The Differences and Similarities of Pneumonia and Tuberculosis

Pneumonia and tuberculosis have been plaguing the citizens of the world for centuries causing millions of deaths. This occurred until the creation and use of antibiotics become more widely available. These two respiratory infections have many differences, which include their etiology, incidence and prevalence, and many similarities in their objective and subject indicators, medical interventions, course, rehabilitation and effects.

To explore the relationship between pneumonia and tuberculosis we will examine a case study. Joan is a 35 year old women who was feeling fine up till a few weeks ago when she develop a sore throat. Since her sore throat she had been experiencing chest pain, a loss of appetite, coughing and a low fever so she went to visit her doctor. Her doctor admitted her to the hospital with bacterial pneumonia and after three days of unsuccessful treatment it was discovered that she actually had active tuberculosis. This misdiagnosis shows the similarities between the two diseases and how easily they can be confused.

Differences in Pneumonia and Tuberculosis

Pneumonia

Pneumonia is a serious infection or inflammation of the lungs with exudation and consolidation. Pneumonia can be one of two types: lobar pneumonia or bronchial pneumonia. Lobar pneumonia affects one lobe of a lung while bronchial pneumonia affects the areas closest to the bronchi (O'Toole, 1992). In the United States over three million people are infected with pneumonia each year; five percent of which die.

Etiology

There are over 30 causes for pneumonia however there are 4 main causes which are bacterial, viral, mycoplasma and fungal (American Lung Association, 1996). Bacterial pneumonia attacks everyone from young to old, however "alcoholics, the debilitated, post-operative patients, people with respiratory disease or viral infections and people who have weakened immune systems are at greater risk" (American Lung Association, 1996). The Pneumococcusis bacteria, which is classified as Streptococcus pneumoniae, causes bacterial pneumonia and can be prevented by a vaccine. In 20 - 30% of the cases the infection spreads to the blood stream (MedicineNet, 1997) which can lead to secondary infections.

Viral pneumonia accounts for half of all pneumonia cases (American Lung Association, 1996) unfortunately there is no effective treatment because antibiotics do not affect viruses. Many viral pneumonia cases are a result of an influenza infection and commonly affect children, however they are not usually serious and last only a short time (American Lung Association, 1996). The "virus invades the lungs and multiplies, but there are almost no physical signs of lung tissue becoming filled with fluid. It finds many of its victims among those who have pre-existing heart or lung disease or are pregnant" (American Lung Association, 1996). In the more severe cases it can be complicated with the invasion of bacteria that may result in symptoms of bacterial pneumonia (American Lung Association, 1996).

During World War II mycoplasma were identified as the "smallest free-living agents of disease in humankind, unclassified as to whether bacteria or viruses, but having characteristics of both" (American Lung Association, 1996). Mycoplasma pneumonia is "often a slowly developing infection" (MedicineNet, 1997) that often affects older children and young adults (American Lung Association, 1996).

The other main cause of pneumonia is fungal pneumonia. This is caused by a fungus that causes pneumocystic carinii pneumonia (PCP) and is often "the first sign of illness in many persons with AIDS and ... can be successfully treated in many cases" (American Lung Association, 1996).

In Joan's case bacterial pneumonia was suspected because her immune system was weakened by her sore throat and her signs and symptoms correlated with pneumonia.

Tuberculosis (TB)

Tuberculosis was discovered 100 years ago but still kills three million people annually (Schlossberg, 1994, p.1). Cases range from race and ethnicity. In 1990 the non-Hispanic Blacks had 9, 634 cases while the American Indians and Alaskan Natives had 371 cases (Galantino and Bishop, 1994). It is caused by bacteria called either Mycobacterium tuberculosis or Tubercle bacillus. Tuberculosis can infect any part of the body but is most often found in the lungs where it causes a lung infection or pneumonia.

Etiology

There has been a resurgence of TB due to a number of factors that include:

1. the HIV / AIDS epidemic,

2. the increased number of immigrants,

3. the increase in poverty, injection drug use and homelessness,

4. poor compliance with treatment regiments and;

5. the increased number of residents in long term facilities (Cook & Dresser, 1995).

The tuberculosis bacteria is spread through the air however transmission will only occur after prolonged exposure. For example you only have a 50% chance to become infected if you spend eight hours a day for six months with someone who has active TB (Cook & Dresser, 1995).

The tuberculosis bacteria enters the air when a TB patient coughs, sneezes or talks and is then inhaled. The infection can lie dormant in a person's system for years causing them no problems however when their immune system is weakened it gives the infection a chance to break free.

