Pulmonology Book

//fpnotebook.com/

Pneumonia

Aka: Pneumonia, Bacterial Pneumonia, Atypical Pneumonia, Community-Acquired Pneumonia, Community Acquired Pneumonia
  1. See Also
    1. Viral Pneumonia
    2. Pneumonia in Children
    3. Pneumonia in the Elderly
    4. Pneumonia in the Nursing Home
    5. Pneumonia Accelerated Diagnostic Protocol
    6. Hospital Acquired Pneumonia
    7. Ventilator Associated Pneumonia
  2. Definition: Community Acquired Pneumonia (CAP)
    1. Lower respiratory tract infection
    2. Develops in non-hospitalized patient
    3. May be Bacterial, viral, fungal or parasitic
    4. May be present despite normal Chest XRay
  3. Epidemiology: Community Acquired Pneumonia
    1. Incidence: 9.2 to 33 per 1000 person-years in U.S.
    2. Adult mortality: 60,000 deaths per year from Pneumonia or Influenza (8th leading cause of death)
    3. Most severe cases in very young and very old
    4. U.S. cost/year for Community Acquired Pneumonia: $10-17 billion (90% of cost is inpatient care)
  4. Causes: Community Acquired Pneumonia
    1. See Pneumonia Causes
    2. Bacteria: Typical
      1. Streptococcus Pneumoniae
      2. Staphylococcus aureus
      3. HaemophilusInfluenzae
      4. Moraxella catarrhalis
    3. Bacteria: Atypical
      1. Mycoplasma pneumoniae
      2. Legionella pneumonia
      3. Chlamydia Pneumonia
      4. Q Fever
      5. Psittacosis
    4. Virus
      1. Adenovirus
      2. Influenza A and B
      3. Parainfluenza
      4. Respiratory Syncytial Virus
    5. Fungus
      1. Blastomycosis
      2. Coccidioidomycosis
      3. Histoplasmosis
  5. Risk Factors
    1. Age over 65 years
    2. Recent antibiotics
    3. Immune compromised (e.g. HIV Infection)
    4. Respiratory illness (COPD, Asthma)
    5. Vascular disease (CHF, CVA)
    6. Diabetes Mellitus
    7. Chronic Liver Disease
    8. Chronic Kidney Disease
    9. Cancer
  6. Findings: Signs and Symptoms
    1. Bacterial Pneumonia
      1. Cough
        1. Productive of Purulent Sputum with typical Bacteria
        2. Non-productive in atypical cases
      2. Sudden onset
      3. Fever and Chills
      4. Fatigue
      5. Ill appearing patient
      6. Pleuritic Chest Pain
      7. Dyspnea
      8. Tachypnea
      9. Tachycardia
    2. Viral Pneumonia
      1. Non-productive cough
      2. Gradual Onset with prodrome (malaise and Headache)
      3. Chest XRay more impressive than exam
      4. Onset in fall or winter
      5. Wheezing more common in viral causes
      6. Low grade Temperature (<101.3 F)
    3. Mycoplasma pneumonia
      1. Constant, harsh, non-productive cough
      2. Wheezing may occur in Mycoplasma pneumonia
      3. Fever typically lasts longer than 3 days
      4. More common in age over 3 years
    4. Legionella
      1. Onset with myalgias and Headache
      2. Fever to 104 F for first few days
      3. Gastrointestinal symptoms predominate in up to 40%
      4. Cough is late onset, mild, often non-productive
  7. Signs
    1. General findings
      1. Fever
        1. Positive Likelihood Ratio: 2.1
        2. Negative Likelihood Ratio: 0.71
      2. Ill appearing patient
      3. Dyspnea
      4. Tachypnea
      5. Tachycardia
      6. Hypoxia (check Oxygen Saturation)
    2. Localized findings at involved lung region
      1. Egophony
        1. Positive Likelihood Ratio: 8.6
        2. Negative Likelihood Ratio: 0.96
      2. Dullness to percussion
        1. Positive Likelihood Ratio: 4.3
        2. Negative Likelihood Ratio: 0.79
      3. Rales
      4. Diminished breath sounds
      5. Bronchial breath sounds
      6. Tactile fremitus
    3. References
      1. Metlay (1997) JAMA 278(17): 1440-5 [PubMed]
  8. Diagnosis
    1. See Diehr Rule to Diagnose Pneumonia
    2. Findings with highest Test Sensitivity for Pneumonia
      1. Fever and chills
      2. Pleuritic Chest Pain
      3. Cough productive of mucopurulent Sputum
      4. Dyspnea
      5. Tachypnea (especially in over age 65 years)
    3. Findings with highest Specificity
      1. Asymmetric breath sounds
      2. Pleural rubs
      3. Egophony
