Blood test for pneumonia in a child

The first signs of pneumonia in children and adults

Pneumonia is a disease that has an infectious origin and is characterized by inflammation of the lung tissue in the event of provoking physical or chemical factors such as:

• Complications after viral diseases (influenza, ARVI), atypical bacteria (chlamydia, mycoplasma, legionella)
• Effects on the respiratory system of various chemical agents - poisonous fumes and gases (see. chlorine in household chemicals is hazardous to health)
• Radioactive radiation, to which infection is attached
• Allergic processes in the lungs - allergic cough, COPD, bronchial asthma
• Thermal factors - hypothermia or burns of the respiratory tract
• Inhalation of liquids, food or foreign bodies can cause aspiration pneumonia.

The cause of the development of pneumonia is the emergence of favorable conditions for the multiplication of various pathogenic bacteria in the lower respiratory tract. The original causative agent of pneumonia is the aspergillus mushroom, which was the culprit of the sudden and mysterious deaths of researchers of the Egyptian pyramids. Owners of domestic birds or lovers of urban pigeons can get chlamydial pneumonia.

For today, all pneumonia is divided into:

• out-of-hospital, arising under the influence of various infectious and non-infectious agents outside the walls of hospitals
• hospital, which cause hospital-acquired microbes, often very resistant to traditional antibiotic treatment.

The frequency of detection of various infectious agents in community-acquired pneumonia is presented in the table.

When the diagnosis is confirmed, depending on the type of pathogen, the patient's age, the presence of concomitant diseases, a corresponding therapy, in severe cases, treatment should be performed in a hospital setting, with mild forms of inflammation, hospitalization of the patient is not is required.

Characteristic first signs of pneumonia, the vastness of the inflammatory process, acute development and danger of serious complications in untimely treatment - are the main reasons for the urgent circulation of the population for medical help. At present, a sufficiently high level of medical development, improved diagnostic methods, and a huge the list of antibacterials of a wide spectrum of action has considerably lowered a death rate from an inflammation of lungs (cm. antibiotics for bronchitis).

Typical first signs of pneumonia in adults

The main symptom of the development of pneumonia is a cough, usually it is first dry, obtrusive and persistent. protivokashlevye, expectorants with a dry cough), but in rare cases cough at the beginning of the disease can be rare and not strong. Then, as the inflammation develops, the cough becomes pneumatic with pneumonia, with a discharge of mucopurulent sputum (yellow-green color).

Any catarrhal virus disease should not last more than 7 days, and a sharp deterioration of the condition later 4-7 days after the onset of an acute respiratory viral infection or influenza indicates the onset of an inflammatory process in the lower respiratory ways.

Body temperature can be very high up to 39-40C, and can remain subfebrile 3, -3, C (with atypical pneumonia). Therefore, even with a low body temperature, coughing, weakness and other signs of malaise, you should definitely consult a doctor. Caution should be a repeated temperature jump after a light gap during the course of a viral infection.

If the patient has a very high temperature, one of the signs of inflammation in the lungs is the inefficiency of antipyretic drugs.

Pain with deep breath and cough. The lung itself does not hurt, as it is devoid of pain receptors, but involvement in the pleura process gives a pronounced pain syndrome.

In addition to cold symptoms, the patient has dyspnea and pale skin.
General weakness, increased sweating, chills, decreased appetite are also characteristic for intoxication and the onset of the inflammatory process in the lungs.

If such symptoms appear either in the midst of a cold, or a few days after the improvement, these may be the first signs of pneumonia. The patient should immediately consult a doctor to undergo a complete examination:

• To pass blood tests - general and biochemical
• To make a roentgenography of a thorax, if necessary and a computer tomography
• Sputum for culture and sensitivity of the pathogen to antibiotics
• Sputum for culture and microscopic determination of mycobacterium tuberculosis

The main first signs of pneumonia in children

Symptoms of pneumonia in children have several characteristics. Attentive parents may suspect the development of pneumonia with the following discomforts in the child:

• Temperature

Body temperature above 38C, lasting for more than three days, not knocked down by antipyretics, there may also be a high temperature of up to 3, especially in young children. At the same time, all signs of intoxication are manifested - weakness, increased sweating, lack of appetite. Small children (as well as elderly people), can not give high temperature fluctuations with pneumonia. This is due to imperfect thermoregulation and immaturity of the immune system.

• Breath

There is frequent shortness of breath: in children up to 2 months of age, 60 breaths per minute, up to 1 year, 50 breaths, after a year, 40 breaths per minute. Often the child spontaneously tries to lie down on one side. Parents may notice another sign of pneumonia in the child, if you undress the baby, then when breathing from the patient lung can be noticed the retraction of the skin in between the ribs and the lag in the process of breathing one side of the chest. There may be irregular breathing rhythm, with periodic stops of breathing, changes in the depth and frequency of breathing. In infants, shortness of breath is characterized by the fact that the child begins to nod his head in time with the breath, the baby can stretch his lips and inflate his cheeks, foamy discharge from the nose and mouth can appear.

• Atypical pneumonia

Inflammation of the lungs caused by mycoplasma and chlamydia differ in that first the disease passes like a cold, there is a dry cough, runny nose, swelling in the throat, but the presence of dyspnea and a stably high temperature should alert parents to the development pneumonia.

• Character of cough

Because of the perspiration in the throat, only coughing can appear first, then the cough becomes dry and painful, which is amplified by crying, feeding the baby. Later, the cough becomes wet.

• Behavior of the child

Children with pneumonia become capricious, whiny, sluggish, they are disturbed by sleep, sometimes can completely refuse to eat, and also to appear diarrhea and vomiting, in babies - regurgitation and rejection of breasts.

• Blood test

In the general analysis of blood, changes are detected that indicate an acute inflammatory process - increased ESR, leukocytosis, neutrophilia. Shift of the leukoformula to the left with increasing stab and segmented leukocytes. In viral pneumonia, along with high ESR, there is an increase in leukocytes due to lymphocytes.

With timely access to a doctor, adequate therapy and proper care for a sick child or adult, pneumonia does not lead to serious complications. Therefore, at the slightest suspicion of pneumonia, the patient should be given medical care as soon as possible.

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Diagnosis of pneumonia

Diagnosis of pneumonia is based on the identification of the five most simple and sufficiently informative clinical and laboratory and instrumental signs, called the "gold standard" of diagnosis:

1. An acute onset of the disease, accompanied by an increase in body temperature above 38 ° C.
2. Sudden appearance or marked increase in cough with separation of sputum mainly purulent and / and hemorrhagic nature.
3. The appearance of previously missing local blunting (shortening) of percussion sound and the auscultatory phenomena described above, characteristic for lobular (croupous) or focal pneumonia (weakening of breathing, bronchial breathing, crepitation, wet fine bubbling sonorous rattles, noise of friction pleura).
4. Leukocytosis or (less often) leukopenia in combination with neutrophil shift.
5. X-ray signs of pneumonia - focal inflammatory infiltrates in the lungs, which had not previously been detected.

Differential diagnosis of pneumonia

Nevertheless, modern approaches to etiotropic treatment of patients with pneumonia require a number of additional laboratory and instrumental tests with a view to the possible identification of the pathogen, differential diagnosis of pulmonary disease, assessment of the functional state of the respiratory system and timely diagnosis of complications disease. To this end, in addition to chest X-ray, general and biochemical blood analysis, the following additional studies are envisaged:

• sputum examination (microscopy of the colored preparation and sowing to identify the pathogen);
• evaluation of the function of external respiration;
• The study of blood gases and oxygen saturation of arterial blood (in cases
• pneumonia of severe course to be treated in the ICU;
• repeated blood tests "for sterility" (with suspicion of bacteremia and sepsis);
• X-ray computed tomography (with insufficient informativeness of the traditional X-ray study);
• Pleural puncture (in the presence of effusion) and some others.

The choice of each of these methods is individual and should be based on an analysis of the clinical picture of the disease and the effectiveness of the diagnosis, differential diagnosis and treatment.

Radiographic diagnosis of pneumonia

X-ray methods of investigation are crucial in the diagnosis of pneumonia. Currently, the clinic is widely used methods such as X-ray and chest X-ray, tomography, computed tomography. The practitioner should be well aware of the possibilities of these methods, so that in each case diseases correctly choose the most informative ones and, if possible, reduce the radiation load on the patient.

X-ray examination

It should be borne in mind that one of the most accessible and common methods of X-ray studies - fluoroscopy of the chest - has a number of significant deficiencies, and exactly:

1. differs in the well-known subjectivity of the interpretation of the radiographic picture,
2. does not provide an opportunity to objectively compare the radiographic data obtained during repeated studies and
3. accompanied by a large radiation burden on the patient and the medical staff.

Therefore, the field of application of fluoroscopy in clinical practice, apparently, should be limited to the study of chest organs in the process of their movement (for example, the study of the mobility of the diaphragm, the nature of the movements of the heart when it is contracted, etc.) and clarifying the topography of pathological changes in the lungs using different positions patient.

Radiography

The main method of radiographic examination of the respiratory system is radiography in two projections - direct and lateral, allowing to receive objective and documented information on the state of the thoracic organs cells. In this case, it is necessary, as far as possible, to encircle not only the nature of the pathological process, but also to accurately determine its localization, corresponding to the projection of a particular proportion of the lung and pulmonary segments.