Types of TB Treatments

Types of treatment will depend on whether the patient has inactive or active tuberculosis. To diagnose active TB the doctor will look at the patients' symptoms, and outcomes of the skin test, sputum tests, and chest x-rays. A person has active tuberculosis when their immune system is weakened and they start to exhibit the signs and symptoms of the disease. They also have positive skin tests, sputum tests and chest x-rays. When this occurs the treatment is more intense.

The disease is treated with at least two different types of antibiotics in order to cure the infection. Within a few weeks the antibiotics will build the body's resistance and slow the poisons of the TB germ to prevent the patient from being contagious. An example of treatment would be short-course chemotherapy, which is the use of isoniazid (INH), rifampin, and pyrazinamide in combination for at least six months (Cook & Dresser, 1995). The drugs need to be taken for six to twelve months or there may be a reoccurrence. Failure to take the antibiotics consistently will result in a multi-drug resistant TB (MDR TB) which "is much harder to treat because the drugs do not kill the germs. MDR TB can be spread to others, just like regular TB" (American Lung Association, 1996).

Inactive tuberculosis is when a person is infected with the tuberculosis bacteria, but their immune system is able to fight the infection, therefore only showing a positive skin test and a negative x-ray and sputum test. The patient may be infected but they are not contagious which means the doctor will start a preventative treatment program. This program includes the use of the drug isoniazid for six to twelve months to prevent the TB from becoming active in the future.

Once the treatment for Joan's pneumonia was unsuccessful it was rediagnosed because she remembered her exposure to TB when her grandfather contracted it when she was seven years old. She has been unaware that she has been caring the infection in a dormant state for 28 years. Due to her sore throat, which weakened her immune system, her TB became active therefore she was given a new treatment plan. This plan included the use of isoniazid, rifampin, and pyrazinamide.

The Similarities of Pneumonia and Tuberculosis

Objective and Subjective Indicators

Tuberculosis and pneumonia have similar objective and subjective indicators because they both cause infection of the lungs. Because of theses similarities in the indicators Joan's case was easily misdiagnosed without the information of the TB exposure.

The subjective indicators are chest pain, headaches, loss of appetite, nausea, stiffness of joints or muscles, shortness of breath, tiredness and weakness. The patient has to be able to tell the doctor these symptoms in order for the correct diagnosis to be made because of the overlap between the two diseases.

The objective indicators include coughing, chills, fever, night sweats and blood-streaked or brownish sputum. These signs will be observable by the doctor.

Medical Interventions

The diagnostic procedures for pneumonia and tuberculosis is also similar. The usual procedure is for the doctor to get a previous medical history along with a history of possible exposure and onset of symptoms. From there a physical examination will occur. The doctor will listen to the patients chest for crackles. After that, tests such as the CBC blood test, x-rays, blood and sputum test, biopsy or a bronchoscopy can confirm an infection of the lungs. A tuberculosis specific test is the Mantoux test which is a skin test that confirms the presence of the TB bacteria in the patients system.

A conservative treatment would include antibiotics such as penicillin and isoniazid (INH) that would treat the infection in the lungs. Or bronchodilators may be used to help keep the airways open. Other treatments may include a proper diet or bed rest.

There are not many choices when it come to surgical management for pneumonia or tuberculosis. In fact there is usually only one that is often used. That surgery is thoracentesis and it is used to remove the pleural effusion from the lungs.

The Course

The course of pneumonia and tuberculosis can vary from person to person.

In general the course begins with the development of symptoms and the visit to the doctor. After the visit to the doctor tests and examinations will occur to confirm the presence of pneumonia or tuberculosis. Once the infection has been confirmed medication may be prescribed along with possible bed rest. A prompt recovery can occur if:

1. they are young,

2. their immune system is working well,

3. the disease is caught early and;

4. they are not suffering from other illnesses.

Most patients will be able to respond to the treatments and begin to improve within a couple of weeks.

Throughout the treatment medical evaluation, drug monitoring and bacteriology is completed. They will check the sputum twice monthly for TB until the smear is negative and the patient is asymptomatic which usually occurs within the first three months (Galantino and Bishop, 1994). For both diseases they will also watch the patient for drug side effects, resistance and compliance.

In Joan's case the TB infection was caught too late to use preventive treatments but once it turned active it was discovered after two weeks.

