Atypical

C pneumoniae

%

Crepitations 84 65.12 5 71.43 3 37.5

Intercostal muscle external traction 40 31 2 28.57 0 0

Table 3:18 and 3:19 shows the distinct functional – physical symptoms betweenL pneumophila,C pneumoniae and M pneumoniae did not differ significantly (p > 0.05)