X-ray diagnosis of pneumonia is based on the results of a study of pulmonary fields, including the evaluation of:

• features of the pulmonary pattern;
• condition of the roots of the lungs;
• presence of widespread or limited darkening of pulmonary fields (compaction of lung tissue);
• the presence of limited or diffuse bleaching of lung tissue (increased airiness).

Of great importance is also the evaluation of the state of the skeleton of the chest and the determination of the position of the diaphragm.

The roots of the lungs located in the middle zone of the pulmonary fields between the anterior ends of the II and IV ribs are formed by shadows of the branches of the pulmonary artery and pulmonary veins, as well as of the large bronchi. Depending on their location in relation to the plane of the screen, they are represented on the X-ray in the form of branching strips or clear round or oval formations. The shadows of the vessels forming the root of the lung continue and beyond its limits in the pulmonary fields, forming a pulmonary pattern. Normally, it is well marked in the central basal zone, and on the periphery is represented by only a few, very small, vascular branches.

The following is a brief description of the radiographic pattern characteristic of the two clinical and morphological variants pneumonia (croup and focal), as well as some features of radiological changes in pneumonia of various etiology.

Tomography

Tomography is an additional method of "layer-by-layer" radiological examination of organs, which is used in patients with pneumonia for a more detailed the study of the pulmonary pattern, the nature of the pathological process in the pulmonary parenchyma and interstitium, the state of the tracheobronchial tree, the roots of the lungs, the mediastinum etc.

The principle of the method is that as a result of the synchronous movement of the X-ray tube and the film cassette in the opposite direction on the film a fairly clear image is obtained only of those parts of the organ (its "layers") that are located at the center level or the axis of rotation of the tube and cassette. All the other details ("elephant") that are outside this plane are, as it were, "smeared their image becomes blurred.

To obtain a multi-layered image, special cassettes are used, in which several films are placed at a suitable distance from each other. More commonly used is the so-called longitudinal tomography, where the separated layers are in the longitudinal direction. The "swing angle" of the tube (and cassette) is usually 30-45 °. This method is used to study pulmonary vessels. To evaluate the aorta, pulmonary artery, lower and upper hollow, it is better to use a transverse tomography.

In all cases, the choice of the depth of tomographic examination, exposure value, swing angle and other technical parameters of the study is carried out only after the analysis of the pre-made x-ray snapshot.

With diseases of the respiratory system, the method of tomography is used to clarify the nature and individual details of the pathological process in the lungs, as well as to assess the morphological changes in the trachea, bronchus, lymph nodes, vessels, etc. This method is particularly important in the study of patients who are suspected of having a tumor in the lungs, bronchi and pleura.

The program of examination for suspected pneumonia

According to the consensus of the Russian Congress of Pulmonology (1995), the following research is recommended for pneumonia.

1. Research, mandatory for all patients
   • clinical examination of patients;
   • a clinical blood test;
   • X-ray of the lungs in two projections;
   • bacterioscopy of sputum stained by Gram;
   • sputum culture with a quantitative assessment of the flora and the definition of its sensitivity to antibiotics;
   • general urine analysis.
2. Studies conducted according to the indications
   • study of the function of external respiration in case of ventilation disorders;
   • study of blood gases and acid-base balance in severe patients with respiratory failure;
   • pleural puncture followed by a pleural fluid study in patients with fluid in the pleural cavity;
   • tomography of the lungs with suspected destruction of lung tissue or lung neoplasm;
   • serological tests (detection of antibodies to the pathogen) - with atypical pneumonia;
   • biochemical analysis of blood in severe pneumonia in persons over 60;
   • fibrobronchoscopy - if suspected of swelling, hemoptysis, with prolonged pneumonia;
   • the study of the immunological status - with a prolonged course of pneumonia and in persons with signs of immunodeficiency;
   • scintigraphy of the lungs - with suspected PE.

X-ray signs of croupous pneumonia

Stage of the tide

The earliest radiologic change that occurs on the first day of croupous pneumonia (tidal stage) is an increase pulmonary pattern in the affected lobe, due to increased blood filling of the vessels of the lungs, as well as inflammatory pulmonary edema tissue. Thus, in the tidal stage, both vascular and interstitial components of the pulmonary pattern are intensified.

There is also a slight expansion of the lung root on the side of the lesion, its structure becomes less distinct. In this case, the transparency of the pulmonary field is practically unchanged or slightly reduced.

If the focus of the forming croupous pneumonia is located in the lower lobe, a decrease in the mobility of the corresponding dome of the diaphragm is observed.

The stage of custody

The stage of curation is characterized by the appearance on the 2nd-3rd day of the onset of the disease of intense homogeneous darkening, corresponding to the projection of the affected lobe of the lung. The intensity of the shadow is more pronounced on the periphery. The size of the affected lobe is slightly enlarged or not changed; a decrease in the volume of the share is observed comparatively rarely. There is an expansion of the lung root on the side of the lesion, the root becomes unstructured. The pleura is compacted. The lumen of large bronchi with croupous pneumonia remains free.

Stage of resolution

The resolution stage is characterized by a gradual decrease in the intensity of the shadow and its fragmentation. In uncomplicated pneumonia, after -3 weeks, complete resolution of the infiltrate occurs. In other cases, the reinforcement of the pulmonary pattern with areas of its deformation is preserved on the site of the affected part, which is the radiographic evidence of pneumofibrosis. At the same time, a small seal of the pleura remains.

X-ray signs of focal pneumonia

Focal bronchopneumonia is characterized by infiltration of alveolar and interstitial tissue and involvement in the inflammatory process of the lung root on the side of the lesion. At the initial stages of the disease there is a local enhancement of the pulmonary pattern and a slight expansion of the lung root. After a while in the pulmonary field, relatively small (from, to, cm in diameter) and diverse in form foci of infiltration (dimming) begin to appear. They are characterized by a multiplicity, different size, low intensity of the shadow, blurred outlines and, as a rule, are accompanied by an intensification of the pulmonary pattern. The roots of the lungs become enlarged, slightly structured, with indistinct contours.

Often there are several enlarged peribronchial lymph nodes. There is also a limitation of the mobility of the dome of the diaphragm.

In uncomplicated cases under the influence of anti-inflammatory treatment, a positive dynamics of the radiographic pattern is usually observed and after 2 weeks, pulmonary infiltrates dissolve. Sometimes bronchopneumonia can be complicated by reactive pleurisy or destruction of lung tissue.

X-ray signs of staphylococcal pneumonia

X-ray picture of staphylococcal pneumonia is characterized by the presence of multiple inflammatory infiltrates, most often located in both lungs. Inflammatory infiltrates often merge. There is a tendency to their disintegration with the formation, against the background of shadows, of limited bleaching with a horizontal liquid level. With the "bullous form" of pneumonia, the cavities can disappear without a trace in one place and appear in others. Often there is effusion in the pleural cavity.

After the resolution of staphylococcal pneumonia the strengthening of the pulmonary pattern persists for a long time, and in some cases Areas of pionmosclerosis are formed, cysts remain on the place of the cavities, the pleural sheets are preserved (mooring lines).

X-ray signs of pneumonia caused by Klebsiella

The peculiarity of Friedlander pneumonia, caused by klebsiella, is the vastness of the lesion of lung tissue, which radiologically manifests itself from the first days of the disease. Multiple large or smaller inflammatory infiltrates quickly merge with each other, capturing large areas of the lung, often corresponding to the projection of a whole lobe of the lung ("pseudoblary" pneumonia). Quite quickly in the infiltrate, multiple decay cavities appear, which also tend to merge and form a large cavity with a horizontal liquid level. Often, the disease is complicated by the development of exudative pleurisy.

The course of Friedlander pneumonia is long (up to 2-3 months). After recovery, as a rule, remain areas of pronounced pynmosclerosis and lung lining. Often formed bronchiectasises, and the pleural cavity is partially obliterated.

X-ray signs of pneumonia caused by intracellular pathogens

With legionellosis pneumonia, radiographic changes are diverse. Most often, multiple infiltrates are detected in both lungs, which later merge into a large shared darkening. Disintegration of the tissue and the formation of abscesses are rare. Degeneration of infiltrates and normalization of the radiographic pattern in uncomplicated course of the disease occurs in 8-10 weeks.

With mycoplasmal pneumonia, only local enhancement and deformation of the pulmonary pattern can be detected on the radiographs, reflecting the infiltration of the interstitial tissue. Some patients in this foyer have low intensity focal shadows that tend to merge. Normalization of the radiographic pattern occurs through 2-4 pedules.

In chlamydial pneumonia, focal reinforcement and deformation of the pulmonary pattern, expansion of the lung root and pleural reaction in the form of its consolidation are also initially determined. Further on this background, numerous inflammatory foci, of low intensity, with indistinct contours can appear. After their disappearance against the background of treatment for a long time, the enhancement of the pulmonary pattern persists, and sometimes discoid atelectasis is seen. Normalization of the radiographic pattern occurs in 3-5 weeks.

