Pneumonia: A Deadly Presence

Puppeteer Jim Henson’s sudden death of pneumonia last week is a reminder that this usually benign disease, which strikes about 3 million Americans each year, can be fatal.

Generally, pneumonia is well understood by doctors and is easily treated with a variety of antibiotics, said Dr. Bisher Akil, an expert in infectious diseases and pulmonary medicine at the University of Southern California.

“You get simple outpatient treatment with antibiotics and you get over it,” Akil said. “In healthy people, it’s not a problem unless you ignore it and let it escalate.”

But pneumonia is fatal for an estimated 70,000 Americans each year, ranking as the sixth leading cause of death, according to the American Lung Assn.

Most of the deaths occur among the elderly, infants and people with illnesses such as cancer or diabetes--all of whom have weak immune systems and may be unable to fight off infection.

In other cases, death can occur if treatment begins too late, as was apparently the case with Henson, or because the particular strain of pneumonia is difficult to identify, as in the case of actress Elizabeth Taylor’s brush with death from pneumonia last month, experts said.

Pneumonia is an infection of lung tissue and is classified according to its cause and its location in the lung, Akil said. The disease is most commonly caused by bacteria, such as the streptococcus bacteria that killed Henson. It is also caused by viral infections, such as influenza. In rarer instances, pneumonia is caused by fungi, parasites, chemical agents or allergic reactions to foreign particles that lodge in the lung.

Streptococcus, a bacterium found in the mouth, is the leading cause of pneumonia and is fatal in about 5% of cases, usually in people with weakened immune systems, experts said. Henson apparently died from a strain called group A streptococcus, which officials at the Centers for Disease Control in Atlanta said is increasing in frequency for reasons that are unclear. Group A streptococcus is fatal in 20% to 30% of cases, the CDC reports.

But the 53-year-old creator of the Muppets apparently did not seek treatment in time to arrest his rapidly spreading infection, said Dr. David M. Gelmont, director of intensive care at New York Hospital, where Henson died early Wednesday.

According to Gelmont, Henson was examined by a physician in North Carolina on May 12 after developing flu-like symptoms, but pneumonia was not diagnosed. Henson reportedly returned to New York on Monday and died less than 24 hours after being admitted to New York Hospital.

When he entered the emergency room at 4:58 a.m. Tuesday, Henson was dying of massive infection and acute respiratory distress, officials said. He received large doses of antibiotics and was placed on a ventilator.

Physicians estimated that the “overwhelming” infection had been progressing for at least three days and said antibiotics were ineffective at that point.

“The pneumonia was not detected by the doctor in North Carolina, but by no means did someone blow the diagnosis,” Gelmont said. “He did not have the textbook symptoms of pneumonia. He did not have a fever or sputum. He did have a mild cough.”

Symptoms of pneumonia can vary according to its type. Four major symptoms common to streptococcus are fever, chest pain, cough and shortness of breath, Akil said. Bacterial pneumonia is usually accompanied by a discharge of sputum, sometimes blood-tinged, from the lungs; viral pneumonia often produces a dry cough. Pneumonia commonly triggers a particular kind of chill, a severe trembling of the body called a rigor, said Dr. Ellie Goldstein, chief of infectious disease at St. John’s Hospital and Health Center in Santa Monica, where Taylor is recovering.

“From the autopsy and from a physical examination, it is apparent that Mr. Henson was a healthy man,” Gelmont said. “He was so healthy he didn’t have a regular physician. The problem was he continued to feel worse over the weekend. By Sunday, I think he should have seen a doctor. Certainly by Monday when he was short of breath. But I’m sure he thought he could shake it off.”

By the time Henson was admitted to the hospital, the infection in his lungs had already migrated throughout his body and had begun to cause failure of his kidneys, heart and blood-clotting ability. Pneumonia can be impossible to arrest after abscesses form in the lungs and then spread through the bloodstream to different organs in the body, experts said.

“Despite all of the antibiotics and modern techniques we possess, patients do die in hospitals because of (rapidly spreading) pneumonia when they are not admitted until after the illness has reached the critical stage,” said Dr. David B. Skinner, president of New York Hospital.

Before the advent of antibiotics, pneumonia was called “the captain of the men of death,” because it commonly caused death among the elderly, Goldstein said. Even before antibiotics came into use, however, healthy young people usually managed to fight off the disease.

Antibiotics don’t actually kill the bacteria causing pneumonia: They allow the body to mount its own natural defenses, said Goldstein. Thus, the seriousness of the illness varies according to the strength of an individual’s defenses.

If the agent causing the pneumonia can be identified, the particular antibiotic that will be most effective is prescribed, Akil said. If a cause is not immediately apparent, doctors must try various drugs and perform laboratory tests of lung sputum or lung tissue.

With viral pneumonia, which may not produce sputum from the lungs that can be used to identify the virus, doctors sometimes remove a piece of lung tissue to test to make a diagnosis.

“The problem with viral pneumonia is that our ability to identify the virus is not good,” Akil said. “Most of the time the diagnosis is one of exclusion. But what happened with Elizabeth Taylor is that they had to go with open-lung biopsy because they couldn’t find a reason. They had to take a big piece of lung tissue and look at it.”

Taylor, 58, was near death with viral pneumonia when doctors performed a lung biopsy to identify which antibiotics would best assist her. (Antiviral drugs have been developed that are effective in treating some viral pneumonias.)

Taylor entered Daniel Freeman Marina Hospital April 10 with a sinus infection. The infection progressed to pneumonia, and the actress was transferred to St. John’s April 16.

Taylor’s pneumonia most likely developed from a virus in her bloodstream. But people can get pneumonia from different kinds of exposures, Akil said.

“One is when you swallow saliva and normal bacteria and it doesn’t go to the stomach, it goes to the lung,” he said. “We do that all time. As long as our immune system is intact, it takes care of the bacteria we accidently inhale into our lungs. Once the immune system is weakened, whamo, you get pneumonia.”

The disease can also enter the bloodstream--from a cut, for example--and can travel to the lung. Or the offending agent can be inhaled, as was the case with Legionnaire’s disease, which is caused by Legionella bacteria and spread through the air, usually from a contaminated air-conditioning system or water system. Legionella bacteria were recognized as a cause of pneumonia after 29 people died after an American Legion Convention in Philadelphia in 1976.

Pneumonia can also develop as a complication of another illness, such as the influenza A or B, smallpox, measles or AIDS. According to Goldstein, 60% of adults with measles also get pneumonia. Pneumonia can spread quickly in hospitals because of the high incidence of infection and the number of people with compromised immune systems.

A vaccine for pneumococcal pneumonia--which encompasses many strains of bacteria--was developed in 1977. The vaccine is recommended for the elderly and people with immune-system problems, such as AIDS patients. Healthy people do not need the vaccine and, despite tragic exceptions like Henson’s death, should be able to recognize pneumonia and receive quick and adequate treatment.

“Usually, pneumonia does not go unnoticed,” Akil said.