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CHAPTER 17
INFECTIONS OF THE RESPIRATORY TRACT

INFECTIONS involving the respiratory tract may be caused by a myriad of organisms – viruses,
bacteria, fungi.

DISEASES OF THE UPPER RESPIRATORY TRACT

1. Common cold

The common cold (acute rhinitis or coryza) is considered a frequent illness in

childhood. Its incidence and seasonal occurrence tends to be predictable. For instance,
in tropical countries, the average occurrence of the illness increases during the rainy
season. It commonly occurs in school settings, especially with the proliferation of day
care centers.
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Close personal contact is necessary for the transmission of the common cold. The
greatest concentration of the etiologic agent is in the nasal secretions and the greatest source
of infection is through sneezing, nose-blowing, and contamination of external surfaces with
nasal secretions.
The manifestations of the common cold may be varied. In older children, its onset may
be associated with fever. More commonly, the onset is characterized by sneezing accompanied
by watery nasal discharge. Nasal obstruction due to congestion may interfere with feeding and
sleeping. After 1-3 days, the nasal secretions may become thicker and purulent.
Overall, viruses remain to be the most common etiologic agents of the common cold.
Antibiotics have no role in the management of the common cold. Management is mainly
symptomatic. Acetaminophen or paracetamol can be given for fever. The true efficacy of the
use of decongestants is not yet determined. In some instances, use of decongestants may cause
rebound vasodilation which can further contribute to the congestion.
a. Rhinovirus
Rhinoviruses are the main cause of the common cold. They are non-enveloped RNA
viruses that occur in more than 100 serologic types. They primarily affect the nose and
conjunctiva and are killed by gastric acid when swallowed.
b. Coronavirus
Coronaviruses are the second most common cause of the common cold. Unlike the
rhinoviruses, coronaviruses are enveloped RNA viruses. Infection occurs
worldwide and the virus is mainly transmitted by respiratory aerosol. In 2002, a
new disease, an atypical
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Pneumonia called SARS (severe acute respiratory syndrome) emerged and

coronavirus was implicated as the etiologic agent (CoV-SARS). The civet cat was
identified as the likely reservoir of CoV-SARS.
The common cold caused by coronavirus has the same manifestation as that
caused by rhinovirus. On the other hand, SARS is a severe form of atypical
pneumonia characterized by fever, non-productive cough, dyspnea, and hypoxia.
Chills, rigors, malaise and headache commonly occur. The incubation period ranges
from 2 to 10 days.
There is no antiviral therapy or vaccine available. A combination of ribavirin and
steroids has been tried in the treatment of SARS but the efficacy is still
undetermined.

2. Pharyngitis
Pharyngitis refers to inflammation of the mucous membranes of the pharynx. The
clinical diagnostic category includes tonsillitis, tonsillopharyngitis, and
nasopharyngitis.
Nasopharyngitis
This is a common illness of childhood, occurring more commonly during the cold
weather months. The most common cause is the Adenovirus family, frequently causing
infection in adolescent and young adults in military training. Other viruses that can also
cause the disease are the influenza and parainfluenza viruses.
Clinical manifestations are varied but fever occurs in nearly all cases. It is an acute, self-
limiting disease lasting 4 to 10 days. Other symptoms depend on the particular etiologic
agent.
Diagnosis is based on clinical manifestations. Management is mainly supportive. The
use of throat lozenges, aseptic mouthwash, and decongestants has no role in the
management of the infection.

Adenoviruses
Adenoviruses are non-enveloped DNA viruses that cause a variety of upper and
lower respiratory tract diseases such as pharyngitis, conjunctivitis, the common cold,
and pneumonia. They also cause keratoconjunctivitis, hemorrhagic cystitis, and
gastroenteritis.
Mode of transmission
1. Aerosol or droplet
2. Fecal-oral – most common mode of transmission among young children and
their families
3. Direct inoculation of conjuntivas by fingers
Clinical findings
1. Upper respiratory tract
a) Nasopharyngitis
 b) Pharyngoconjunctival fever – acute respiratory disease characterized
by fever, sore throat, coryza (runny nose), and conjunctivitis

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2. Lower respiratory tract
a) Bronchitis
b) Atypical pneumonia