Computed tomography with pneumonia

Computed tomography (CT) is a highly informative method of X-ray examination of a patient, which is becoming increasingly common in clinical practice. The method is characterized by high resolution, allowing to visualize foci up to 1-2 mm in size, the possibility of obtaining quantitative information about the density of tissues and the convenience of presenting an x-ray picture in the form of thin (up to 1 mm) successive transverse or longitudinal "slices" of the investigated bodies.

The transmission of each tissue layer is carried out in a pulsed mode by means of an X-ray tube with a slot collimator that rotates about the longitudinal axis of the patient's body. The number of such translucent images at different angles is 360 or 720. Each time the X-rays pass through the tissue layer, the radiation attenuates, depending on the density of the individual structures of the layer under study. The degree of attenuation of X-ray radiation is measured by a large number of special highly sensitive detectors, after which all the information obtained is processed by a high-speed computer. As a result, a cut image of the organ is obtained in which the brightness of each coordinate point corresponds to the density of the tissue. Image analysis is carried out both in automatic mode using computers and special programs, and visually.

Depending on the specific tasks of the study and the nature of the pathological process in the lungs, the physician-operator can choose the thickness of the axial sections and the direction of tomography, as well as one of the three modes research.

1. Continuous CT, when all images of all sections of the organ are successively obtained. This method of tomography makes it possible to obtain maximum information about morphological changes, but it differs in the large radiation load and in the cost of the study.
2. A discrete CT with a given relatively large interval between slices, which significantly reduces the radiation load, leading to the loss of some information.
3. Aimed CT scan consists of a careful layer-by-layer examination of one or several areas of the organ of interest to the physician, usually in the area of ​​pathology previously identified.

Continuous CT of the lung allows you to get maximum information about pathological changes in the organ and is shown before all with volumetric processes in the lungs, when there is no evidence of lung cancer or metastatic lesion bodies. In these cases, CT provides an opportunity to study in detail the structure and dimensions of the tumor itself and to clarify the presence of metastatic lesion pleura, mediastinal lymph nodes, lung roots and retroperitoneal space (with CT of the abdominal cavity and retroperitoneal space).

Discrete CT is more indicated for diffuse pathological processes in the lungs (pyevmoconiosis, alveolitis, chronic bronchitis, etc.), when operative treatment is supposed.

Sighting CT is used mainly in patients with established diagnosis and the established nature of the pathological process, for example, to clarify the contour of volumetric formation, the presence of necrosis, the state of the surrounding lung tissue etc.

Computer tomography has significant advantages over conventional X-ray examination, since it allows to detect more subtle details of the pathological process. Therefore, indications for the use of CT in clinical practice are in principle quite broad. The only significant factor limiting the application of the method is its high cost and its low availability for some medical institutions. Considering this, one can agree with the opinion of a number of researchers that "the most common indications for CT of the lungs arise when the informativeness routine radiographic examination is not sufficient for the establishment of a languorous diagnosis and the results of CT can affect the tactics treatment ".

In patients with pneumonia, the need for CT is about 10%. With CT, infiltrative changes in the lungs are detected at earlier stages of the disease.

General clinical blood test for pneumonia

The general clinical analysis of blood is included in the mandatory plan of examination of all inpatients and outpatients with pneumonia. The greatest diagnostic value is counting the number of leukocytes, determining the leukocyte formula and ESR.

Number of leukocytes

Normally, the total number of leukocytes is (, ) × 109 / l.

Leukocytosis is typical for the majority of patients with bacterial pneumonia. It indicates the acceleration of the maturation of leukocytes in the organs of hematopoiesis under the influence of numerous natural stimulants of leukopoiesis: physical and chemical factors of inflammation, including inflammatory mediators, tissue decay products, hypoxemia, formed immune complexes, some toxic substances, increased function of the pituitary-adrenal system, which controls the maturation of leukocytes, and others. Most of these factors are natural signals to the activation of protective functions of leukocytes.

Leukocytosis in patients with pneumonia in most cases reflects a satisfactory reactivity of the system of bone marrow hematopoiesis in response to the action of external and internal stimulants of leukopoiesis. At the same time, leukocytosis is a fairly sensitive marker of the severity of the inflammatory process in the lungs

At the same time, it should be remembered that in pneumonia caused by chlamydia, in most cases there is moderate leukopenia (a decrease in the number of leukocytes is less, x 10 ° / l). With mycoplasmal pneumonia, the total number of leukocytes usually remains normal (about, x 109 / L), although in 10-15% of cases, leukocytosis or leukopenia is determined. Finally, viral infections are usually accompanied by an increase in ESR and a normal or reduced number of leukocytes (leukopenia).

In all other cases of bacterial pneumonia caused by pneumococci, streptococci, staphylococci, hemophilic rod, Legionella, Klebsiella, Pseudomonas rod, etc., the appearance of leukopenia, as a rule, indicates a significant oppression of leukopoiesis in the hematopoietic organs and is a very unfavorable prognostic sign. More often it is observed in the elderly, exhausted and weakened patients, which is associated with a decrease in immunity and the general resistance of the body. In addition, it should be remembered that leukopenia can be associated with the use of certain drugs (antibiotics, cytostatics, non-steroidal anti-inflammatory drugs, etc.) and autoimmune processes complicating, in particular, the course pneumonia.

Leukocytosis is typical for most patients with bacterial pneumonia. The exception is pneumonia caused by chlamydia and mycoplasma, as well as most viral infections in which moderate leukopenia or normal white blood cell count can be observed.

The appearance of leukopenia in patients with bacterial pneumonia may indicate a significant inhibition of leukopoiesis and is a very unfavorable prognostic sign, indicating a decrease in immunity and overall resistance organism. In addition, leukopenia can develop on the background of treatment with antibiotics, cytostatics and non-steroidal anti-inflammatory drugs.

Leukocyte formula

The leukocyte formula is the percentage of different types of leukocytes in the peripheral blood. Counting of the leukocyte formula is carried out by immersion microscopy of stained smears stained by Romanovsky-Giemsa or by other methods.

Differentiation of different types of leukocytes and counting of the leukocyte formula requires a good knowledge of the morphological features of different leukocytes and the general scheme of hematopoiesis. Myeloid hematopoiesis is represented by cells of granulocyte, megakaryocytic, monocytic and erythrocyte germs of hematopoiesis.

Granulocytes are blood cells, the most characteristic morphological feature of which is the clearly expressed granularity of the cytoplasm (neutrophilic, eosinophilic or basophilic). These cells have a common precursor and a single evolution up to the stage of promyelocyte, after which a gradual differentiation of granulocytes into neutrophils, eosinophils and basophils, which differ significantly in their structure and function.

Neutrophils have abundant, fine, dust-like granularity of a pinkish-violet color. Mature eosinophils differ large, occupying the entire cytoplasm, granularity, which has a scarlet color ("ketovaya caviar"). The granularity of basophils is large, heterogeneous, dark purple or black in color.

Young immature granulocyte cells (myeloblast, promyelocyte, neutrophilic, eosinophilic and basophilic myelocytes and megayelocytes) of larger sizes, have a large round or slightly concave nucleus with a more gentle and fine pattern and light color. Their nuclei often contain nucleols (nucleoli).

Mature granulocytes (rod and segmented nuclei) are smaller in size, their nuclei of a darker color have the appearance of curved rods or individual segments connected by a "thread" of nuclear matter. The nuclei do not contain nucleol.

Cells of monocyte sprouts are characterized by a pale blue or grayish color of the cytoplasm, devoid of the pronounced granularity that is characteristic of granulocytes. In the cytoplasm, only individual small azurophil granules can be detected, as well as vacuoles. In immature cells of the monocytic series (monoblast, promonocyte), the nucleus is large, occupying a large part of the cell. The nucleus of a mature monocyte is smaller and has the appearance of a butterfly or fungus, although it can often take quite bizarre forms.

For cells of the lymphoid germ of hematopoiesis (lymphoblasts, prolymphocytes and lymphocytes), a very large, rounded, sometimes Bobovidio nucleus of a dense structure that occupies almost the entire cell is characteristic. The blue or blue cytoplasm is located in a narrow band around the nucleus. It is devoid of specific granularity, and therefore lymphocytes along with monocytes are called agranulocytes. Normally, as is known, in peripheral blood only mature cells of leukocytes are detected:

• segmented neutrophils, eosinophils and basophils;
• stab neutrophils (sometimes - eosinophils);
• monocytes;
• lymphocytes.

Degenerative forms of leukocytes

In addition to the cells described above, with pneumonia, infections and purulent-inflammatory diseases, there are so-called pre-generative forms of leukocytes. The most common are their following forms

1. Neutrophils with toxic granularity and vacuolation of the cytoplasm. The toxic granularity of neutrophils arises from the coagulation of the cytoplasmic protein under the influence of an infectious or toxic agent. In these cases, in addition to the fine, fine granularity typical for neutrophils, large coarse basophil-colored granules and vacuoles appear in the cytoplasm. The toxic granularity and vacuolization of the cytoplasm of neutrophils and monocytes is often found in severe pneumonia, for example with severe pneumococcal croupous pneumonia and other purulent-inflammatory diseases, accompanied by severe intoxication.
2. Hypersegmented neutrophils, the core of which consists of 6 or more segments, occur with B12 folio-deficient anemia, leukemia, as well as some infections and purulent-inflammatory diseases, reflecting the so-called nuclear shift of neutrophils to the right.
3. Degenerative changes in lymphocytes in the form of a picnotically altered nucleus, sometimes having a bilobate structure, and weak development or absence of cytoplasm
4. Atypical mononuclears are cells that combine certain morphological signs of lymphocytes and monocytes: they are larger than normal lymphocytes, but sizes do not reach monocytes, although they contain a monocytic nucleus. According to morphology, lymphomonocytes resemble blast cells and are often found in infectious mononucleosis.

