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Year 3 > Case 12 - Pneumonia and TB > Flashcards

Case 12 - Pneumonia and TB Flashcards

1
Q

What are normal host defences against respiratory tract infections?

A

Epithelium - cilia, mucus, antimicrobials
Mechanical - nasal hairs, turbinate bones, coughing, sneezing
Inflammatory cell recruitment
Immunity
Specific pathogen recognition

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2
Q

What is humoral immunity?

A

Mediated by B cells
Antigens presented to B cells
Plasma cells made > make antibodies that recognise and bind to, antigens on the pathogen’s surface
They can then mark the cells out for phagocytosis by macrophages or opsonisation

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3
Q

What is cell mediated immunity?

A

Mediated by T cells
Antigens are presented by dendritic cells and macrophages, that then induce clonal expansion of T cells
T cells can be cytotoxic (CD8 directly destroy pathogen), or helper cells (CD4 activate the plasma cells with cytokines to produce antigen-specific antibodies)

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4
Q

What are signs and symptoms of pneumonia?

A

Depends on the organism causing it:

  • Sputum production - in pneumonia, purulent; in pneumococcal, red rusty
  • Cough
  • Fever
  • Arthalgia/myalgia - in legionella and mycoplasma
  • Abdo pain
  • SOB
  • Hameoptysis
  • Anorexia
  • Crackles in lung fields
  • Dullness to percussion
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5
Q

What is the pathophysiology of pneumonia?

A

An organism infects the alveolar sac
Immune cells flock to the site of infection
Inflammatory exudate is produced which reduces gas exchange and fills the lung interstitium along with neutrophils
May be obstruction caused by the exudate
Over time the inflammation should reduce, but in some may leave lasting damage e.g. fibrosis or abscess

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6
Q

What do you want to ask in a cough history?

A 
Duration
Productive
Any blood
SOB
Fever
Night sweats
Chest pain
Wheeze
Myalgia
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7
Q

What are atypical and typical organisms?

A

Typical can be cultured, atypical are unable to be cultured ie. they are intracellular and thus need to be treated with abx that get into the cell like macrolides

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8
Q

What are common causes of children’s CAP?

A

Depends on the age:

Neonates - E.Coli, group B. Strep, Listeria
1-6 months - RSV, Stap Aureus
6 months - 5y - RSV, parainfluenzae virus

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9
Q

What are typical and atypical bacterial causes of CAP?

A 
Typical:
Streptococcus pneumoniae (seen in pairs)
Haemophilius Influenza
Klebsiella pneumoniae
Staph Aureus (bunch of grapes appearance)

Atypical:
Mycoplasma pneumoniae
Legionella
Chlamydia strains

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10
Q

What are viral causes of CAP?

A

Influenza
Adenovirus
Parainfluenza
RSV

Diagnosis made with PCR after throat swab

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11
Q

What are fungal causes of CAP?

A

Pneumocystis jivorecii

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12
Q

What is HAP?

A

New onset of symptoms alongside CXR changes within 48 hours of hospital stay

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13
Q

What is early and late onset HAP?

A

Early is within 5 days of discharge - these are usually community and antibiotic sensitive
Later is greater than 5 days discharge - usually more resistant to treatment

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14
Q

RFs for HAP?

A 
Ventilator required
ICU admission
Extended period of hospital stay
Underlying respiratory disease
Severe illness/comorbidities
Abdo surgery/vomiting/aspiration
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15
Q

What are bacterial causes of HAP?

A 
E.Coli
Klebsiella
Enterobacter
Staph Aureus
Pseudomonas
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16
Q

How does pneumonia present in the immunosuppressed?

A

Will often be more rare organisms - more likely to be commensal or fungal etc.
Organism that wouldn’t usually cause an infection in immunocompetant patients
Can lead to complications and severe symptoms more quickly

17
Q

What is aspiration pneumonia?