3. Hemorrhagic cystitis – characterized by hematuria and dysuria

4. Gastroenteristis with non-bloody diarrhea in children younger than 2 years of
age
Laboratory diagnosis
Diagnosis can be confirmed by isolation of the virus in cell culture and detection of 4-
fold increase in antibody titer.
Treatment and prevention
There is no antiviral therapy. Three live, non-attenutated vaccines are available but are
used only by the military. The vaccines are administered orally and are not available for civilian
use.
Tonsillopharyngitis
Tonsillopharyngitis is inflammation involving both the pharynx and the tonsils. It has a seasonal
occurrence and usually involves children 5-10 years of age, with a secondary peak at 12 and 18-
20 years of age. The most common cause is Streptococcus pyogenes (see discussion in
Infections of the Skin). It is obtained primarily by direct contact with large droplets or
respiratory secretions.
The disease manifests are sudden onset of fever, sore throat, headache, nausea, malaise, and
pain. There is marked tonsillopharyngeal erythema. The gold standard for diagnosis is culture of
specimen obtained by a swab of the prosterior pharyngeal and tonsillar regions. Complications
include sinusitis, otitis media, peritonsillar and retropharyngeal abscess, acute rheumatic fever,
and acute glomerulonephritis.
It is generally a self-limited disease. However, because of the possible sequelae, antibiotic
treatment is necessary. The drug of choice is penicillin. Erythromycin or Clindamycin may be
given to patients allergic to penicillin.

3. Scarlet fever
This infection occurs in association with streptococcal pharyngitis and is caused by
Streptococcus pyogenes strains that produce erythrogenic toxin. The toxin causes a
hypersensitivity reaction that produces a pinkish-red rash on the skin. The rash appears on the
trunk and spreads to the extremities. The tongue has a spotted, strawberry-like appearance and
eventually becomes very red and enlarged. As the disease progress, the skin peels off as if
sunburned.
 The drug of choice for treatment is penicillin G. since the disease is transmitted primarily
by inhalation of infective droplets from an infected person, control measures are directed
mainly at the human source.
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4. Sinusitis
Sinusitis is inflammation of the mucosal lining of one or more of the paranasal sinuses. It
is common in children with allergies, in children with adenoids and enlarged tonsils, dental
infections, and in children with chronic ear infection. The principal pathogens in all age groups
are Haemophilus influenzae and Streptococcus pneumoniae, both of which will be discussed
later under lower respiratory tract infections.
The clinical features are age-dependent. In young children, manifestations may include
persistent rhinorrhea (nasal discharge), with cough that is worse at night. They also manifest
with periorbital edema, post-nasal drip, and foul-smelling breath. In older children and adults,
manifestations may include headaches, dental and facial pain with tenderness over the
involved sinuses on palpation.
Specific diagnosis involves culture with specimen taken from the infected sinus. X-ray
may also be done to demonstrate the involved sinus. Antimicrobial therapy is done to achieve
clinical improvement and sterilization of sinus secretions, and are given for 7 days or more.
Other measures include:
1. Normal saline washes to liquefy secretions and enhance mucociliary transport
2. Use of anti-histamines if allergic rhinitis is contributory
3. Corticosteroids – use with caution because of risk of superinfection

5. Otitis externa
Otitis externa is inflammation involving the external ear. The more common cause in
tropical countries is Pseudomonas aeruginosa (discussed in Infections of the Skin). Other causes
are Staphylococcus aureus, Proteus vulgaris, Klebsiella, and Escherichia coli. Itching and pain are
prominent. Periaural edema and complete obliteration of the canal may be seen in severe
infection. Intense pain is felt when the tragus is pulled.
Diagnosis is made based on clinical presentation. Management includes flushing or
irrigation of the external auditory canal with 3% hypertonic saline. If there is no evidence of
infection, use of tropical corticosteroid cream is sufficient. In the presence of overt infection,
Neosporin cream applied three times a day is recommended. Preventive measures include
minimizing swimming and exposure to water, and minimizing excessive cleaning of the ears.
6. Otitis media
Otitis media refers to inflammation of the mucoperiosteal lining of the middle ear. Two-
thirds of case are caused by bacteria, with Streptococcus pneumoniae as the most common and
Haemophilus influenzae as the second most common cause. Viral causes include repiratory
syncytial virus, influenza virus, adenovirus, and rhinovirus.
The condition begins with non-specific signs and symptoms of fever, irritability,
headache, anorexia, and vomiting. Cough and coryza usually occur prior to the signs of ear
infection. The most common specific manifestation is otalgia (ear pain). Other signs and
symptoms include otorrhea (ear discharge), hearing impairment, and tinnitus (ringing in the
ears). Management involves giving of antibiotics for the specific etiologic agent.
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Complications
1. perforation of the tympanic membrane
2. mastoiditis
3. hearing loss
4. meningitis
5. brain abscess
7. Croup (laryngitis, laryngotracheeitis, laryngotracheobronchitis)
Croup is a term used to identify several respiratory illness characterized by varying
degrees of inspiratory stridor, cough, and hoarseness (“seal bark”) resulting from obstruction in
the region of the larynx. Majority of cases occur within the first 3 years of life. The major cause
of croup is the parainfluenza virus. It can also be caused by the respiratory syncitial virus. Both
are enveloped RNA viruses.
Croup is transmitted mainly by respiratory droplets. In addition croup, other repiratory
diseases caused by parainfluenza viruses include the common cold, pharyngitis, laryngitis, otitis
media, bronchitis, and pneumonia.
The diagnosis of croup is based on clinical manifestations. There is no antiviral therapy
or vaccine available.