Bio-Psycho-Social Effects

There are many secondary biological effects from pneumonia and tuberculosis. Tuberculosis and Bacterial Pneumonia can enter the body's blood steam and cause damage or further infection to any part of the body, which includes the kidney, joints, bones, liver, brain, reproductive organs or urinary tract. Other secondary problems that may arise from either disease include anemia, pleurisy, lung abscess, pulmonary edema, chronic interstitial pneumonia, acute respiratory failure, empyema, slowing of the intestines or hyponatremia which is low blood sodium (National Jewish Center for Immunology and Respiratory Medicine, 1989).

The patient may also suffer from psychological and social problems throughout the course of the disease. In extreme cases patients may be unable to participate in physical, recreational, or normal day activities which may cause social deprivation or depression. However most patients can expect to keep their jobs, stay with their families throughout the treatment and lead normal lives.

In Joan's case she was hospitalized so had become socially deprived and was becoming very depressed. This is in part due to the fact the her treatment was ineffective for the first three days from the misdiagnoses.

Goals and Interventions for the Pneumonia or Tuberculosis Patient

To facilitate the recovery of patients who have pneumonia or TB there will be interventions from the Physical Therapist, Respiratory Therapist and Social Worker. Each profession will have roles in motivating , supporting and increasing the functional capability of the patient. The most common objectives of treatment include:

1. to decrease discomfort,

2. to facilitate the exchange of oxygen and carbon dioxide in the lungs,

3. to prevent atrophy from the increased bed rest, and

4. to prevent social withdrawal.

Rehabilitation Goals and Interventions

!. Maintain or increase muscle strength during decreased activity

-provide a progressive resistive exercise program

-promote weight bearing activities engage in recreational activities and self care activities

2. Maintain or increase mobility of soft tissue and joints during bed rest and decreased level of activity

- provide passive and active range of motion

-recreational activities combining aerobic, stretching, and strengthening

3. Develop, improve, restore or maintain coordination

- practice skills with walking, dressing, hygiene and standing

4. Promote psych-social adaptation to disability and prevent social withdrawal

- educate to adapt lifestyle

- get involved in support groups and social interactions

- body positions that decrease discomfort

- Social Worker may help here

5. Alleviation of chest pain and aid in respiration

- use chest physio, oxygen treatments and respiratoy therapy

- teach effective breathing techniques and postural drainage to keep airways open

6.Prevention of reoccurrence

- preventive therapy that includes education on proper diet

Joan was referred to see a Physical Therapist, Respiratory Therapist and Social Worker. Her goals where to decrease her discomfort, education to adapt her lifestyle and in different body positions that will promote easier breathing. The Social Worker was also there to encourage her to join a support group to help her cope with the restraints from her disease.

Conclusion

Every year millions of people throughout the world are affected by the pneumonia and tuberculosis disease. These two respiratory infections have similarities and differences. These similarities stem from the fact that both diseases attack a persons lungs causing inflammation and consolidation. In fact tuberculosis is a chronic infection that can affect the lungs and cause pneumonia. Since both infections cause consolidation indicators like coughing, chest pain and shortness of breath are found in pneumonia and tuberculosis. The problem with these similarities, as was seen in Joan's case, is that it can be easily misdiagnosed when the proper tests are not used. The differences in the two infections are mainly just in their etiologies. For pneumonia there are over 30 different causes but the four main categories are bacterial, viral, mycoplasma and fungal while tuberculosis is only caused by a bacteria called Tubercle bacillus. Fortunately pneumonia and tuberculosis can be kept under control with the use of antibiotics and the earlier that the infection is caught the better chance of a prompt recovery.

References

American Lung Association. (1996). Pneumonia [Online]. Available URL: http://www.lungusa.org/noframes/learn/lung/lunpneumonia.html

American Lung Association. (1996) Tuberculosis [Online]. Available URL: http://www.lungusa.org/noframes/learn/lung/luntb.html

Cook, Allan R., & Dresser, Peter D. (Ed.). (1995). Respiratory diseases and disorders sourcebook (6). Detroit: Omnigraphics Inc.

Galantino, Mary Lou., & Bishop, Kathy Lee. (1994, February). The new TB. PT Magazine. P. 53-61

MedicineNet. (1997). Diseases & treatments: pneumonia [Online]. Available URL: http://www.medicinenet.com/mainmenu/encyclop/ARTICLE/Art_P/pneumon.htm

National Jewish Center for Immunology and Respiratory Medicine. (1989). Med Facts Pneumonia [Online]. Available URL: http://www.hjc.org/MFhtml/PNE_MF.html

O'Toole, M. (Ed.). (1992). Miller-Keane encyclopedia and dictionary of medicine, nursing, and allied health. Toronto: W.B. Saunders.

Schlossberg, David. (Ed.). (1994). Tuberculosis (3rd ed.). New York: Springer - Verlag.