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Year 3 - TCD > Case 12 - Pneumonia + TB > Flashcards

Case 12 - Pneumonia + TB Flashcards

1
Q

How is pneumonia transmitted?

A

Aspiration of airborne pathogens or aspiration from stomach contents.

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2
Q

What is community acquired pneumonia?

Which organisms normally lead to CAP?

A
  • Pneumonia not acquired in healthcare setting.
  • Streph.pneumoniae
  • H.influenza
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3
Q

What is hospital acquired pneumonia?

A

Pneumonia originating in the hospital with onset >48 hours after admission or within 1 month after discharge.

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4
Q

What ventilation acquired pneumonia?

A

HAP occurring in patients with mechanical ventilation.

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5
Q

Which micro-organism leads to VAP?

A

Pseudomonas aeruginosa

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6
Q

What is typical pneumonia?

A
  • Classic symptoms, typical findings on auscultation and percussion.
  • Can be cultured using standard methods in the lab
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7
Q

What is atypical pneumonia?

A
  • Less distinct classical symptoms and often remarkable findings on auscultation and percussion
  • Cannot be cultured in the lab, needs alternative tools
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8
Q

How is pneumonia classified based on location?

A
  • Bronchopneumonia
  • Atypical or interstitial pneumonia
  • Lobar pneumonia
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9
Q

How does bronchopneumonia appear on CXR?

A

Poorly defines patchy infiltrates scattered across lungs

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10
Q

How does interstitial pneumonia appear on CXR?

A

Diffuse reticular opacity

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11
Q

How does lobar pneumonia appear on CXR?

A

Extensive opacity restricted to one pulmonary lobe

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12
Q

What are the typical pathogens that lead to pneumonia?

A
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Klebsiella pneumoniae
  • Staphylococcus aureus
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13
Q

What are the atypical pathogens that lead to pneumonia?

A

Legions of psittaci MCQs:

  • Legionella pneumophila
  • Chlamydia psittaci
  • Mycoplasma pneumoniae
  • Chlamydia pneumoniae
  • Coxiella burnetti
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14
Q

Which organisms are likely to cause HAP?

A
  • Enterobacteria
  • Pseudomonas aeruginosa
  • Staphylococcus aureus
  • Streptococcus pneumoniae
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15
Q

Who is more likely to get pneumocystis jirovecii pneumonia?

A

Immunocompromised and HIV patients

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16
Q

What type of pathogen is pneumocystis jirovecii?

A

Fungal

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17
Q

How do people with pneumocystis jirovecii pneumonia present?

A
  • Dry cough without sputum
  • SoB on exertion
  • Night sweats
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18
Q

How to treat pneumocystis jirovecii pneumonia?

A

Co-trimoxazole (trimethoprim/sulfamethoxazole)

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19
Q

Which bacteria is the cause of pneumonia in COPD patients?

A

Haemophilus influenzae

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20
Q

Which bacteria is the cause of pneumonia in cystic fibrosis patients?

A
  • Pseudomonas aeruginosa

- Staphylococcus aureus

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21
Q

How is legionella pneumophila (Legionnaires’ disease) spread?
What can it also cause?

A
  • Infected water supplies or air conditioning units

- Hyponatreamia due to SIADH

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22
Q

How might an exam question about legionella pneumophila (Legionnaires’ disease) present?

A

Recently had a cheap hotel holiday and presents with hyponatraemia.

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23
Q

Who is at more risk of chlamydia psittaci?

- Typical exam question

A
  • Typically contracted from contact with infected birds

- Patient is parrot owner

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24
Q

Who is at more risk of coxiella burnetii?

- Typical exam question

A
  • Exposure to animals and their bodily fluids.

- Farmer with a flu like illness

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25
Q

How might chlamydophila pneumoniae present?

A

School aged child with a mild to moderate chronic pneumonia and wheeze

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26
Q

What sign might be present for mycoplasma pneumoniae?

A

Erythema multiforme rash - “target lesions” formed by pink rings with pale centres.

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27
Q

How might mycoplasma pneumoniae present?

A

Young patient has neurological symptoms

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28
Q

What are the risk factors for CAP?