8. Influenza
Influenza attacks mainly the upper respiratory tract. It is caused by the influenza viruses
which are members of the family Orthomyxoviridae. There are three immunologic types of
influenza viruses: influenza A, influenza B, and influenza C.
Influenza A is responsible for most cases of epidemics and pandemics. It is also the
cause of influenza in birds (avian flu), pigs, horses, and seals. Some of the strains isolated are
similar to those causing disease in the human population. Influenza B mainly causes epedemics,
while influenza C, because it is antigenically stable, causes only mild illness.
Influenza viruses undergo antigenic changes, with the exception of influenza C. There
are two types of antigenic change that involve the two surface antigens of influenza (HA and NA
antigens): antigenic drift and antigenic shift. Antigenic drift is a minor change and is due to
accumulation of point mutations in the gene resulting in amino acid changes. This is seen in
both influenza A and influenza B. Antigenic drift is responsible for the occurrence of epidemics.
Antigenic shift is a major change that involves rearrangement of the gene segments, resulting in
the development of new strains. It is responsible for pandemics and occurs only in influenza A.
A new strain, H5N1, was identified as the cause of the avian flu epidemic in recent years. It was
closely monitored for fear that it can lead to development of a pandemic.
Mode of transmission
The virus is transmitted by airborne respiratory droplets.
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Clinical findings
1. Uncomplicated influenza
 The symptoms abruptly appear and consist of chills, headache, and dry cough,
followed by high fever, generalized muscular pains, malaise, and anorexia.
Symptoms in children are similar to those in adults, although the fever may be
higher in children. Febrile convulsions may occur.

2. Pneumonia
 This can complicate influenza and may be viral, secondary bacterial, or a
combination of two. This usually occurs in the elderly and debilitated patients,
especially those with underlying chronic disease. The common bacterial
pathogens implicated are S. aureus, S. pneumoniae, and H. influenzae.