      4. Increased tactile fremitus
  9. Labs
    1. General
      1. Consider specific testing based on risks
        1. See Pneumonia Causes (as well as indications below)
      2. Lab Indications
        1. Moderate or severe Community Acquired Pneumonia
        2. Patient with comorbid conditions
      3. Efficacy of Labs
        1. No value in non-severe Community Acquired Pneumonia
        2. Theerthakarai (2001) Chest 119:181-4 [PubMed]
    2. Sputum Gram Stain and Culture
      1. See Sputum Culture
      2. Adequacy
        1. Good quality sample: <25 epithelial cells/LPF and contains Neutrophils
      3. Indications (IDSA/ATA 2007)
        1. ICU Admission (consider endotracheal aspirate if intubated)
        2. Failed outpatient antibiotic therapy
        3. Cavitary infiltrates (obtain specific fungal and Tuberculosis cultures)
        4. Active Alcohol Abuse
        5. Severe COPD
        6. Pleural Effusion (also perform Thoracentesis for Pleural Fluid culture and analysis)
        7. Positive Legionella urine antigen (Legionella culture requires special media)
        8. Positive Pneumococcal urine antigen
      4. Efficacy
        1. Sputum has low diagnostic yield in Community Acquired Pneumonia
          1. Not recommended in outpatient Community Acquired Pneumonia
          2. Ewig (2002) Chest 121:1486-92 [PubMed]
    3. Blood Culture
      1. Indications (IDSA/ATA 2007)
        1. Not indicated unless severe disease (highest yield in severe Pneumonia)
        2. Consider in hospitalized Community Acquired Pneumonia (especially if possible ICU patient)
        3. Intensive care unit admission
        4. Cavitary infiltrates
        5. Leukopenia
        6. Active Alcohol Abuse
        7. Chronic severe liver disease
        8. Asplenia
        9. Pleural Effusion
        10. Positive Pneumococcal urine antigen
      2. Efficacy
        1. Low sensitivity: Positive in only 5-10% of cases
        2. Does not predict severity or outcome
      3. References
        1. Campbell (2003) Chest 123:1142-50 [PubMed]
    4. Specific Testing with reasonable efficacy
      1. Influenza
        1. Rapid Influenza Test (Influenza DFA)
      2. Legionella pneumophila
        1. Rapid PCR of Sputum (80% Test Sensitivity)
        2. Urinary antigen
          1. Test Sensitivity 70-90% (for serogroup 1, responsible for >80% of cases)
          2. Test Specificity 99%
        3. Indications (Legionella UAT per IDSA/ATS 2007)
          1. Intensive care unit admission
          2. Failed outpatient antibiotic therapy
          3. Active Alcohol Abuse
          4. Travel within prior 2 weeks
          5. Pleural Effusion
      3. Mycoplasma pneumoniae
        1. Rapid PCR of Sputum (>30% Test Sensitivity)
      4. Chlamydia Pneumonia
        1. Rapid PCR (>30% Test Sensitivity)
      5. Streptococcus Pneumoniae (Pneumococcus)
        1. Pneumococcal Urine antigen Test (UAT)
          1. Test Sensitivity 60-80%
          2. Test Specificity >90%
        2. Indications (Pneumococcal UAT per IDSA/ATS 2007)
          1. Intensive care unit admission
          2. Failed outpatient antibiotic therapy
          3. Active Alcohol Abuse
          4. Chronic severe liver disease
          5. Leukopenia
          6. Asplenia
          7. Pleural Effusion
    5. Thoracentesis with fluid analysis
      1. Indicated for Pleural Effusion >5 cm
      2. Send for Gram Stain, aerobic and anaerobic culture
    6. Fungal and TB Culture
      1. Cavitary lesions
      2. Foreign travel or immigration
    7. References
      1. Mandell (2007) Clin Infect Dis 44:S27–72 [PubMed]
  10. Imaging: Chest XRay
    1. Indications: All cases of suspected Community Acquired Pneumonia
      1. Any patient with at least 1 of the following
        1. Temperature >100 F (37.8 C)
        2. Heart Rate >100 beats/min
        3. Respiratory Rate >20 breaths/min
      2. Any patient with at least 2 of the following
        1. Decreased breath sounds
        2. Rales or crackles
        3. No Asthma history to explain findings
      3. Other indications (not included in Ebell protocol)