A
  • Very old/young people
  • Cystic fibrosis
  • COPD, HF, bronchial asthma
  • Immunosuppressed: HIV, DM
  • Smoking
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29
Q

What are the risk factors for HAP?

A
  • ICU stay
  • Mechanical ventilation
  • COPD, CF
  • Abdominal surgery
  • Vomiting/aspiration
30
Q

What are the symptoms of pneumonia?

A
  • Severe malaise
  • High fever and rigors
  • Productive cough with purulent sputum (rusty with strep pneumonia)
  • Tachypnoea
  • Dyspnoea
  • Pleuritic chest pain
  • Pain projecting to the abdomen and epigastric region
31
Q

What are the signs of pneumonia?

A
  • Coarse crackles, bronchial, and decreased breath sounds
  • Enhanced bronchophony, egophony, and increased tactile vocal fremitus
  • Dullness on percussion over affected sites
32
Q

How to test for streptococcus pneumoniae and legionella antigen?

A

Send a urine sample for antigen testing

33
Q

What investigations to do in pneumonia?

A
  • FBC: WCC raised in acute infection
  • CRP levels
  • Lactate: sepsis, shock
  • Urinary antigen testing
  • U+Es
  • Sputum culture
  • Blood culture
34
Q

How does typical pneumonia appears on CXR?

A

Lobar pneumonia

35
Q

How does atypical pneumonia appears on CXR?

A

Interstitial pneumonia

36
Q

In which CXR (effusion or consolidation) are margins of opacification are not clear?

A

Consolidation

37
Q

In which CXR (effusion or consolidation) are opacifications dense and there are no markings visible in the lung field?

A

Effusions

38
Q

In which CXR (effusion or consolidation) is the diaphragm, angles more visible?

A

Effusions

39
Q

What is the CURB 65 score?

A 
Confusion 
Urea > 7 mmol/L 
Respiratory rate ≥ 30/min
Blood pressure: systolic BP ≤ 90 mm Hg or diastolic BP ≤ 60 mm Hg
Age ≥ 65 years
40
Q

What do the results of CURB 65 mean?

A
  • Score 0-1: The patient may be treated as an outpatient.
  • Score 2: Hospitalisation is indicated.
  • Score 3-5: Admit to ICU
41
Q

What is the mortality risk with each CURB 65 score?

A
  • Score 0-1: <3%
  • Score 2: 3-15%
  • Score 3-5: >15%
42
Q

How soon after admission into hospital for pneumonia should someone receive antibiotics?

A

4 hours

43
Q

How is CAP treated?

A
  • Low severity (0 or 1): oral amoxicillin
  • Moderate (score 2) – oral amoxicillin and clarithromycin
  • Severe (score 3 to 5) - IV co-amoxiclav + clarithromycin
44
Q

How is HAP treated?

A
  • Non severe signs or symptoms – Co-amoxiclav

- Severe signs or symptoms (or high risk of resistance) – IV Piperacillin with tazobactam

45
Q

What antibiotics should be considered for pseudomonas?

A

Tazocin and quinolones

46
Q

What antibiotics should be considered for legionella pneumophilia?

A

Levofloxacin and rifampicin

47
Q

What are the complications of pneumonia?

A
  • Para-pneumonic exudative pleural effusion
  • Para-pneumonic pleuritis
  • Empyema
  • Lung abscess
  • Metastatic infections
  • Pulmonary VTE
  • Sepsis
  • Respiratory failure, ARDS
48
Q

What is the follow up after pneumonia?

A
  • 1 week: fever should have resolved
  • 4 weeks: chest pain and sputum production should have reduced
  • 6 weeks: cough and breathlessness should have substantially reduced
  • 3 months: most symptoms should have resolved but fatigue may still be present
  • 6 months: most people will feel back to normal.
49
Q

How soon after should a CXR be done to ensure opacity has cleared?

A

6 weeks

50
Q

What are the 2 types of bacterias that lead to TB?

A
  • Mycobactrium tuberculosis: 95% of cases

- Mycobacterium bovis (cow’s milk)

51
Q

How is TB transmitted?