3. Reye’s Syndrome
 This is a complication associated usually with influenza B and varicella-zoster
infections. It is an acute encephalopathy of children and adolescents and is
associated with the intake of aspirin or salicylate.
Laboratory diagnosis
Most diagnoses of influenza are made on clinical grounds. However, laboratory test s
are available for confirmation. This includes isolation of the virus and identification of viral
antigens in the patient’s cells.
Treatment and prevention
Amantadine and its derivative rimantatine are used for both treatment and prevention
of influenza A. The newer drugs zanamivir (Relenza) and oseltamivir (Tamiflu) are now being
used for the treatment of both influenza A and B. To be effective, they must be administered
very early in the course of the disease.
The main mode of prevention is the vaccine, consisting of influenza A and B viruses. It is
given annually, especially to high-risk groups, such as elderly individuals and individual
personnel.
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Current News: The influenza A/H1:N1 Virus
A novel influenza virus has been noted to emerge, first in California and then in northern
Texas in the United States. However, a high number of cases were also reported in Mexico.
Hence, the virus was called Mexican swine flu virus. It is a “reassortant” virus resulting from
genetic re-assortment of two swine, one avian, and one human influenza A/H 1:N1. The disease
was officially proclaimed a pandemic on June 11, 20099.
The disease produces a mild form of influenza (or flu) among infected patients. Death is
seen in a number of patients with co-existing disease although a number of deaths were also
noted among young, healthy individuals so that a possibility of genetic predisposition is
currently being postulated.
The drug of choice for treatment are oseltamivir (Tamifllu) and zanamivir (Relenza). A
vaccine is currently undergoing clinical trial.
9. Diphteria
Etiologic agent: Corynebacterium diphtheria
C. diphtheria are gram-positive, non-spore-forming rods that are club-shaped
and arranged in V-or L-shaped formations, giving rise to a “Chinese character” appearance.
Toxigens strains produce toxin (diphtheria toxin) which is responsible for the disease.
Mode of transmission
Humans are the only natural hosts. The main mode of transmission is by air-
borne droplets or by contact to susceptible individuals.
Clinical findings
Inflammation begins in the respiratory tract, leading to sore throat and fever.
The most prominent sign is the thick, gray, adherent pseudomembrane over the tonsils and
throat. Extension of the membrane into the larynx and trachea causes airway obstruction
manifesting as dyspnea. The obstruction may even cause suffocation that is relieved only by
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Intubation or tracheostomy. Damage to the heart may manifest as arrhythmia (irregularity in
rhythm). Nerve weakness or paralysis may occur, especially involving the cranial nerves.
Cervical lymphadenopathy is also prominent, giving the patient’ a “bull neck” appearance.
Manifestations tend to subside spontaneously.
Laboratory diagnosis
Swabs from the nose, throat, or other suspected lesions must be obtained before
antimicrobial drugs are given. Gram-staining and microscopic examination of the Gram-staining
specimen can help identify the organism. Definitive diagnosis can be made by doing a culture of
the specimen using Loeffler’s medium.
Treatment and prevention
Management involves prompt administration of antimicrobial agents and antitoxin.
Treatment with antitoxin is mandatory if there is strong clinical suspicion of diphtheria. The
antibiotics of choice are penicillin G or erythromycin.
The major aims of prevention are to limit the distribution of the toxigenic strains in the
population and to maintain a high level of active immunization. Infected patients must be
isolated. All children must receive an initial course of immunizations and boosters. Diphtheria
toxoid is given in combination with tetanus toxoid and acellular pertussis vaccine (DTaP).

DISESASES OF THE LOWER RESPIRATORY TRACT

1. Chronic bronchitis
Individuals with functional and anatomic abnormalities of the respiratory tract (e.g.,
COPD) are subject to attacks of chronic bronchitis, an inflammatory condition involving the
bronchi. This is a recurrent bacterial infection that is often precipitated by viral infections. The
most common etiologic agents are Streptococcus pneumoniae (Pneumococci) and Haemophilus
influenzae. Other causative agents include adenovirus, Bordetella pertussis, and parainfluenza
virus.
2. Bronchiolitis
Bronchiolitis is a severe inflammatory condition involving the bronchioles. This is most
commonly caused by the respiratory syncytial virus (RSV), but metapneumovirus, adenovirus,
coronavirus, rhinovirus and the influenza and parainfluenza viruses are occasionally involved.
Respiratory syncytial virus (RSV)
RSV is the major cause of bronchiolitis. It is the most important cause of severe lower
respiratory tract infection in infants and young children. It is a member of the family
Paramyxoviridae.
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Mode of transmission
RSV is spread by respiratory droplets and direct contact. The main portal of entry of the
virus into the host is through the nose and eyes.
Clinical finding
a. Severe wheezing illness with rapid progression of symptoms culminating in death
b. Common cold
c. Influenza-like illness
d. Pneumonia – in elderly or immunocompromised patients
e. Otitis media
Laboratory diagnosis
Isolation of the virus and detection of viral antigen in respiratory secretions are the
procedures of choice.
Treatment and prevention
The antiviral drug ribavirin has been approved for the treatment of RSV bronchiolitis.
Supportive care is essential consisting of removal of secretions and administration of oxygen.
Administration of immune globulin may be beneficial. Control measures to prevent nosocomial
outbreaks include contact isolation, hand washing, and restriction of visitors.
3. Pneumonia
Pneumonia is an infection involving lung parenchyma. Most cases of pneumonia are
caused by bacteria. Based on the clinical manifestations, pneumonia may be classified as typical
pneumonia or atypical pneumonia. Pneumonias may also be classified based on the portions of
the lower respiratory tract affected. If entire lobes of the lungs are involved, it is referred to as
lobar pneumonia. If the alveoli are not involved and the inflammation is confined to the
interstitial spaces, it is termed interstitial pneumonia. If the bronchus and the alveoli of the
lungs adjacent to the bronchi are involved, then it is called bronchopneumonia.
Acute bacterial pneumonia typically presents with abrupt onset of fever and chills,
cough productive of purulent sputum, and pleuritic chest pain. The pleuritic chest pain occurs if
there is involvement of the pleural membranes. The patients appear ill and usually manifest
with tachypnea (rapid breathing) and tachycardia (rapid heart rate). The most sommon cause of
community-acquired pneumonia are Streptococcus pneumoniae (most common), Mycoplasma
pneumoniae (in young person), and Legionella pneumophila. Other causes are Haemophilus
inflluenzae, Staphylococcus aureus, and Klebsiella pneumoniae in chronic alcoholics.
Nosocomial pneumonia, on the other hand, is most often caused by Escherichia coli,
Pseudomonas aeruginosa, and Staphylococcus aureus.
Viral pneumonia is characterized by inflammation of the interstitial spaces. The
manifestations may be less severe than that of bacterial pneumonia and physical examination
may only reveal rales on auscultation. It is most commonly caused by respiratory cyncytial virus,
parainfluenza viruses, influenza viruses, adenoviruses, measles virus, and varicella-zoster virus.
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Diagnosis can be made by Gram stain and microscopic examination of the sputum
specimen. However the gold standard for diagnosis remains to be culture (blood culture or
sputum culture).