Interpretation of results

Leukocyte formula in healthy people

At various pathological conditions, including at pneumonia, can occur:

• change in the leukocyte formula (increase or decrease of any type of white blood cells);
• the appearance of various degenerative changes in the nucleus and cytoplasm of mature leukocyte cells (neutrophils, lymphocytes and monocytes);
• appearance in the peripheral blood of young immature leukocytes.

To correctly interpret changes in the leukocyte formula, it is necessary to evaluate not only the percentage ratios of different types of leukocytes, but also their absolute content in 1 liter of blood. This is due to the fact that the change in the percentage of individual types of white blood cells does not always correspond to their true increase or decrease. For example, with leukopenia due to a decrease in the number of neutrophils, blood can be detected a relative increase in the percentage of lymphocytes and monocytes, whereas their absolute number will in fact be fine.

If along with the percentage increase or decrease of individual types of leukocytes, a corresponding change in their absolute content in 1 liter of blood is observed, it is said about their absolute change. The increase or decrease in the percentage of cells with their normal absolute content in the blood corresponds to the concept of relative change.

Consider the diagnostic significance of some changes in the leukocyte formula, the most common in clinical practice, including in patients with pneumonia.

Neutrophilia - an increase in the number of neutrophils is greater, x 109 / l - is a reflection of a unique defense of the organism in response to the action of numerous exogenous and endogenous factors. The most frequent (but not the only) causes of neutrophilia, in most cases combined with leukocytosis, are:

1. Acute infections (bacterial, parasitic, fungal, rickettsial, etc.).
2. Acute inflammatory and purulent processes (pneumonia, sepsis, abscess, exudative pleurisy, empyema of the pleura and many others).
3. Diseases accompanied by necrosis, decay and tissue damage.
4. Intoxication.

When evaluating the diagnostic and prognostic significance of a neutrophil shift, it is important to determine the percentage of immature and mature forms of neutrophils. To do this, calculate the nuclear neutrophil shift index - the ratio of the content of myelocytes, metamyelocytes and stab neutrophils to segmented nuclei.

Nuclear shear index = myelocytes + metamyelocytes + stab-stem / segment-nuclear

Normally, the nuclear shear index is equal to 5,.

• The shift of the blood formula to the left is an increase in the number of stab neutrophils in the peripheral blood and (rarely) the appearance in a small number of immature granulocytes (metamyelocytes, myelocytes and even single myeloblasts), which indicates a significant stimulation of the bone marrow and acceleration leukopoiesis. The nuclear neutrophil shift index is greater than,.
• The shift of the blood formula to the right is an increase in the number of mature segment neutrophils in the peripheral blood, the appearance of hypersegmented ones, and the decrease or disappearance of stab neutrophils. The nuclear shear index is less, 5.

In the majority of patients with pneumonia, acute infections, purulent-inflammatory and other diseases accompanied by neutrophilia, the shift of formula blood to the left is limited only by an increase in the number of stab neutrophils (hyporegenerative nuclear shift), which in combination with moderate leukocytosis, as a rule, indicates a relatively easy flowing infection or a limited purulent-inflammatory process and good resistance organism.

With a severe course of the disease and the preserved resistance of the body, a shift in the blood formula to metamyelocytes, myelocytes and (less often) to myeloblasts (hyperregenerative nuclear shift to the left), which, in combination with high leukocytosis and neutrophilia, is referred to as a leukemoid reaction of the myeloid type, because it resembles a picture of the blood at myeloid leukemia. These changes are usually accompanied by hypo- and aneosinophilia, relative lymphocytopenia and monocytopenia.

Neutrophilia with degenerative nuclear shift to the left, which is manifested by an increase in immature forms of neutrophils and appearance in peripheral blood degenerate changed segment neutrophils (toxic granularity, pycnosis of nuclei, vacuolation of the cytoplasm) is also observed in severe pneumonia. Purulent-inflammatory diseases and endogenous intoxications and indicates oppression of the functional activity of the bone marrow.

Neutrophilia with a marked shift of the blood formula to the left in combination with a slight leukocytosis or leukopenia, as a rule, indicates a severe course of the pathological process and poor resistance organism. Often such a picture of blood is observed in elderly and senile patients and in weakened and depleted patients.

Neutrophilia with nuclear shift to the right (increase in segmented and hyperpigmented neutrophils, decrease or disappearance of stab neutrophils), as rule, speaks about a good, adequate protective reaction of bone marrow hematopoiesis on infection or inflammation and about the favorable course of the disease.

Severe course of many pneumonia, also infectious, generalized pyoinflammatory, degenerative and other diseases with the preserved resistance of the organism is often accompanied by severe neutrophilia, leukocytosis and hyperregenerative shift of the blood formula to the left.

The appearance in the peripheral blood of degenerative forms of neutrophils (toxic granularity, pycnosis of nuclei and other changes), as well as pronounced neutrophilia and nuclear shift to the left in combination with a small leukocytosis or leukopenia in most cases indicate a depression of the functional activity of the bone marrow, a decrease in the body's resistance and are very unfavorable signs.

Neutropenia - a decrease in the number of neutrophils below, x 109 / l - indicates functional or organic oppression of the medullary hematopoiesis or the intensive destruction of neutrophils under the influence of antibodies to leukocytes, circulating immune complexes or toxic factors (autoimmune diseases, tumors, aleukemic forms of leukemia, the effect of certain medications, hypersplenism and etc.). It should also be borne in mind the possibility of a temporary redistribution of neutrophils within the vascular bed, which can be observed, for example, in shock. Neutropenia is usually combined with a decrease in the total number of leukocytes - leukopenia.

The most common causes of neutropenia are:

1. Infections: viral (influenza, measles, rubella, chicken pox, infectious hepatitis, AIDS), some bacterial (typhoid fever, paratyphoid, brucellosis), rickettsial (typhus), protozoal (malaria, toxoplasmosis).
2. Other acute and chronic infections and inflammatory diseases that occur in severe form and / or acquire the character of generalized infections
3. The effect of certain medications (cytostatics, sulfonamides, analgesics, anticonvulsants, antithyroid drugs, etc.).

Neutropenia, especially associated with a neutrophilic shift to the left, and developing against a background of purulent-inflammatory processes, for which is typical of neutrophilia, indicates a significant decrease in the body's resistance and unfavorable prognosis disease. Such a reaction of bone marrow hematopoiesis in patients with pneumonia is most typical for depleted, weakened patients and persons of elderly and senile age.

Eosinophilia - an increase in the number of eosinophils in the peripheral blood is greater, x 10 e / l - most often a consequence of pathological processes in which the basis lies the formation of antigen-antibody complexes or diseases accompanied by autoimmune processes or bone marrow proliferation of the eosinophilic germ hematopoiesis:

1. Allergic diseases (bronchial asthma, hives, hay fever, angioedema, serum sickness, drug disease).
2. Parasitic infestations (trichinosis, echinococcosis, opisthorchiasis, ascariasis, diphyllobothriasis, giardiasis, malaria, etc.).
3. Diseases of connective tissue (nodular periarteritis, rheumatoid arthritis, scleroderma, systemic lupus erythematosus).
4. Nonspecific ulcerative colitis.
5. Diseases of the skin (dermatitis, eczema, pemphigus, skinwort, etc.).
6. Diseases of the blood (lymphogranulomatosis, erythremia, chronic myelogenous leukemia).
7. Eosinophilic lung infiltrate.
8. Fibroplastic parietal endocarditis of Leffler.

Moderate eosinophilia often develops during the reconvalescence of patients with pneumonia and other acute infectious and inflammatory diseases ("scarlet dawn of recovery"). In these cases, eosinophilia, as a rule, is combined with a decrease in the previously observed neutrophilia and leukocytosis.

Eosinopenia - a decrease or disappearance in the peripheral blood of eosinophils - is often detected with infectious and purulent-inflammatory diseases and, along with leukocytosis, neutrophilia and a nuclear shift of the blood formula to the left, is an important laboratory sign of an active inflammatory process and a normal (adequate) reaction of bone marrow hematopoiesis inflammation.

Eosinopenia, detected in patients with pneumonia and purulent-inflammatory diseases, in combination with neutropenia, leukopenia and shear The formula of blood to the left, as a rule, reflects a decrease in the body's resistance and is a very unfavorable prognostic sign.

Basophilia - an increase in the number of basophils in the blood - in clinical practice, including with pneumonia, is rare. Among the diseases most often accompanied by basophilia, we can distinguish the following:

1. Myeloproliferative diseases (chronic myelogenous leukemia, myelofibrosis with myeloid metaplasia, true polycythemia - Vaquez disease);
2. Hypothyroidism (myxedema);
3. Lymphogramulomatosis;
4. Chronic hemolytic anemia.