        1. Hypoxemia
        2. Confusion
        3. Known structural lung disease
        4. Age > 60 years old
        5. Systemic illness signs
      4. Ebell (2007) Am Fam Physician 76(4): 560-2 [PubMed]
    2. Precautions: False negatives in early presentation
      1. Serial Chest XRays may be needed
      2. Does not exclude Pneumonia in severe illness
        1. Positive in only 40% of acute pneumococcal Community Acquired Pneumonia (CAP)
    3. Precautions: Underlying malignancy
      1. Confirm infiltrate resolution at 6 weeks after management (especially in smokers, or those over age 50)
    4. Interpretation
      1. Lobar infiltrate suggests typical Bacterial Community Acquired Pneumonia (CAP)
      2. Diffuse, bilateral infiltrates suggests atypical Community Acquired Pneumonia (CAP)
  11. Imaging: Lung Ultrasound
    1. May be more accurate than Chest XRay in the diagnosis of Pneumonia
    2. Also defines other respiratory conditions at the bedside (e.g. Pneumothorax, Pleural Effusion)
    3. Test Sensitivity: 94 to 95%
    4. Test Specificity: 90 to 96%
    5. Chavez (2014) Respir Res 15:50 [PubMed]
    6. Ye (2015) PLoS One 10(6): e0130066 [PubMed]
  12. Differential Diagnosis
    1. See Pneumonia Causes
    2. See Cough Causes
    3. Acute Respiratory Distress Syndrome
    4. Severe Acute Respiratory Syndrome
    5. Churg-Strauss Syndrome
    6. Congestive Heart Failure
    7. Inflammatory Lung Disease
    8. Idiopathic Pulmonary Fibrosis
    9. Interstitial pneumonitis
    10. Pulmonary Embolism
    11. Lung Cancer
    12. Sarcoidosis
    13. Granulomatosis with Polyangiitis (previously known as Wegener's Granulomatosis)
    14. Bronchiolitis Obliterans with Organizing Pneumonia
    15. Bioterrorism Agents
      1. Anthrax
      2. Plague
      3. Tularemia
      4. Q Fever
      5. Brucellosis
  13. Management
    1. See Pneumonia Management
    2. See Pneumonia Accelerated Diagnostic Protocol
    3. See Community Acquired Pneumonia Refractory to Standard Management
    4. Convert to oral antibiotic within 72 hours if possible
    5. See Pneumonia Hospitalization Criteria
    6. See Pneumonia Hospitalization Criteria in the Elderly
    7. See Severe Community Acquired Pneumonia Criteria
    8. See Mortality Prediction Tool for Patients with Community Acquired Pneumonia (CURB-65)
    9. See Pneumonia IRVS Prediction Tool (SMART-COP)
  14. Complications
    1. Pulmonary
      1. Parapneumonic Effusion or empyema
      2. Pneumothorax
      3. Lung Abscess
      4. Bronchopleural Fistula
      5. Necrotizing Pneumonia
      6. Acute Respiratory Failure
    2. Metastatic spread
      1. Meningitis or CNS abscess
      2. Pericarditis or endocarditis
      3. Osteomyelitis or Septic Arthritis
    3. Systemic
      1. Sepsis or SIRS
      2. Hemolytic Uremic Syndrome
    4. References
      1. Bradley (2011) Clin Infect Dis 53(7): e1-52 [PubMed]
  15. Prognosis: Predictors of increased mortality
    1. See Pneumonia Prognostic Factors in Older Patients
    2. See Mortality Prediction Tool for Patients with Community Acquired Pneumonia (CURB-65)
    3. See Pneumonia Severity Index
    4. Comorbid neurologic disease
    5. Renal disease
    6. Congestive Heart Failure
    7. Hypotension
    8. Tachypnea
    9. Hypothermia
    10. Hypoglycemia (Serum Glucose <70mg/dl on presentation)
  16. Prevention
    1. See Pneumonia Prevention in the Elderly
    2. See Influenza Vaccine
    3. See Pneumococcal Vaccine
  17. References
    1. Bernstein (1999) Chest 115:9S-13S [PubMed]
    2. Cunha (2001) Med Clin North Am 85(1):43-77 [PubMed]
    3. Fine (1997) N Engl J Med 336:243-50 [PubMed]
    4. Fine (1990) Am J Med 89:713-21 [PubMed]
    5. Gleason (1997) JAMA 278:32-9 [PubMed]
    6. Kaysin (2016) Am Fam Physician 94(9); 698-706 [PubMed]
    7. Lim (2009) Thorax 64(suppl 3):1-55 [PubMed]
    8. Lutfiyya (2006) Am Fam Physician 73:442-50 [PubMed]
    9. Marrie (2000) Clin Infect Dis 31(4):1066-78 [PubMed]
    10. Metlay (2003) Ann Intern Med 138:109-18 [PubMed]
    11. Watkins (2011) Am Fam Physician 83(11): 1299-306 [PubMed]