a. Streptococcus pneumoniae
Also called pneumo coccus, this is a Gram-positive, encapsulated, lancet-shaped diplococcus. It
is alpha-hemolytic (causes partial hemolysis in culture), and is a normal inhabitant of the upper
respiratory tract of 5-40% of humans. It is also transient flora of the nasopharynx. It produces
disease through its ability to multiply in the tissues. The main virulence factor is the capsule
which is anti-phagocytic.
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Mode of transmission
It is mainly transmitted through droplet respiratory secretions. Nasopharyngeal
carriers serve as the source of infection in 10% of cases.
Cases of findings
The disease begins with abrupt onset of fever and chills, cough, and pleuritic
chest pain. The sputum is red or brown (“rusty”) in color. From the respiratory tract, the
organism may reach other sites. The middle ear and sinuses are the most frequently involved,
causing sinusitis and otitis media. The infection may spread from the mastoid to the meninges.
The disease is terminated promptly if antimicrobial therapy is given early.
Laboratory diagnosis
1. Gram stain and microscopic examination of sputum
2. Blood and sputum culture
3. Capsular swelling test (Quellung reaction)
4. Optochin sensitivity
Treatment and prevention
The drug of choice is penicillin G. Alternative drugs are ceftizoxime and
vancomycin. Primary prevention consists of administration of vaccine, especially to
high-risk individuals, such as the elderly and those who do not have a spleen. Other
preventive measures include avoidance of high risk factors (e.g., upper respiratory tract
infection, alcohol or drug intoxication, malnutrition), establishment of early diagnosis,
and early administration of antimicrobial agents.
b. Haemophilus influenza
The term “haemophilus” means blood-loving and is attributed to the organism’s
requirement for enriched media, usually containing blood, for isolation. H. influenzae is
found on the mucous membranes of the upper respiratory tract of humans. The most
virulent and invasive strain is the encapsulated strain, H. influenzae type B. Most infections
occur in children between the ages of 6 months and 6 years.

Mode of transmission
The organism enters the body through the upper respiratory tract. Humans are the
only reservoirs.
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Clinical findings
1) Sinusitis and Otitis media
 H. influenzae is second only to pneumococci as the most common cause of
bacterial sinusitis and otitis media.
2) Epiglottitis
 An inflammation of the epiglottis which can cause severe, life-threatening
disease in young children due to airway obstruction, this is almost
exclusively caused by H. influenzae.
3) Meningitis
 The organisms are usually carried to the meninges by way of the
bloodstream. Prior to the use of vaccine, H. influenza used to be the most
common cause of bacterial meningitis in children aged 5 months to 5 years.
The rapid onset of fever, headache, and stiff neck along with drowsiness is
typical.
4) Bronchitis and Pneumonia
 These are commonly seen in elderly adults, especially those with chronic
respiratory disease.
Laboratory diagnosis
1) Gram stain and microscopic examination
2) Culture
 Specimens consist of nasopharyngeal swabs, pus, blood, and spinal fluid.
Treatment and prevention
Ampicillin is the drug of choice for strains that do not produce beta-lactamase.
Essentially all strains are susceptible to the newer cephalosporins. Primary prevention is
through administration of haemophilus b conjugate vaccine (Hib vaccine) to children.
c. Mycoplasma pneumoniae
Mycoplasmas are the smallest free-living organisms that can self-replicate in
laboratory media. They are part of the normal flora of the mouth. The most unique
characteristic of the organism is the absence of a cell wall. This characteristic makes all
mycoplasmas completely resistant to penicillin.