Absence of basophils in peripheral blood (basbopenia) has no diagnostic value. It is sometimes seen in hyperthyroidism, acute infections, after taking corticosteroids.

Lymphocytosis - an increase in the number of lymphocytes in the peripheral blood. In clinical practice, there is a relative lymphocytosis, that is, an increase in the percentage of lymphocytes with a normal (or even slightly reduced) absolute number of lymphocytes. Relative lymphocytosis is detected in all diseases accompanied by absolute neutropenia and leukopenia, including in viral infections (influenza), purulent - inflammatory diseases that occur against the background of a decrease in body resistance and neutropenia, as well as in typhoid, brucellosis, leishmaniasis, agranulocytosis, and others.

Absolute increase in the number of lymphocytes in the blood is greater, x 109 / l (absolute lymphocytosis) is typical for a number of diseases:

1. Acute infections (including the so-called childhood infections: pertussis, measles, rubella, chicken pox, scarlet fever, infectious mononucleosis, mumps, acute infectious lymphocytosis, acute viral hepatitis, cytomegalovirus infection and etc.).
2. Tuberculosis.
3. Hyperthyroidism.
4. Acute and chronic lymphatic leukemia.
5. Lymphosarcoma.

Contrary to popular belief, lymphocytosis with purulent-inflammatory diseases and pneumonia can not considered as a reliable laboratory indication of the compensatory response of the immune system and the onset of recovery. Lymphocytopenia - a decrease in the number of lymphocytes in the peripheral blood. Relative lymphocytopenia is observed in such diseases and at a stage in the development of the pathological process for which characterized by an absolute increase in the number of neutrophils (neutrophilia): various infections, purulent-inflammatory diseases, pneumonia. Therefore, in most cases, such relative lymphocytopenia of independent diagnostic and prognostic value does not matter

Absolute lymphocytopenia with a decrease in the number of lymphocytes is lower, x 109 / l may indicate a deficiency of the T-system of immunity (immunodeficiency) and requires more thorough immunological examination of blood, including evaluation of the parameters of humoral cellular immunity and phagocytic activity white blood cells.

Monocytosis is also relative and absolute.

Relative monocytosis is often found in diseases that occur with absolute neutropenia and leukopenia, and its independent diagnostic value in these cases is small.

Absolute monocytosis, detected in certain infections and purulent-inflammatory processes, should to evaluate, first of all, bearing in mind that the main functions of the monocyte-macrophage series are:

1. Protection against certain classes of microorganisms.
2. Interaction with antigens and lymphocytes in separate stages of the immune reaction.
3. Elimination of affected or aged cells.

Absolute monocytosis occurs in the following diseases:

1. Some infections (infectious mononucleosis, subacute septic endocarditis, viral, fungal, rickettsial and protozoal infections).
2. Prolonged leaking inflammatory diseases.
3. Granulomatous diseases (active tuberculosis, brucellosis, sarcoidosis, nonspecific ulcerative colitis, etc.).
4. Diseases of the blood: acute myocytic leukemia, chronic myelogenous leukemia, myeloma, lymphogranulomatosis, other lymphomas, aplastic anemia.

In the first three cases (infections, purulent-inflammatory diseases), absolute monocytosis may indicate the development of pronounced immune processes in the body.

Monocytonies - a decrease or even a complete absence of monocytes in peripheral crocks - often develops during severe pneumonia, infectious and purulent-inflammatory diseases.

Leukemoid reactions are pathological reactions of the hematopoietic system, accompanied by the appearance in the peripheral blood of young immature leukocytes, which indicates a significant stimulation of the bone marrow and acceleration leukopoiesis. In these cases, the picture of the blood outwardly resembles the changes detected in leukemia. Leukemoid reactions are more often combined with pronounced leukocytosis, although in more rare cases can develop and against the background of a normal number of leukocytes or even leukopenia.

There are leukemoid reactions 1) myeloid type, 2) lymphatic (or monocytic-lymphatic) type, 3) eosinophilic type.

The leukemoid reaction of the myeloid type is accompanied by a shift in the blood formula to metamyelocytes, myelocytes and myeloblasts and are observed in severe infectious, purulent-inflammatory, septic, degenerative and other diseases and intoxications, which are characterized by hyper-regenerative nuclear shift neutrophils to the left. A particularly severe and prognostically unfavorable symptom in these diseases is the combination leukemia reaction with a normal or decreased number of leukocytes and neutrophils (leukopenia and neutropenia).

Erythrocyte sedimentation rate (ESR)

The determination of ESR is based on the property of erythrocytes to settle on the bottom of the vessel under the influence of gravity. To this end, the micromethod TP is usually used. Panchenkov. ESR is determined 1 h after the start of the study for plasma column size over the settled red blood cells. In norm or rate ESR at men makes 2-10, and at women - 4-15 mm at an o'clock.

The mechanism of agglomeration of erythrocytes and their subsidence is extremely complex and depends on many factors, first turn from the qualitative and quantitative composition of blood plasma and from the physicochemical properties of erythrocytes.

As is known, the most frequent cause of increased ESR is an increase in plasma content coarsely dispersed proteins (fibrinogen, and beta and gamma globulins, paraproteins), as well as a decrease the content of albumins. Coarse proteins have a smaller negative charge. Adsorbed on negatively charged erythrocytes, they reduce their surface charge and promote the convergence of red blood cells and their faster agglomeration.

The increase in ESR is one of the characteristic laboratory signs of pneumonia, the immediate cause of which is accumulation in the blood of coarsely dispersed fractions of globulins (more often than beta and gamma fractions), fibrinogen and other proteins of the acute phase inflammation. There is a definite correlation between the severity of inflammation of the lung tissue and the degree of ESR increase.

At the same time, it should be remembered that the increase in ESR is, although very sensitive, according to the nonspecific hematological index, the increase of which can be associated not only with inflammation, but also with any pathological process leading to severe disproteinemia (connective tissue diseases, hemoblastoses, tumors, anemia, tissue necrosis, liver and kidney disease, and etc.).

On the other hand, in patients with pneumonia, ESR may not be increased, if there is also condensation blood (increase in viscosity) or a decrease in pH (acidosis), which causes, as is known, a decrease in agglomeration erythrocytes

In addition, in the early stages of some viral infections there is also no increase in ESR, which can to some extent distort the results of the study in patients with viral-bacterial pneumonia.

Biochemical blood test for pneumonia

Evaluation of the results of biochemical blood testing in patients with pneumonia, especially in dynamics - in the course of the development of the disease, has great diagnostic and prognostic value. Changes in various biochemical indicators, being in most cases nonspecific, allow us to judge the nature and degree of disruption of processes metabolism both in the whole organism and in separate organs Comparison of this information with the clinical picture of the disease and the results of other laboratory and instrumental methods of investigation makes it possible to assess the functional state of the liver, kidneys, pancreas, endocrine organs, the system of hemostasis, and often - to make representations about the nature of the pathological process, the activity of inflammation and to recognize in a timely manner a number complications of pneumonia.

Protein and protein fractions

Determination of protein and protein fractions in patients with pneumonia is of particular importance, primarily to assess the activity of the inflammatory process. The concentration of proteins in a healthy person's plasma ranges from 65 to 85 g / l. The bulk of the total protein of the blood plasma (about 90%) is accounted for by albumins, globulins and fibrinogen.

Albumins are the most homogeneous fraction of simple proteins, almost exclusively synthesized in the liver. About 40% of albumin is in the plasma, and 60% in the intercellular fluid. The main functions of albumins are maintenance of colloid osmotic (oncotic) pressure, and also participation in transport of many endogenous and exogenous substances (free fatty acids, bilirubin, steroid hormones, magnesium ions, calcium, antibiotics and others).

Globulins of blood serum are represented by four fractions (a1, a2, beta and gamma), each of which is not homogeneous and contains several proteins that differ in their functions.

The composition of a1-globulins normally includes two proteins that have the greatest clinical significance:

• a1-antitrypsin, which is an inhibitor of a number of proteases (trypsin, chymotrypsin, kallikrein, plasmin);
• a1-glycoprotein, involved in the transport of progesterone and testosterone, binding small amounts of these hormones.
• and 2-globulins are represented by the following proteins:
• a2-macroglobulin - an inhibitor of a number of proteolytic enzymes (trypsin, chymotrypsia, thrombin, plasmin, kallikrein), is synthesized outside the liver;
• Haptoglobin - a protein that binds and transports free hemoglobin A into the cells of the reticuloedothelial system;
• ceruloplasmin - has oxidase activity and oxidizes bivalent iron to trivalent, which provides its transport with transferrin;
• apoproteids A, B and C, which are part of the lipoproteins.

The globulin fraction also contains several proteins:

• transferrin - a protein involved in the transport of ferric iron;
• hemopexin - the carrier of free heme and porphyrin, binds the hemine-containing chromoproteins (hemoglobin, myoglobia, catalase) and delivers them to the cells of the liver RES;
• lipoproteins;
• a part of immunoglobulins;
• some protein components of complement.

Gamma globulins are immunoglobulins, which are characterized by the function of antibodies produced in the body in response to the introduction of various substances with antigenic activity; modern methods make it possible to distinguish several classes of immunoglobulins (IgG, IgA, IgM, IgD and IgE).

