Case 12- Pneumonia And TB Flashcards
Investigations for suspected pneumonia
Resp examination
Observations
Sputum culture and urinalysis (legionella, pneumococcal antigens)
FBC, UE (urea), LFT, CRP, blood cultures (2 sets at 2 different times, from 2 locations), blood gas for lactate (sepsis)
CURB 65 score
CXR
NB- diagnosis is X-RAY change and signs of LRTI . Must qualify what type eg. HAP/ CAP- read question info carefully (are they in hospital or are they in the community). 4-6 weeks repeat the CXR to make sure consolidation gone/ no neoplasm
Atypical pneumonia organisms
Legionella pneumophilia- infected water supply/ air conditioning. Causes hyponatraemia via SIADH
Mycoplasma pneumoniae- young patients. Erythema multiforme rash. May cause neurological signs eg. GBS/encephalitis
Chlamydophilia pneumoniae- young child with wheeze
Coxiella burnetti (Q fever)- exposure to animals/ their bodily fluids (raised liver enzymes)
Chlamydia psittaci- infected birds eg. Parrots
Patients shouldn’t be discharged if in last 24 hours they have had 2 of the following
Temp higher than 37.5
Resp rate above 24
Bpm above 100
02 under 90 on room air
Abnormal mental status
Inability to eat without assistance
Causes of a transudative pleural effusion (less than 30mg protein)
Increased venous pressure- CCF, constrictive pericarditis, fluid overload
Hyponatraemia- cirrhosis, nephrotic syndrome, malabsorption
Hypothyroidism
Hypoalbuminaemia
Meigs syndrome- ovarian malignancy
NB- transudative more likely to be bilateral
Causes of an exudative pleural effusion >30g/L)
Increased permeability of the pleural capillaries- pneumonia, TB, malignancy, pancreatitis, pulmonary infarction eg. PE, SLE
Pneumonia
Must say whether HAP or CAP, never just pneumonia
Sx of pneumonia
Fevers, rigors, malaise, dyspnoea, cough, sputum, haemoptysis, confusion, cyanosis, fever, pleuritic pain, tachycardia, tachypnoea, hypotension, bro chill breathing, reduced expansion, dull percussion, increased tactile fee it’s, increased vocal resonance
Pneumonia differentials
Acute bronchitis, asthma exacerbation, TB, lung neoplasia, CHF
Typical pneumonia organisms
Strep pneumoniae (causes reactivation of HSV- cold sores)
H influenzae
Klebsiella pneumoniae
Staph aureus
Moraxella catarrhalis
TB Sputum
Grows acid fast bacilli that stain red with Ziegler’s Nielsen staining (mycobacterium tuberculosis)
TB Sx
Cough, fever, weight loss, malaise, night sweats, pleuritic chest pain, erythema nodosum (painful red nodules over the pretibial region)
TB differentials
CAP, lung cancer, sarcoidosis
Suspected TB investigation and management
Isolate in hospital, appropriate PPE, test contacts for TB, test for other ID’s, then test appropriately as below;
Sputum culture- acid fast bacilli positive
Mantoux tuberculin test- 5mm or more requires further investigation
Bloods- FBC- increased WCC, anaemia, UE deranged (not eating perhaps), LFT- damage
CXR- fibronodular opacities
Interferon release gamma assays- meausre T cell response to TB antigens to diagnose prior exposure
RIPE treatment (also get given pyridoxine- 5 things)
ABCDE Assessment
Never forget- acutely unwell patient you actually have to do this. Remember this in OSCE
Acute respiratory distress syndrome
Non cardiogenic pulmonary oedema
Causes of ARDS
Infection- sepsis or pneumonia
Blood transfusion
Trauma
Smoke inhalation
Acute pancreatitis
Cardio pulmonary bypass
Clinical features of ARDS
Dyspnoea
Elevated respiratory rate
Bilateral lung crackles
Low oxygen saturations
Criteria for ARDS
Acute onset (1 week of known risk factor)
Bilateral infiltrates on CXR
Non cariogenic (pulmonary artery wedge pressure is normal)
pO2/FiO <40 kPa
Management of ARDS
Treat underlying condition
Oxygen
ITU support
Allergic bronchopulmonary aspergillosis features
Bronchoconstriction- wheeze, cough, dyspnoea, previous asthma label
Bronchiectasis
Investigations for ABPA
Eosinophilia
CXR changes
Positive RAST test to aspergillus
Positive IgG precipitins
Raised IgE
Management of ABPA
Glucocorticoids- primary
Itraconazole- secondary
Imaging features of ABPA
CXR- mass overlying the hilum, tram track opacities (bronchiectasis)
CT- branching lesion/ finger in glove (bronchocoele)
What lobe is most commonly affected by aspiration
Right middle and lower lobes
Right bronchus is more vertical and has a larger calibre
Atelectasis management
Position patient upright
Chest physiotherapy (breathing exercises)
NB- suspect 72 hours post op if patient has dyspnoea and hypoxaemia
Klebsiella
Typically causes aspiration pneumonia and UTI’s
More common in alcoholics and diabetics
Red currant jelly sputum
Affects upper lobes
Causes lung abscesses and empyema
Features of a pleural effusion
Dyspnoea
Non productive cough or chest pain
Dullness to percussion, reduced breath sounds, reduced chest expansion
Differentiating exudative and transudative pleural effusions
> 30g/L- exudative
<30g/L- transudative
If protein level between 25-35- apply lights criteria
Lights criteria
An exudative is likely if pleural fluid protein divided by serum protein is greater than 0.5
Characteristic pleural fluid findings
Low glucose- TB, RA
Raised amylase- pancreatitis, oesophageal perforation
Blood staining- mesothelioma, PE, TB
Pleural effusion and infection
If fluid purulent- chest drain inserted
If fluid clear but pH less than 7.2 in suspected infection- chest drain inserted
Recurrent pleural effusion
Pleurodesis
Indwelling pleural catheter
Mycoplasma pneumoniae
Autoimmune haemolytic anaemia
Erythema multiforme
CNS involvement eg. GBS/encephalitis
Legionella
Hyponatraemia and lymphopenia
CURB65
Confusion (AMT10 score 8/10)
Urea (>7)
Resp rate (>30)
BP (<90 or <60)
Aged 65+
CURB65 Outcome
0- community
1- if sats above 92%, do CXR and if only one area of consolidation, manage in community
2- transfer to hospital
Management of pneumonia
Low severity- 5 day amoxicillin course (macrolide eg. Clarithromycin if required)
Moderate or severe severity- 7-10 day course of amoxicillin and macrolide eg. Clarithromycin
Symptom resolution in pneumonia
1 week- fever disappear
4 week- chest pain and sputum reduced
6 weeks- cough and breathlessness reduced
3 months- fatigue may still be present
6 months- most people back to normal
Aspergillosis
Fungal infection of the lungs. It can take several forms;
-chronic pulmonary aspergillosis (CPA)
-aspergilloma
-allergic bronchopulmonary aspergillosis (ABPA)
ABX for pneumonia
CAP- amox (doxy if allergy)
HAP- co-amox (48 hours+ in hospital)