Mode of transmission
Person-to-person by means of infected respiratory secretions

Clinical findings
M. pneumoniae is the most common cause of atypical pneumonia or “walking
pneumonia”. The term “atypical” means that the organism cannot be isolated on
routine media in the diagnostic laboratory or that the disease does not resemble
pneumococcal pneumonia. It is a generally mild form of pneumonia and complications
are uncommon.
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Laboratory diagnosis
Diagnosis is not made by culture since it reveals only normal flora. Serologic
testing is the mainstay of diagnosis.
d. Klebsiella pneumoniae
The organism is usually an opportunistic pathogen that causes nosocomial
infections. K pneumoniae is frequently found in the large intestine, but is also present in
soil and water. The organism has a very large capsule (anti-phagocytic). Patients who
develop infection are usually elderly patients, those with chronic respiratory tract
disease, diabetics, and alcoholics.
Clinical findings
The organism produces a primary lobar pneumonia that is characterized by
production of a thick, bloody sputum (“currant jelly” sputum). Necrosis and abscess
formation is common.
Laboratory diagnosis
Culture of MacConkey’s agar on EMB and biochemical tests.
Treatment and prevention
The organism is highly resistant to a lot of antimicrobial drugs. The choice of
drug depends on the results of sensitivity testing. Preventive measures include changing
the site of intravenous catheters, removing urinary catheters when no longer needed,
and proper care of respiratory therapy devices. There is no vaccine available.
e. Legionella pneumophila
Legionellae are Gram-positive rods that stain poorly with the standard Gram
stain, although they have a Gram-negative type of cell wall. It causes diseaseboth in the
community and in hospitalized immunocompromised patients. The major virulence
factor is lipopolysaccharide (LPS).
Mode of transmission
The organism is associated chiefly with environmental water sources, such as air
conditioners and water cooling towers. Outbreaks of pneumonia in hospital have been
attributed to the presence of the organism in water taps, sinks, and showers.
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Clinical findings
1) Pontaic fever
 This is a mild flu-like form of infection that does not result in pneumonia. It has
an abrupt onset but resolves completely in less than one week.
2) Legionnaire’s disease (legionellosis)
 This is also considered to be an atypical type of pneumonia and is characterized
by very high fever and severe pneumonia accompanied by mental confusion and
non-bloody diarrhea. This can be fatal in immunocompromised patients.
Laboratory diagnosis
Diagnosis depends on a significant increase in antibody titer by the indirect immune-
fluorescence assay.
Treatment and prevention
The drug of choice is azithromycin or erythromycin. Prevention involves reduction of
cigarette and alcohol consumption, elimination of aerosols from water sources, and the use of
high temperatures and hyperchlorination of hospital water supplies
f. Staphylococcus aureus
S. aureus pneumonia can occur in post-operative patients or following viral repiratory
tract infections, especially influenza. It frequently leads to empyema (lung abscess). It is the
most common cause of nosocomial pneumonia in many hospitals.
g. Pseudomonas aeruginosa
P. aeruginosa is another major cause of nosocomial pneumonia. Involvement of the
respiratory tract, especially from contaminated respirators, results in necrotizing pneumonia.
4. Pertussis (whooping cough)
Etiologic agent: Bordetella pertussis
The organism is a small, encapsulated, Gram-negative rod. It is a
pathogen only for humans.
Mode of transmission
The organism is transmitted by airborne droplets during the severe coughing episodes.
Clinical findings
Pertussis is a highly contagious disease. It occurs primarily in infants and young children.
It is an acute tracheobronchitis that consists of three stages, namely:
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a. Catarrhal stage
 This is the most contagious stage and lasts 1-2 weeks. It manifests as a mild
upper respiratory tract infection with non-specific signs and symptoms.
b. Paroxysmal stage
 The paroxysmal stage is characterized by a series of 5-20 forceful, hacking
coughs accompanied by production of copious amounts of mucus that ends in a
high-pitched indrawn breath (“whoop”). During paroxysms, the patient may
turn cyanotic, the tongue protrudes, the eye bulge, and neck veins engorge.
This may last for 2-10 weeks.
c. Convalescent stage
 This is characterized by a reduction in the symptoms of the patient leading to
recovery. The patient is no longer contagious.
Laboratory diagnosis
Culture of specimens taken from nasopharyngeal swabs taken during the paroxysmal
stage.