Fibrinogen is the most important component of the blood coagulation system (factor I). It forms the basis of a blood clot in the form of a three-dimensional network in which blood cells are retained.

The content of total serum protein in a healthy person ranges from 65 to 85 g / l, and albumin - from 35 to 50 g / l. It should be emphasized that in different clinical laboratories using different automatic analyzers and methods for determining protein fractions, the specifications may differ slightly from those given in table.

Normal values ​​of protein fractions of blood serum (in%)

The albumin-globulin coefficient (A / T) is normally equal to, .

The change in the content of globulin fractions, which is very typical for any acute or chronic inflammation, is usually found in patients with pneumonia,

An increase in the content of the a1 and a2 fractions of globulins is most often observed. This is due to the fact that the so-called acute phase proteins (al-antitrypsin, o1-glycoprotein, a2-macroglobulin, haptoglobulin, ceruloplasmin, seromucoid, C-reactive protein), which naturally increase in any inflammatory process in the body. In addition, an increase in the content of a-globulins is observed with significant damage and decay of tissues (dystrophic, necrotic processes), accompanied by destruction of cells and release of tissue proteases, kallikrein, thrombin, plasmin, etc., which naturally leads to an increase in the content of their natural inhibitors (a1-antitrypsin, a1-glycoprotein, a2-macroglobulin, etc.). Damage to tissues also results in the release of pathological C-reactive protein, which is the product of cell disintegration and is part of the a1 fraction of globulins.

An increase in the beta-globulin fraction is usually observed in acute and chronic diseases, accompanied by an increase in the content of blood of immunoglobulins (usually simultaneously with an increase in the content of y-globulins), including in infections, chronic inflammatory processes in the bronchi, liver cirrhosis, connective tissue diseases, malignant neoplasms, autoimmune and allergic diseases.

An increase in the fraction of y-globulins is found in diseases accompanied by an intensification of immune processes, since the fraction of y-globulin consists mainly of immunoglobulins: with chronic infections, chronic liver diseases (chronic hepatitis and cirrhosis of the liver), autoimmune diseases (including diseases connective tissue - RA, SLE, etc.), chronic allergic diseases (bronchial asthma, recurrent urticaria, drug disease, atopic dermatitis and eczema, etc.). An increase in the y-globulin fraction is also possible with pneumonia, especially prolonged flow.

Proteins of the acute phase of inflammation

In addition to the described changes in protein fractions in patients with pneumonia, an increase in the content of the so-called proteins of the acute phase of inflammation is characteristic: fibrinogen, ceruloplasmin, haptoglobulin, a2-macroglobulin, C-reactive protein, etc., which also refer to nonspecific markers inflammatory process

Glycoproteins

Among the important in the diagnostic relation carbohydrate-containing compounds are glycoproteins - proteins containing relatively short carbohydrate chains, consisting of 10-20 monosaccharides. Their concentration in the blood also significantly increases with inflammatory processes and tissue damage (necrosis).

The composition of carbohydrate components of glycoproteins, the quantitative determination of which underlies the majority of diagnostic tests, includes:

1. hexoses (galactose, mannose, less often - glucose);
2. pentoses (xylose and arabinose);
3. deoxysugars (fucose and rhamnose);
4. aminosugar (acetylglucosamine, acetylgalactosamine);
5. sialic acids - derivatives of neuraminic acid (acetylneuraminic and glycolylneuraminic acid).

In clinical practice, the most widely used methods are the determination of sialic acids and the total amount of protein-bound hexoses.

An important diagnostic value is also the determination of hexoses associated with the so-called seromucoids. Seromucoids are a special group of carbohydrate-containing proteins that differ from conventional glycoproteins with the ability to dissolve readily in perchloric acid. This last property of seromucoids makes it possible to identify them from other glycoproteins containing hexoses.

Normally, the total content of hexoses associated with plasma proteins or blood serum is, mmol / L. Of these, the share of seromucoids is, mmol / l. The concentration in blood of sialic acids in a healthy person does not exceed, 3 mmol / l. The content of total hexose, seromucoid, and sialic acids associated with proteins increases substantially in all inflammatory processes and tissue damage (pneumonia, myocardial infarction, tumors, etc.).

Lactate dehydrogenase (LDH)

Lactate dehydrogenase (LDH) (KF 1.1.1.27) is one of the most important cellular enzymes involved in the process glycolysis, and catalyzes the reversible reaction for the reduction of pyruvic acid (pyruvate) into the lactic (lactate).

As is known, pyruvate is the final product of glycolysis. Under aerobic conditions, pyruvate, undergoing oxidative decarboxylation, is converted to acetyl-CoA and then oxidized in a cycle of tricarboxylic acids (Krebs cycle), releasing a significant amount energy. Under anaerobic conditions, pyruvate is reduced to lactate (lactic acid). This last reaction is catalyzed by lactate dehydrogenase. The reaction is reversible: in the presence of O2, lactate is again oxidized to pyruvate.

With electrophoresis or chromatography, it is possible to detect 5 isoenzymes of LDH, which differ in their physico-chemical properties. The most important are two isoenzymes - LDG1 and LDG5. Most organs contain a complete set of LDH isoenzymes, including fractions of LDH2, 3, 4.

Normally, the serum LDH activity does not exceed, mmol / h х l). Any damage to tissue cells that contain a large amount of LDH, including damage, observed during pneumonia, leads to an increase in the activity of LDH and its isoenzymes in blood serum.

Nonspecific biochemical criteria of the inflammatory process in patients with pneumonia are:

• an increase in the content of alpha and beta globulin in the blood serum, and with a more significant activation of the immune system and / or the process of chronization, an increase in the content of y-globulins;
• an increase in the content of acute phase proteins in the blood: fibrinogen, ceruloplasmin, haptoglobulin, C-reactive protein, etc .;
• increase in the content of total, protein-bound hexoses, seromucoid and sialic acids;
• an increase in the activity of lactate dehydrogenase (LDH) and its isoenzymes LDH3.

Determination of sensitivity to antibiotics

The determination of sensitivity to antibiotics is based on the evaluation of the growth of microorganisms cultivated in dense or liquid nutrient media in the presence of antibiotics. The easiest way is to sow a suspension of microorganisms of the isolated culture on the surface of a dense nutrient medium (agar) in plates of Petri, disks with antibiotics in standard concentrations are placed on the surface of the dishes and incubated at 3 ° C for 18 hours. The results are evaluated by measuring the diameter of the microbial growth retardation zone using a ruler.

More accurate data can be obtained by using quantitative methods with the determination of the minimum inhibitory concentration (MIC) of antibiotics. To this end, a series of two-fold dilutions of antibiotics in a liquid nutrient medium (broth) is prepared and added, ml of a suspension of culture of the investigated microorganisms in a concentration of 105-106 mt / ml. All samples, including control, containing no antibiotics, are incubated at 3 ° C for 24 hours. The minimum concentration of antibiotic in the last tube, in which there was complete growth retardation culture, corresponds to the MPC of the preparation and reflects the degree of sensitivity of microorganisms to antibiotic.

According to the degree of sensitivity to antibiotics, microorganisms are divided into three groups:

1. Sensitive - microorganisms, the growth of which is suppressed at the MIC, corresponding to the concentration of the drug in the blood serum with the application of usual therapeutic doses of the drug.
2. Moderately resistant - such strains of microorganisms, IPC of which is achieved with the appointment of maximum therapeutic doses of antibiotic.
3. Stable microorganisms, the growth of which is not suppressed by the maximum permissible doses of drugs.

Such a determination of the degree of sensitivity to antibiotics is possible with the use of quantitative methods of dilution in liquid nutrient media. Nevertheless, there is a definite correlation between the MIC values ​​and the size of the microbial growth retention zones when paper disks are used with antibiotics, which makes it possible to use this simple and convenient method for an approximate quantitative description of the degree sensitivity.

It should nevertheless be remembered that the results of determining the sensitivity to antibiotics in vitro do not always correspond to the real clinical situation, especially with a mixed infection, a decrease in the immunological reactivity of the organism, difficulties arising when trying to isolate the culture of the main pathogen and etc.

Formulation of the diagnosis

When formulating the diagnosis of pneumonia, it is necessary to reflect:

• etiological variant;
• localization and prevalence of the inflammatory process (segment, proportion, one- or two-sided lesion);
• severity of pneumonia;
• presence of complications;
• phase of the disease (height, resolution, ekonvalesentsiya, protracted course);
• accompanying illnesses.

Examples of the formulation of the diagnosis

1. Pneumococcal lobar pneumonia in the lower lobe of the right lung, severe course, high-grade phase. Acute subcompensated respiratory failure.
2. Streptococcal pneumonia in 6, 8, 10 segments of the right lung, moderate course, midsection. The initial stage of acute respiratory failure. Exudative pleurisy.

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Pneumonia in a child - symptoms, treatment, causes

Inflammation of the lungs or pneumonia is one of the most common acute infectious and inflammatory diseases of a person. Moreover, the concept of pneumonia does not include various allergic and vascular lung diseases, bronchitis, and also pulmonary function disorders, caused by chemical or physical factors (injuries, chemical burns).