Pneumonia, Bacterial (C0004626)

Definition (MSH) Inflammation of the lung parenchyma that is caused by bacterial infections.
Definition (NCI) Acute infection of the lung parenchyma caused by bacteria (e.g., Streptococcus pneumoniae, Haemophilus influenzae, Chlamydia pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila). Signs and symptoms include productive cough, fever, chills, shortness of breath, and chest pain.
Definition (CSP) pneumonia caused by various species of bacteria; commonly results from bronchogenic spread of infection following microaspiration of secretions.
Concepts Disease or Syndrome (T047)
MSH D018410
ICD9 482.9
ICD10 J15.9
SnomedCT 195891009, 195892002, 155553007, 53084003
English Bacterial Pneumonia, Bacterial Pneumonias, Pneumonia, Bacterial, Pneumonias, Bacterial, Bacterial pneumonia, unspecified, Pneumonia due to bacteria NOS, BACT PNEUMONIA, PNEUMONIA BACT, bacterial pneumonia (diagnosis), bacterial pneumonia, Pneumonia bacterial NOS, Bacterial pneumonia NOS, Unspecified bacterial pneumonia, Pneumonia, Bacterial [Disease/Finding], Pneumonia;bacterial, pneumonia bacterial, Pneumonia due to bacteria NOS (disorder), Bacterial pneumonia NOS (disorder), Pneumonia bacterial, Bacterial pneumonia, Bacterial pneumonia (disorder), bacterial; pneumonia, pneumonia; bacterial, Bacterial pneumonia, NOS
Dutch bacteriële pneumonie NAO, bacteriële pneumonie, niet-gespecificeerd, bacterieel; pneumonie, pneumonie; bacterieel, Bacteriële pneumonie, niet gespecificeerd, bacteriële pneumonie, Bacteriële pneumonie, Pneumonie, bacteriële
French Pneumonie bactérienne non précisée, Pneumonie bactérienne SAI, Pneumonie bactérienne, Pneumopathie bactérienne
German Pneumonie bakteriell NNB, bakterielle Pneumonie, unspezifisch, Bakterielle Pneumonie, nicht naeher bezeichnet, Pneumonie durch Bakterien, Pneumonie, bakterielle
Italian Polmonite batterica NAS, Polmonite batterica, non specificata, Polmonite batterica
Portuguese Pneumonia bacteriana NE, Pneumonia bacteriana, Pneumonia Bacteriana
Spanish Neumonía bacteriana no especificada, Neumonía bacteriana NEOM, neumonía bacteriana, SAI, neumonía bacteriana, SAI (trastorno), neumonía debida a bacterias, SAI (trastorno), Bacterial pneumonia NOS, neumonía debida a bacterias, SAI, neumonía bacteriana (trastorno), neumonía bacteriana, neumonía bactérica, Neumonía bacteriana, Neumonía Bacteriana
Japanese 細菌性肺炎、詳細不明, 細菌性肺炎ＮＯＳ, ｻｲｷﾝｾｲﾊｲｴﾝｼｮｳｻｲﾌﾒｲ, ｻｲｷﾝｾｲﾊｲｴﾝ, ｻｲｷﾝｾｲﾊｲｴﾝNOS, 肺炎-細菌性, 細菌性肺炎
Swedish Lunginflammation, bakteriell
Finnish Bakteeripneumonia
Russian PNEVMONIIA BAKTERIAL'NAIA, ПНЕВМОНИЯ БАКТЕРИАЛЬНАЯ
Czech Bakteriální pneumonie, Bakteriální pneumonie, blíže neurčená, Bakteriální pneumonie NOS, bakteriální pneumonie, pneumonie bakteriální
Korean 상세불명의 세균성 폐렴
Croatian PNEUMONIJA, BAKTERIJSKA
Polish Zapalenie płuc bakteryjne
Hungarian bacterialis pneumonia, bacterialis pneumonia k.m.n., bacterialis tüdőgyulladás, nem meghatározott
Norwegian Bakteriell lungebetennelse, Lungebetennelse, bakteriell, Bakteriell pneumoni, Pneumoni, bakteriell
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Pneumonia (C0032285)