Treatment and prevention

The drug of choice is erythromycin. It is given not to only to the patient, but also
exposed individuals. Administration of the drug during the paroxysmal stage will not alter the
course of the disease. Supportive care, such as oxygen therapy and suction of mucus, during the
paroxysmal stage is important.
5. Tuberculosis
Etiologic agent: Mycobacterium tuberculosis
M. tuberculosis is an acid-fast, obligately aerobic bacillus that is stained poorly by the
dyes used in Gram stain. Its cell wall contains complex lipids, one of which mycolic acid, which
contributes to the acid-fastness of the organism.
Mode of transmission
a. Person-to-person by respiratory aerosol – aerosols generated by the coughing of infected
individuals
b. Kissing
c. Ingestion of unpasteurized cow’s milk – gastrointestinal tuberculosis caused by M. bovis
d. Fomites (e.g., utensils, glassware)
Clinical findings
1. Primary infection (primary complex)
 Primary infection usually happens during childhood. It may affect any part of
the lung, but most commonly involves the middle and lower lobes of the
lungs. The lesion is called Ghon complex. Most patients are asymptomatic.
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2. Secondary type or reactivation pulmonary tuberculosis

 This type is usually caused by tubercle bacilli that have survived in the primary
lesion. It almost always begins at the apex of the lung, where the oxygen tension
is highest. Classical symptoms include easy fatigability, afternoon rises in
temperature, weight loss, night sweats, loss of appetite, and chronic non-
productive cough with or without hemoptysis.
3. Miliary tuberculosis
 Miliary tuberculosis is characterized by multiple disseminated lesions.
Tuberculous meningitis and tuberculous osteomyelitis (Pott’s disease) are
important disseminated forms.
 Other disseminated forms: gastrointestinal, oropharyngeal, renal, genitourinary
TB, pericardial TB, TB lymphadenitis

Laboratory diagnosis
a. Acid-fast staining of sputum or other specimens – initial test
b. Culture using Lowenstein-Jensen medium is not usually done because the organism is
a slow grower.
c. Chest x-ray
d. Skin test
 Tuberculin Skin Test using purified protein derivative (PPD) as antigen:
method: Mantoux (intradermal)
 The skin test is evaluated by measuring the diameter of the induration
(thickening) surrounding the skin test and not simply observing for the
presence of erythema.
 A positive skin test result indicates previous infection by the organisms, but
not necessarily active disease.
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 Interpretation: the skin test is considered positive in the following:

a) Induration of 15 mm or more in a person with no known risk factors
b) Induration of 10 mm or more in a person with high-risk factors (e.g., homeless
person, IV drug users, or nursing home residents)
c) Induration of 5 mm or more in a person with deficient cell-mediated immunity
(e.g., AIDS patients)
 The test becomes positive 4-6 weeks after infection. Immunization with BCG may
cause a positive test, but the reactions are usually only 5-10 mm and tend to
decrease with time. People with a skin test result of 15 mm or more are assumed to
be infected with M. tuberculosis, even if they have received the BCG vaccine.
Treatment and prevention
Multi-drug anti-Koch’s or anti-TB therapy is used to prevent emergence of drug resistance.
Preventive measures include: (1) improvement of housing conditions and nutritional status of
the population; (2) prompt identification and adequate treatment of patients; (3) careful
follow-up of contacts of patients with active TB (e.g., tuberculin tests, x-rays, sputum
examination); (4) use of masks and other respiratory isolation procedures to prevent spread to
medical personnel; public health education; (5) eradication of tuberculosis in cattle and
pasteurization of milk; and (6) immunization with BCG vaccine.

6. Pulmonary anthrax
Pulmonary or inhalation anthrax is also called woolsorter’s disease and is transmitted by
inhalation of spores into the lungs. It begins with non-specific symptoms that resemble
influenza, which rapidly progresses to bloody pleural effusion, eptic shock, and death.
Hemorrhagic meningitis and hemorrhagic mediastinitis are severe life-threatening
complicatioons. The drug of choice is ciprofloxacin, with doxycycline as an alternative drug.