Especially often there are pneumonia in children, the symptoms and signs of which are reliably determined only on the basis of X-ray data and a general blood test. Pneumonia among all pulmonary pathologies in young children is almost 80%. Even with the introduction of progressive technologies in medicine - the discovery of antibiotics, improved methods of diagnosis and treatment - until now this disease is among the top ten most frequent causes of death. According to statistics in various regions of our country, the incidence of pneumonia in children is, %.

When and why can a child develop pneumonia?

Lungs in the human body perform several important functions. The main function of the lungs is the gas exchange between the alveoli and the capillaries, which envelop them. Simply put, oxygen from the air in the alveolus is transported to the blood, and from the blood carbon dioxide enters the alveolus. They also regulate body temperature, regulate blood coagulability, are one of the filters in the body, contribute to the purification, removal of toxins, disintegration products arising from various traumas, infectious inflammatory processes.

And when food poisoning, a burn, a fracture, surgical interventions occur, in case of any serious injury or disease, there is a general decrease in immunity, it is easy to cope with the filtration load toxins. That is why very often after a child has suffered or is suffering from injuries or poisonings, pneumonia occurs.

The most common pathogens are pathogens - pneumococci, streptococci and staphylococci, and recently cases of lung inflammation from such pathogens as pathogenic fungi, legionella (usually after staying at airports with artificial ventilation), mycoplasma, chlamydia, which are not often mixed, associated.

Pneumonia in a child, as an independent disease that occurs after a serious, strong, prolonged hypothermia, it is extremely rare, as parents try not to allow such situations. As a rule, in most children, pneumonia occurs not as a primary disease, but as a complication after an acute respiratory viral infection or influenza, less often other diseases. Why is this happening?

Many of us believe that acute viral respiratory diseases in the last decades have become more aggressive, dangerous their complications. Perhaps this is due to the fact that both viruses and infections have become more resistant to antibiotics and antiviral drugs, so they are so hard for children and cause complications.

One of the factors contributing to the increase in the incidence of pneumonia in children in recent years has been the overall poor health in the younger generation - how many children are born with congenital pathologies, malformations, lesions of the central nervous system. Especially severe pneumonia occurs in premature or newborn babies, when the disease develops against the background of intrauterine infection with insufficiently formed, not mature respiratory system.

In congenital pneumonia, the herpes simplex virus, cytomegalovirus, mycoplasmas are not infrequently causative agents, and with infection during labor, chlamydia, group B streptococci, opportunistic fungi, E. coli, Klebsiella, anaerobic flora, when infected with hospital infections, pneumonia begins on day 6 or 2 weeks after birth.

Naturally, pneumonia often happens in cold weather, when the organism is subjected to seasonal adjustment from heat to cold and vice versa, there are overloads for immunity, at this time there is a lack of natural vitamins in foods, temperature changes, damp, frosty, windy weather contribute to children's hypothermia and their infection.

In addition, if a child suffers from any chronic diseases - tonsillitis, adenoids in children, sinusitis, dystrophy, rickets (see. rickets in infants), cardiovascular disease, any severe chronic pathologies, such as congenital lesions central nervous system, malformations, immunodeficiency states - significantly increase the risk of developing pneumonia, weighed down its course.

The severity of the disease depends on:

• Extensibility of the process (focal, focal, draining, segmental, lobar, interstitial pneumonia).
• The child's age, the younger the baby, the narrower the airways, the less intense gas exchange in the child's body and the heavier the course of pneumonia.
• Places where and for what reason there was a pneumonia:
  - community-acquired: most often have an easier flow
  - hospital: more severe, because it is possible to infect bacteria resistant to antibiotics
  - Aspiration: when inhaled foreign objects, mixture or milk.
• The most important role in this is played by the general health of the child, that is, his immunity.

Improper treatment of influenza and ARVI can lead to pneumonia in the child

When a child falls ill with an ordinary cold, SARS, influenza - the inflammatory process is localized only in the nasopharynx, trachea and larynx. With a weak immune response, and also if the causative agent is very active and aggressive, and the treatment in the child is carried out incorrectly, the process of reproduction of bacteria descends from the upper respiratory tract to the bronchi, then bronchitis. Further, the inflammation can affect the lung tissue, causing pneumonia.

What happens in the body of a child in a viral disease? Most adults and children in the nasopharynx always have different opportunistic microorganisms - streptococci, staphylococci, without causing harm to health, because local immunity holds them back growth.

However, any acute respiratory disease leads to their active reproduction and with the correct action of the parents during the illness of the child, immunity does not allow their intensive growth.

What should not be done during ARVI in the child, so as not to cause complications:

• You can not use antitussives. Coughing is a natural reflex that helps the body to clear the trachea, bronchi and lungs from mucus, bacteria, toxins. If for the treatment of a child, in order to reduce the intensity of dry cough, use antitussives that affect the cough center in the brain, such as Stoptosin, Broncholitin, Libexin, Paxeladin, then sputum and bacteria may accumulate in the lower respiratory tract, which ultimately leads to inflammation lungs.
• It is not possible to conduct any preventive therapy with antibiotics for colds, with a viral infection (see. antibiotics for colds). Against the virus, antibiotics are powerless, and with opportunistic bacteria immunity should cope, and only when complications arise according to the doctor's appointment is shown their use.
• The same applies to the use of various nasal vasoconstrictors, their use contributes to a faster penetration of the virus into the lower respiratory tract; therefore, galazoline, naphthysine, sanorin should not be used in case of a viral infection safely.
• Abundant drink - one of the most effective methods of removing intoxication, dilution of sputum and rapid cleansing respiratory tract is an abundant drink, even if the child refuses to drink, parents should be very persistent. If you do not insist that the child drink enough fluids, in addition, the room will have dry air - this will help to dry the mucosa, which can lead to a longer course of the disease or complication - bronchitis or pneumonia.
• Permanent ventilation, lack of carpets and carpeting, daily wet cleaning of the room in which the child is, Humidification and air purification with the help of a humidifier and an air cleaner will help to cope faster with the virus and prevent development pneumonia. As clean, cool, moist air helps to dissolve sputum, quickly remove toxins with sweat, cough, wet breath, which allows the child to recover faster.

Acute bronchitis and bronchiolitis - differences from pneumonia

With SARS usually the following symptoms:

• High temperature in the first 2-3 days of the disease (see Fig. antipyretics for children)
• Headache, chills, intoxication, weakness
• Qatar upper respiratory tract, runny nose, cough, sneezing, sore throat (it does not always happen).

In acute bronchitis with Orvy, the following symptoms may occur:

• Minor increase in body temperature, usually up to 38C.
• First the cough is dry, then it becomes wet, there is no shortness of breath, unlike pneumonia.
• Breathing becomes hard, on different sides there are variously scattered rales that change or disappear after coughing.
• On the roentgenogram, the intensification of the pulmonary pattern is determined, the structure of the roots of the lungs decreases.
• There are no local changes in the lungs.

Bronchiolitis occurs most often in children up to a year:

• The difference between bronchiolitis and pneumonia can be determined only by X-ray examination, based on the absence of local changes in the lungs. According to the clinical picture, the acute symptoms of intoxication and the increase in respiratory insufficiency, the appearance of dyspnoea - very much resemble pneumonia.
• In bronchiolitis, the breathing in a child is weakened, shortness of breath with the help of an auxiliary musculature, nasolabial the triangle becomes a bluish hue, a common cyanosis is possible, a pronounced pulmonary-cardiac failure. When listening to a boxed sound is detected, the mass of scattered small bubbling rales.

Signs of pneumonia in the child

With a high activity of the causative agent of the infection, or with a weak immune response of the body to it, when even the most effective preventive medical measures do not stop inflammatory process and the child's condition worsens, parents can for some symptoms guess that the child needs more serious treatment and urgent examination doctor. In this case, in no case should not begin treatment by any popular method. If it really is pneumonia, it will not only not help, but the condition may worsen and time for adequate examination and treatment will be missed.

Symptoms of pneumonia in a child 2 - 3 years and older

How to identify attentive parents with a cold or viral illness that it is necessary to urgently call a doctor and suspect a pneumonia in the child? Symptoms that require an X-ray diagnosis:

• After Orvi, influenza within 3-5 days there is no improvement or after a slight improvement again there is a temperature jump and increased intoxication, coughing.
• Lack of appetite, sluggishness of the child, sleep disturbance, capriciousness persist within a week after the onset of the illness.
• The main symptom of the disease remains a strong cough.
• The body temperature is not high, but the baby has shortness of breath. In this case, the number of breaths per minute in a child increases, the rate of breaths per minute in children aged 1-3 years 25-30 breaths, children 4-6 years - a rate of 25 breaths per minute, if the child is in a relaxed calm condition. With pneumonia, the number of breaths becomes larger than these figures.
• With the other symptoms of a viral infection - cough, temperature, cold, severe pallor of the skin is observed.
• If the temperature is high for more than 4 days and antipyretic agents such as Paracetamol, Efferalgan, Panadol, Tylenol are not effective.

Symptoms of pneumonia in infants, children under one year of age

The onset of the disease can be noticed by the mom by changing the behavior of the baby. If the child constantly wants to sleep, become sluggish, apathetic or vice versa, a lot of naughty, crying, refuses to eat, while the temperature may slightly increase - mom should urgently turn to pediatrician.