Definition (MSH) Inflammation of any part, segment or lobe, of the lung parenchyma.
Definition (MEDLINEPLUS)

Pneumonia is an infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia. You can also get pneumonia by inhaling a liquid or chemical. People most at risk are older than 65 or younger than 2 years of age, or already have health problems.

Symptoms of pneumonia vary from mild to severe. See your doctor promptly if you

  • Have a high fever
  • Have shaking chills
  • Have a cough with phlegm that doesn't improve or gets worse
  • Develop shortness of breath with normal daily activities
  • Have chest pain when you breathe or cough
  • Feel suddenly worse after a cold or the flu

Your doctor will use your medical history, a physical exam, and lab tests to diagnose pneumonia. Treatment depends on what kind you have. If bacteria are the cause, antibiotics should help. If you have viral pneumonia, your doctor may prescribe an antiviral medicine to treat it.

Preventing pneumonia is always better than treating it. Vaccines are available to prevent pneumococcal pneumonia and the flu. Other preventive measures include washing your hands frequently and not smoking.

NIH: National Heart, Lung, and Blood Institute
Definition (NCI_NCI-GLOSS) A severe inflammation of the lungs in which the alveoli (tiny air sacs) are filled with fluid. This may cause a decrease in the amount of oxygen that blood can absorb from air breathed into the lung. Pneumonia is usually caused by infection but may also be caused by radiation therapy, allergy, or irritation of lung tissue by inhaled substances. It may involve part or all of the lungs.
Definition (NCI) An acute, acute and chronic, or chronic inflammation focally or diffusely affecting the lung parenchyma, due to infections (viruses, fungi, mycoplasma, or bacteria), treatment (e.g. radiation), or exposure (inhalation) to chemicals. Symptoms include cough, shortness of breath, fevers, chills, chest pain, headache, sweating, and weakness.
Definition (CSP) inflammation of the lungs with consolidation and exudation.
Concepts Disease or Syndrome (T047)
MSH D011014
ICD10 J18.9
SnomedCT 274103002, 155552002, 155558003, 266391003, 155548002, 60363000, 205237003, 233604007
LNC LP21407-9, MTHU020831, LA7465-3
English Pneumonitis, Pneumonia, Pneumonias, Pneumonia, unspecified, Pneumonitides, Pneumonia NOS, pneumonia (diagnosis), pneumonia, Pneumonitis NOS, Pneumonia [Disease/Finding], Pneumoniae, inflammation lungs, unspecified pneumonia, pneum, pulmonary inflammation, lung inflammation, Inflammation, Lung, Inflammation, Pulmonary, Inflammations, Lung, Inflammations, Pulmonary, Lung Inflammation, Lung Inflammations, Pulmonary Inflammation, Pulmonary Inflammations, Pneumonia NOS (disorder), Pulmonary inflammation, Lung inflamed, Pulmonitis, PNEUMONIA, Pneumonia (disorder), Pneumonia, NOS, Pneumonia (disorder) [Ambiguous], pneumonitis
French PNEUMONIE, Congestion pulmonaire SAI, Pneumonite, Pneumonie SAI, Pneumopathie infectieuse, Pneumonie
Portuguese PNEUMONIA, Pneumonite NE, Pulmonite, Pneumonia NE, Pulmonia, Pneumonia, Inflamação do Pulmão, Inflamação Pulmonar, Pneumonite