A
  • Inhalation of infected droplets through the air

- Infected milk (M. bovis)

52
Q 
What is:
1- Active TB
2- Latent TB
3- Secondary TB
4- Extra-pulmonary TB
A

1- Active infection in various areas within the body
2- Person is infected with TB but does not have any symptoms of disease and is not infectious.
3- TB reactivates again with symptoms and they are contagious.
4- Immune system is unable to control the disease this causes disseminated TB

53
Q

What are the common sites of extra-pulmonary TB?

What is miliary TB?

A

Bones, pleura, lymphatic system (known as miliary TB and is the most dangerous spread of TB), liver and urinary.

54
Q

What is the chance of getting primary TB if exposed to an infectious cause?

A

30%

55
Q

What are the symptoms of active TB?

A
  • Fever,
  • Weight loss
  • Night sweats
  • Fatigue
  • Lymphadenopathy
  • Dyspnea
  • Productive cough (possibly haemoptysis) lasting > 3 weeks
  • Pleuritic pain and bone pain
56
Q

What can be seen on a CXR for primary TB?

A
  • Patchy consolidation
  • Pleural effusions
  • Hilar lymphadenopathy
57
Q

What can be seen on a CXR for reactivated TB?

A
  • Patchy or nodular consolidation with cavitation (gas filled spaces in the lungs) typically in the upper zones
58
Q

What stain do you use to identify TB on sputum microscopy?

- What colour does it stain?

A
  • Acid fast stain (Zeihl-Neelsen)

- Stains red

59
Q

How is the tuberculin skin test (mantoux test) used?

A
  • A test to assess for latent TB, in which 5 units of purified protein derivative tuberculin is injected intradermally.
  • The skin reaction should be read 48–72 hours
  • The test only becomes positive 6–8 weeks after infection.
  • A healthy individual without any risk factors for TB infection who has an induration smaller than 15 mm is considered negative for TB
60
Q

How is the IGRA (interferon gamma release assay) used in the assessment of TB?

A
  • An ELISA test that measures the level of interferon-γ expressed by T cells after coming into contact with Mycobacterium tuberculosis.
  • Used to diagnose latent tuberculosis infection in at-risk populations.
  • Elevated interferon-γ levels indicate a positive result.
  • In contrast to tuberculin skin testing, there are no false-positive results with IGRA in patients who received the bacillus Calmette-Guérin (BCG) vaccine.
61
Q

When is IGRA test used?

A

Patients that do not have features of active TB but do have a positive Mantoux test to confirm a diagnosis of latent TB.

62
Q

What is the treatment for active TB?

A
  • Initiation phase: 2 months of isoniazid + rifampin + pyrazinamide + ethambutol
  • Continuation phase: 4 months of isoniazid + rifampin
63
Q

What is the treatment for latent TB for those at risk of reactivation?

A
  • Isoniazid and rifampicin for 3 months OR

- Isoniazid for 6 months

64
Q

What are the side effects of isoniazid?

A
  • Hepatotoxicity (acute hepatitis, chronic liver failure).
  • Peripheral polyneuropathy and other symptoms of pyridoxine deficiency (e.g., stomatitis, glossitis, convulsions, and anemia).
65
Q

What should be prescribed with isoniazid to reduce side effects?

A

Pyridoxine (vitamin B6)

66
Q

What are the side effects of rifampicin?

A
  • Hepatotoxicity
  • Red or orange body fluids (e.g., urine, tears).
  • Thrombocytopenia.
  • Flu/GI sx.
67
Q

What are the side effects of pyrazinamide?

A
  • Hepatotoxicity
  • Hyperuricemia
  • Arthralgia
  • Myopathy
  • GI symptoms
68
Q

What are the side effects of ethambutol?

A

Retrobulbar neuritis: can lead to blindness

69
Q

Poly-resistance to TB meds is resistance to….

A

More than one medication other than both Rifampicin and Isoniazid

70
Q

Multi-drug resistant TB is resistant to….

A

Both Rifampicin and Isoniazid

71
Q

Which bacteria is the more likely cause of pneumonia in alcoholic misusers and elderly?

A

Klebsiella pneumonia

Year 3 - TCD (17 decks)

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