Body temperature

In the first year of life, pneumonia in a child, a symptom which is considered to be high, not knocked down temperature, is different in that at this age it is not high, does not reach 3, or even 3, -3,. The temperature is not an indication of the severity of the state.

The first symptoms of pneumonia in an infant

This causeless anxiety, lethargy, decreased appetite, the baby refuses from the breast, the sleep becomes restless, short, there is a loose stool, there may be vomiting or regurgitation, a runny nose and a paroxysmal cough that worsens during crying or feeding child.

Child's breathing

Pain in the chest with breathing and coughing.
Sputum - with a damp cough, purulent or mucopurulent sputum (yellow or green) is secreted.
Shortness of breath or an increase in the number of respiratory movements in young children is a clear sign of pneumonia in a child. Dyspnoea in babies can be accompanied by nodding to the breath, as well as the baby blows his cheeks and extends his lips, sometimes there are foamy discharge from the mouth and nose. The symptom of pneumonia is considered to be the excess of the number of breaths per minute:

• In children up to 2 months - the norm is up to 50 breaths per minute, more than 60 is considered a high frequency.
• In children, after 2 months to a year, the norm is 25-40 breaths, if 50 or more, this is an excess of the norm.
• In children older than one year, the number of breaths more than 40 is considered a shortness of breath.

The skin relief during breathing changes. Attentive parents can also notice the retraction of the skin during breathing, more often on one side of the patient's lung. To notice this, it is necessary to undress the baby and observe the skin between the ribs, it retracts when breathing.

With extensive lesions, there may be a lag of one side of the lung with deep breathing. Sometimes you can notice periodic stopping of breathing, disturbance of rhythm, depth, breathing frequency and the child's desire to lie on one side.

Cyanosis of the nasolabial triangle

This is the most important symptom of pneumonia, when the blue skin appears between the lips and the spout of the baby. Especially this sign is pronounced when the child sucks the breast. With severe respiratory failure, a slight blueing can be not only on the face, but also on the body.

Chlamydia, mycoplasmal pneumonia in children

Among the pneumonias, the causative agents of which are not banal bacteria, but various atypical representatives secrete mycoplasmal and chlamydial pneumonia. In children, the symptoms of such pneumonia are slightly different from the course of the usual pneumonia. Sometimes they are characterized by a hidden sluggish current. Symptoms of SARS in a child can be as follows:

• The onset of the disease is characterized by a sharp rise in body temperature to 3, C, then a stable subfebrile temperature of -3, -3 is formed, or even a temperature normalization occurs.
• It is also possible the onset of the disease with the usual signs of ARVI - sneezing, choking in the throat, a bad cold.
• Persistent dry debilitating cough, shortness of breath may not be permanent. Such a cough usually occurs with acute bronchitis, and not pneumonia, which complicates the diagnosis.
• When listening to a doctor, scanty data are usually presented: rare variegated rattles, pulmonary percussion sound. Therefore, according to the nature of wheezing, it is difficult for a doctor to determine atypical pneumonia, since there are no traditional signs, which greatly complicates the diagnosis.
• In the analysis of blood in atypical pneumonia there may be no significant changes. But usually there is increased ESR, neutrophilic leukocytosis, a combination with anemia, leukopenia, eosinophilia.
• On the x-ray of the chest reveals a pronounced enhancement of the pulmonary pattern, non-uniform focal infiltration of the pulmonary fields.
• Both chlamydia and mycoplasma have a feature that exists for a long time in the epithelial cells of the bronchi and lungs, therefore, pneumonia usually has a prolonged recurrent character.
• Treatment of atypical pneumonia in the child is carried out by macrolides (azithromycin, josamycin, clarithromycin), because the pathogens to them are most sensitive (to tetracyclines and fluoroquinolones, too, but they are children contraindicated).

Indications for hospitalization

The decision on where to treat a child with pneumonia - in a hospital or at home, the doctor takes, while he takes into account several factors:

• The severity of the condition and the presence of complications - respiratory failure, pleurisy, acute disorders of consciousness, heart failure, falls AD, lung abscess, pleural empyema, infectious-toxic shock, sepsis.
• The defeat of several lobes of the lung. Treatment of focal pneumonia in the child at home is entirely possible, but with croupous pneumonia treatment is best done in a hospital.
• Social indications are poor living conditions, inability to perform care and doctor's prescriptions.
• Age of the child - if the infant is sick, this is the reason for hospitalization, because the pneumonia of the baby is a serious threat to life. If pneumonia develops in a child under 3 years of age, treatment depends on the severity of the condition and most often doctors insist on hospitalization. Older children can be treated at home provided that the pneumonia is not severe.
• General health - in the presence of chronic diseases, weakened overall health of the child, regardless of age, the doctor may insist on hospitalization.

Treatment of pneumonia in children

How to treat pneumonia in children? The basis of therapy for pneumonia is antibiotics. At a time when there were no antibiotics in the arsenal of doctors with bronchitis and pneumonia, a very frequent cause of death of adults and children there was pneumonia, therefore, in no case should one refuse to use them, no folk remedies for pneumonia are effective. From the parents it is required to strictly follow all the doctor's recommendations, the proper care of the child, the observance of the drinking regime, nutrition:

• Reception of antibiotics must be carried out strictly in time, if the appointment of the drug 2 times per day, this means that there should be a break of 12 hours between meals, if 3 times a day, then a break of 8 hours (cm. 11 rules how to take antibiotics correctly). Antibiotics are prescribed - penicillins, cephalosporins for 7 days, macrolides (azithromycin, josamycin, clarithromycin) - 5 days. The effectiveness of the drug is estimated within 72 hours - an improvement in appetite, a decrease in temperature, dyspnea.
• Antipyretics are used if the temperature is above 39C, in infants above 38C. Initially, antibiotic treatment of antipyretics is not prescribed, as the evaluation of the effectiveness of therapy is difficult. It should be remembered that during a high temperature in the body, the maximum amount antibodies against the causative agent of the disease, so if the child can tolerate the temperature of 38C, it is better not to knock down. So the body quickly cope with the microbe that caused pneumonia in the baby. If the child had at least one episode of febrile seizures, the temperature should be knocked down already at 3, C.
• Nutrition of the child with pneumonia - lack of appetite in children during illness is considered natural and the child's refusal from food intake due to increased strain on the liver when fighting infection, so you can not force a child to feed. If possible, prepare light food for the patient, exclude any ready-made chemicals, fried and fatty, try to feed child simple, easily assimilated food - cereals, soups on a weak broth, steam cutlets from low-fat meat, boiled potatoes, various vegetables, fruit.
• Oral hydration - in water, natural freshly diluted juices - carrot, apple, weakly boiled tea with raspberries, rose hips infusion, water-electrolyte solutions (Regidron and etc).
• Airing, daily wet cleaning, use of air humidifiers - ease the condition of the baby, and the love and care of parents works wonders.
• No restorative (synthetic vitamins), antihistamines, immunomodulating agents are not used, as often lead to side effects and do not improve the course and outcome of pneumonia.

Reception of antibiotics for pneumonia in a child (uncomplicated) usually does not exceed 7 days (macrolides 5 days), and if bed rest is observed, perform all the doctor's recommendations, in the absence of complications, the child quickly recovers, but for a month there will still be residual effects in the form of a cough, slight weakness. With atypical pneumonia, treatment can be delayed.

In the treatment of antibiotics in the body, the intestinal microflora is broken, so the doctor prescribes probiotics - RioFlora Immuno, Acipol, Bifiform, Bifidumbacterin, Normobakt, Lactobacterin. Analogues of Linex - a list of all probiotics). To remove toxins after the end of therapy, the doctor can prescribe sorbents, such as Polysorb, Enterosgel, Filtrum.

With the effectiveness of treatment for general regimen and walks, it is possible to transfer the child from the 6th to the 10th day of the disease, the hardening to resume after 2-3 weeks. With a mild pneumonia, large physical exertion (sport) is allowed after 6 weeks, with complicated after 12 weeks.

zdravotvet.ru

Can there be a good blood test for pneumonia ???

Answers:

Mikhail Morozov

An error may occur. Good analysis, with pneumonia, can not be!
Changes in the general blood test for pneumonia:

- with mild pneumonia in the blood test, moderate leukocytosis and shift of the leukocyte formula to the left, increased ESR;

- with moderate severity - pronounced leukocytosis with a shift to the left to young forms, increased ESR;

- with severe course in the analysis high leukocytosis, toxic granulocyte neutrophil, sharp shift leukocyte formula to the left right up to myelocytes, decrease in the number of eosinophils, lymphocytes, very high ESR. In the blood, anemia is also possible with prolonged intoxication; an increase in the number of eosinophils more than 5% is an early and characteristic sign of allergization and allergy.

- with a favorable course of pneumonia (pneumonia) in the analysis of blood before the crisis, the number of eosinophils and monocytes increases;

- the absence of leukocytosis in blood analysis is observed in weakened and elderly patients and is a prognostically unfavorable sign.

Lelya Ivanova

Pneumonia is a clear inflammatory process, blood is unlikely to show a good analysis

Nos

if you have a blood test that consists of a single ESR, then there may be a normal figure for pneumonia.

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