Chronic Pulmonary Infection Flashcards
How is chronic pulmonary infection diagnosed?
Shadow on CXR Weight loss Persistent sputum production Chest pain Increased SOB
What can be the differential diagnosis if pulmonary infection is suspected?
Lung cancer Intrapulmonary abscess Emypema Bronchiectasis CF
What are the risk factors for developing chronic pulmonary infections?
Abnormal host response
Abnormal innate host defence
Repeated insult
What is abnormal host response?
Immunnodeficiency: Congenital, acquired
Immunosuppression: Drugs, malignancy
What is abnormal innate host defence?
Damaged bronchial mucosa
Abnormal cillia
Abnormal secretions
What is repeated insult?
Aspiration
Indwelling material
What is immunodeficiency?
Immunoglobulin deficiency
Hypo-splenism
Immune paresis
HIV
What are the different types of immunoglobulin deficiency?
IgA deficiency: common, increased risk of acute infections, rarely chronic infections
Hypogammaglobulinaemia: rarer, increased risk of acute and chronic infections
CVID: commenest cause of immunodeficiency, recurrent infections
Specific Polysaccharide Antibody Deficiency SPAD
What are the different types of immune paresis?
Myeloma
Lymphoma
Metastatic malignancy
What can cause immunosuppression?
Steroids Azathioprine Methotrexate Cyclophosphamide Monoclonal antibodies: Infliximab Rituximab Chemotherapy
What can cause damaged bronchial mucosa?
Smoking
Recent pneumonia or viral infection
Malignancy
What can cause abnormal cilia?
Kartenager’s Syndrome
Youngs Syndrome
What can cause abnormal secretions?
CF
Channelopathies
What can cause recurrent aspirations?
NG feeding
Poor swallow
Pahyngeal pouch
What can cause indewlling of material?
NG tube in the wrong place
Chest drain
Inhaled foreign body (peanut, chicken bone ect)
What are different forms of chronic infection?
Intrapulmonary abscess Empyema Chronic Bronchial Sepsis Bronchiectasis CF or other oddities
What are the signs and symptoms of intrapulmonary abscess?
Indolent presentation Weight loss common Lethargy, tiredness, weakness Cough - can be with or without sputum High mortality if not treated Usually a preceding illness of some sort
What can be the preceding illness that leads to intrapulmonary abscess?
Pneumonia: Flu - Staph pneumonia - cavitating pneumonia - abscess
Aspiration pneumonia: vomiting, lowered conscious level, pharyngel pouch
Poor host immune response: Hypogammaglobulinaemia
What pathogens can cause intrapulmonary abseccess?
Bacteria: Streptococcus, Staphylococcus, E-coli, Gram negatives
Fungi: Aspergillus
What can cause a septic emboli?
Right sided endocarditis
Infected DVT
Septicaemia
IV drug users (PWID) - inject into groin, DVT, infection, PE + abscesses
What is an empyema?
Pus in the pleural space
57% of all patients with pneumonia develop pleural fluid
Remainder are primary empyema - often iatrogenic, many idiopathic
High mortality - 20% of all patients with empyema die
What are the characteristics of a simple parapneumonic effusion?
Clear fluid
pH > 7.2
LDH < 1000
Glucose > 2.2
What does LDH measure?
Tissue damage
What are the characteristics of a complicated parapneumonic effusion?
pH <7.2
LDH >1000
Glucose <2.2
Requires chest tube drainage
What are the characteristics of am empyema?
Frank pus
What is the bacteriology of an empyema?
Aerobic organisms most frequently
Gram positives: Strep milleri, staph aureus (usually post-operative or nosocmial in immunocompromised individuals)
Gram negatives: E-coli, pseudomonas, haemophilus influenzae, kelbsiellae
Anaerobes in 13% of cases - usually in severe pneumonia or poor dental hygiene
How is an empyema diagnosed?
Clinical suspicion: slow to resolve pneumonia with lateral CXR
CXR: persisting effusion
USS: simple bedside test, targetted sampling
CT: Differentiation between empyema and abscess
What does a CXR look like in empyma?
Look for D sign
Better CXR increase sensitivity and specificity
How can empyema’s be treated?
USS guided drainage
IV antibiotics - broad spectrum, amoxicillin and metrondioazole
Oral antibiotics - directed towards cultured bacteria for at least 14 days
What is bronchiectasis?
The localised, irreversible dilation of the bronchial tree
Involved bronchi are dilated, inflamed and easily collapsed
This causes airflow obstruction and impaired clearance of secretions
What is the presentation of bronchiectasis?
Recurrent chest infections
Recurrent antibiotics prescriptions but no response to antibiotics or a short lived response to antibiotics
Persistent sputum production
How is bronchiectasis diagnosed?
Clinical - cough production of sputum, chest pain, recurrent LRTIs
Radiological - HRCT
What can cause bronchiectasis?
Bronchial obstruction CF Young's syndrome Kartanger's syndrome ABPA Immunodeficiency Rheumatoid arthritis Bronchopulmonary sequestration Mounier-Khun syndrome Yellow nail syndrome Traction bronchiectasis associated with pulmonary fibrosis
What is chronic bronchial sepsis?
Has all the hallmarks of bronchiectasis but no findings on the HRCT. Confirmed positive sputum results, often in younger patients, mainly women, often in involved in childcare
Others are older, usually with COPD or airways disease
Same work up as bronchiectasis
The sinuses are resovoirs of infections
What are treatment options for bronchiectasis?
Stop smoking
Flu vaccine
Pneumococcal vaccine
Reactive antibiotics - send sputum sample, give antibiotics appropriate to most recent positive culture
What is the treatment when the patient with bronchiectasis is colonised with bacteria?
Prophylactic antibiotics
Nebulised gentamicin, colomycin
Pulsed IV antibiotics
Alternating oral antibiotics
What is the prognosis for patients with bronchiectasis?
Recurrent infections
Abscesses and empyema
Colonisation
What are some complications of CF?
Bronchiectasis - cystic saccular Tenacious sputum Biliary obstruction and obstructive hepatitis Pancreatic dysfunction Psychological issues for all