Spanish NEUMONIA, Neumonitis NEOM, Neumonía NEOM, neumonia, SAI (trastorno), Pneumonia NOS, neumonia, SAI, Pneumonía, Pulmonía, neumonía (concepto no activo), neumonía (trastorno), neumonía, Neumonitis, Inflamación del Pulmón, Inflamación Pulmonar, Neumonía
German PNEUMONIE, Pneumonie NNB, Pulmonitis, Pneumonitis NNB, Pneumonie, nicht naeher bezeichnet, Lungenentzuendung, Pneumonie, Pneumonitis, Lungenentzündung
Italian Infezione polmonare, Polmonite aspecifica, Infezione dei polmoni, Infezione polmonare aspecifica, Pneumonite, Infiammazione del polmone, Infiammazione polmonare, Polmonite
Dutch pneumonie NAO, pneumonitis NAO, pulmonitis, Pneumonie, niet gespecificeerd, pneumonie, Pneumonie, Longontsteking, Pneumonitis
Japanese 肺炎ＮＯＳ, 肺臓炎, 肺臓炎ＮＯＳ, ﾊｲｴﾝNOS, ﾊｲｴﾝ, ﾊｲｿﾞｳｴﾝNOS, ﾊｲｿﾞｳｴﾝ, 肺炎
Swedish Lunginflammation
Czech pneumonie, Pneumonie, Pulmonitida, Pneumonie NOS, Pneumonitida NOS, zápal plic, zánět plic
Finnish Keuhkokuume
Russian PNEVMONIIA, ПНЕВМОНИЯ
Korean 상세불명의 폐렴
Croatian PNEUMONIJA
Polish Zapalenie płuc
Hungarian pneumonia, Pneumonitis k.m.n., pneumonia k.m.n., Pulmonitis
Norwegian Pneumoni, Lungebetennelse
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Community acquired pneumonia (C0694549)

Concepts Disease or Syndrome (T047)
SnomedCT 385093006
Dutch community-acquired pneumonie
French Pneumonie communautaire
German Community acquired Pneumonie (CAP)
Italian Polmonite comunitaria
Portuguese Pneumonia adquirida na comunidade
Spanish Neumonía adquirida en la comunidad, neumonía adquirida en la comunidad, neumonía extrahospitalaria (trastorno), neumonía extrahospitalaria
Japanese 市中感染性肺炎, ｼﾁｭｳｶﾝｾﾝｾｲﾊｲｴﾝ
English community-acquired pneumonia, community-acquired pneumonia (diagnosis), community acquired pneumonia, acquired community pneumonia, Community acquired pneumonia, Community acquired pneumonia (disorder)
Czech Komunitní pneumonie
Hungarian Közösségben szerzett pneumonia
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Atypical pneumonia (C1412002)

Concepts Disease or Syndrome (T047)
SnomedCT 195932001, 233606009, 35037009
English Atypical pneumonia, Pneumonia;atypical, atypical pneumonia (diagnosis), Atypical pneumonia (disorder), atypical; pneumonia, pneumonia; atypical, atypical pneumonia
Czech Atypická pneumonie
Dutch atypische pneumonie, atypisch; pneumonie, pneumonie; atypisch
French Pneumonie atypique
German atypische Pneumonie
Hungarian atípusos pneumonia
Italian Polmonite atipica
Japanese ｲｹｲﾊｲｴﾝ, 異型肺炎
Portuguese Pneumonia atípica
Spanish Neumonía atípica, neumonía atípica (trastorno), neumonía atípica
Sources
Derived from the NIH UMLS (Unified Medical Language System)


You are currently viewing the original 'fpnotebook.com\legacy' version of this website. Internet Explorer 8.0 and older will automatically be redirected to this legacy version.

If you are using a modern web browser, you may instead navigate to the newer desktop version of fpnotebook. Another, mobile version is also available which should function on both newer and older web browsers.

Please Contact Me as you run across problems with any of these versions on the website.

Navigation Tree