A

When an object is aspirated, it will block air entry to one part of the lung
Anaerobic bacteria become pathogens
Chemical pneumonitis
Those with swallowing problems and low GCS are at risk
Usually RLL

18
Q

What is CURB-65?

A

Used to assess the severity of CAP

Confusion (new onset)
Urea >7
RR 30+
BP (<90 systolic, diastolic <60)
Over 65

One point for each

0-1 = low
2 = moderate 
3-5 = high
19
Q

When should you admit a patient with pneumonia?

A

Low can often be managed in the community
In someone with CURB-65 of 2+, should admit
Also those who can’t manage at home
Those with severe signs
Those who need further investigation

20
Q

What investigations should you do for pneumonia?

A 
FBC- WCC
U and Es - contrast
Gas exchange tests
CRP - inflammation
Blood cultures - and microscopy for mycoplasma
Urine culture and antigen testing for legionella and Pneumococcal
Throat swab for PCR
Sputum cultures
Bronchial lavage if unable to get sputum sample
HIV test
CXR
CT potentially
USS for pleural effusion
21
Q

How do you treat pneumonia?

A

For mild - 5 days amoxicillin
Broad spectrum antibiotics - amoxicillin and clarithromycin
Add tazocin if not working
Then narrow down based on culture and sensitivity

Can be given IV if severe

Step down to oral when apyrexial for 24 hours

22
Q

What are the complications of pneumonia?

A 
Para-pneumonic effusion
Abscess
PE
Metastatic infections
SE of antibiotics
Sepsis
23
Q

What causes TB?

A

Mycobacterium strains
All types cause varying illnesses and are acid and alcohol fast
Mycobacterium tuberculosis causes TB

24
Q

How can TB be transmitted?

A

Through air droplets:
Coughing
Sneezing
Breathing

Also post-mortem, abscess and through infected milk
Stop becoming infective 2 weeks of completed treatment

25
Q

What is the primary TB infection?

A

The first time the patient is infected with TB
Small lung lesion and local lymph node involvement
Some organisms stay latent inside macrophages

26
Q

What is the post-primary TB disease?

A

Re-activation of the primary infection by becoming infected with TB again
Leads to a severe infection - bronchiectasis, haemoptysis, COPD

27
Q

What is the epidemiology of TB?

A

Most TB in the UK originiates in people who were not born in the UK, or who have become infected outside of the UK
They come in with latent TB and it becomes reactivated within the UK upon exposure to the infection again
Hand in hand with HIV
Disease of deprivation

28
Q

Who do you screen for TB?

A 
High risk populations:
Homelesss
Prisoners
IVDU
Those who enter the UK from high risk countries
Healthcare workers
29
Q

Who do you vaccinate against TB?

A

HCP and haven’t been vaccinated
Those who enter the UK from a high risk country and haven’t been vaccinated
Those born in high risk areas in the UK
Those with parents/grandparents from high risk areas
Those with a FHx of TB in last 5 years

30
Q

Symptoms of TB?

A 
Respiratory TB:
Cough
Night sweats
Fever
Weight loss
Haemoptysis

Can affect any bodily system though, so can present with a wide variety of symptoms and signs

31
Q

Investigations for TB?

A

FBC, CRP, U and E, LFTs (baseline for rifampicin)
Blood culture for mycoplasma and acid fast testing
CXR
HIV test
Sputum smear/culture
Aspirate/biopsy
Tuberculin skin test for latent TB

32
Q

Diagnosis of TB?

A

Acid fast stain will show up the TB
Can culture from blood and sputum
Histology from biopsy will show granulomas

33
Q

What is TB treatment?

A 
RIPE
Rifampicin - give orange bodily fluids
Isoniazid
Pyrazinamide
Ethambutol

Have all 2 months, then RI for 4 months

Need to contact trace and give all contacts rifampicin
If a child presents, need to find who has infected the child by contact tracing

34
Q

Complications of TB

A 
Death
Treatment SE
Recurrence
Cavities in lung
Bronchiectasis
Pleural thickening

Year 3 (23 decks)

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