Everyone is familiar with the classic signs of pneumococcal pneumonia: high fever, stunning chills, pleural pain in the chest, pink sputum, gentle wheezing during inhalation, bronchophony and egophony. However, as might be expected, this classic picture is often incomplete or completely different.
Bacterial pneumonia, caused by pneumococcus or other pathogens, often gives a much less dramatic picture. Cough is noted in almost all cases of acute bacterial pneumonia, with the exception of newborns or very young children, who often have no cough even with severe pneumonia. The author, however, had the opportunity to conduct a prospective study of 100 children with pneumococcal pneumonia. As shown by anamnestic and clinical data, cough was not only one child.
The time to start a fever may be the key to diagnosing pneumonia. Thus, with ordinary infections of the upper respiratory tract (tracheitis or bronchitis), fever develops in the first 24–48 hours of the disease and lasts from 2 to 4 days against the backdrop of increased cough. After resolving a fever, cough often increases dramatically and can last days or even weeks.
A fever that occurred 3-4 days after the onset of a respiratory disease or persists for more than 4-5 days should serve as a warning to the doctor about the possible development of purulent complications such as pneumonia or otitis.
Wheezing, bronchial breathing, bronchophony, an increase in finger tremor, weakened breathing and dullness in percussion should immediately lead the doctor to the idea of pneumonia. However, in some cases, the only sign of pneumonia in children with cough and fever may be tachypnea, and diagnosis can be difficult because the fever itself causes an increase in the number of breaths. According to Pizzo, for every 1 ° C increase in body temperature, the number of respiratory cycles increases by 2 per minute.
Theoretically, one can calculate whether the number of breaths corresponds to the degree of increase in body temperature. But more information is provided by re-examining the patient and counting the respiratory rate after taking appropriate antipyretic measures and normalizing the temperature.
Stenotic (“grunting”) breathing is an infrequent but important symptom. If coughing and tachypnea can be caused by a variety of causes, most of which are benign, then stenotic respiration is caused by a few causes, but most of them are very serious.
Stenotic respiration occurs when the upper airway is constricted during exhalation. This leads to an increase in pressure in the alveoli, which prevents their collapse and fluid penetration through the alveolar capillary membrane. Stenotic respiration indicates an alveolar lesion – most often pneumonia or pulmonary edema. It can also be one of the early signs of septic shock, possibly due to endotoxin damage to the alveolar capillaries and penetration of protein and fluid into the alveoli. In the absence of heart disease or shock, stenotic breathing should be considered a symptom of pneumonia until its other cause is proven.
In some cases, the first signs of pneumonia may be extrapulmonary symptoms. Thus, neck stiffness is noted not only in meningitis, but also in upper lobe pneumonia (in at least two cases, the author observed the stiffness of the occipital muscles in inferior lobar pneumonia and normal cerebrospinal fluid). The mechanism of this phenomenon is unclear. It is possible that the involvement of the back of the pleura causes pain when the muscles of the back or neck are stretched. Sometimes the earliest or most prominent manifestation of pneumonia is intestinal obstruction.
Most often it develops in case of lower lobe pneumonia and is probably associated with inflammation of the diaphragmatic part of the pleura. The first symptom of pneumonia can be abdominal pain in combination with signs of intestinal obstruction or without them.