CLINICAL 1 Flashcards
What is a Ranke complex?
Enlarged hilar lymph nodes in a person infected with TB
How does an IGRA work to detect presence of TB?
This is an Interferon Gamma Release Assay (Quantiferon Gold), you draw a patient’s blood and expose it to TB and if there is high release of IFN-gamma, you know they have been exposed to TB b/c the mechanism of controlling TB is the Type IV hypersensitivity which involves the release of IFN gamma
What are the (Rowane) drugs for Tx of CAP in the ICU patient? What if you are concerned about staph?
Beta lactam with IV azithromycin OR IV fluoroquinolone ; if suspect MRSA then ADD vanco or linezolid
What may be the Dx test of choice for IPF?
High resolution CT scan aside from surgical Bx and clincal picture
How long does it take to grow TB on Lowenstein-Jensen?
7 weeks but it is the gold standard for Dx
What is Lofgren’s Syndrome?
A form of sarcoidosis that has fever, erythema nodosum, polyarthritis, and bilateral hilar lymphadenopathy
What is the mainstay of Tx for sarcoid?
Corticosteroids but ONLY IF severe disease; otherwise, azathioprine, methotrexate, and cyclosporine
What is the typical presentation of Idiopathic pulmonary fibrosis?
Middle aged male with exertional dyspnea and bibasilar rales (prob honeycombing on CXR)
What areas of the lungs are affected by interstitial pulmonary fibrosis and sarcoidosis respectively?
IPF = lower lungs (recall: bibasilar rales) and Sarcoid = upper lungs
What is the only proven Tx for interstitial pulmonary fibrosis to show survival benefit?
Lung transplant
This interstitial disease results from repeated exposure to organic dusts
Hypersensitivity pneumonitis
What is the algorithm for the Tx of nosocomial pneumonia?
(1) A beta lactam OR antipseudomonal OR (if allergic to beta lactam) aztreonam AND (2) Antipseudomonal fluoro OR tobramycin AND (3) vancomycin
What is probably the best way to test for TB in a person with BCG?
Quantiferon Gold test or CXR
Which fungal pneumonia is likely to spread to skin and bone?
Blastomyces dermatidis
Which pnuemonia has scant and watery sputum? What is the maximum # of epithelial cells you want on a sputum sample?
Mycoplasma; 25 because otherwise it is probably just spit
Cases of TB decreased from the early to mid 80’s, what was responsible for the new increase in cases from the late 90’s to early 90’s?
AIDS, defective immune systems allowed for easier infection as well as reactivation of latent TB
Who is at risk for sarcoid?
Mostly black females
What are the minor criteria for admission to ICU?
SBP < 90 mmHg, multilobar dz, Pa02/FiO2, or Respiratory rate >30 min (need 2 of these criteria)
What are 2 important ways to isolate a patient with active TB?
Put them in a negative pressure room so their expired air doesn?t affect other patients; give them an N95 mask which only allows 5% of expired particles through
How is desquamative interstitial pneumonitis different from interstitial pulmonary fibrosis
Desquamative is ASSOCIATED with smoking and has less destruction than IPF and involves alveoli filled with macros (they are there to eat up the smoking particles)
Aside from involving lung and intrathoracic lymph nodes, where does sarcoidosis commonly go?
SKIN
What pulmonary artery systolic pressure indicates the need for lung transplant?
> 50 mmHg
What is the specificity and sensitivity of PCR in Dx of TB?
Highly specific but only moderately sensitive, clinical judgment is still more important
What are the major criteria for admission to the ICU?
Need for mechanical ventilation or septic shock
Why should patients who are being treated for TB be given vitamin B6?
Because isoniazid is a folate inhibitor
Given that CHF and idiopathic pulmonary fibrosis can have crackles, SOB, hypoxemia, and LE edema from cor pulmonale, how would you distinguish on CXR?
IPF should not have “batwing” hilar pulmonary edema; diuresis is NOT helpful in these patients
What ion changes may occur in Legionanaires?
Hyponatremia and Hypophosphatemia
The basis of the Tuberculin Skin test is this type of hypersensitivity reaction:
Type IV
A patient has both AIDS and TB but displays no Sx despite the fact that the TB is active, after a few days on ART therapy, the patient begins to develop a fever, and is hypotensive, why?
This is IRIS which is immune reconstitution inflammatory syndrome and occurs because before they received their ART (antiretroviral therapy) they had no immune system, now that it has been RECONSTITUTED they appear sick. That is because the Sx of TB are FROM the immune system
Miliary tuberculosis that spreads to the bone (spine, in particular) was named after whom?
Percivall Potts
What is an extrapulmonary restrictive disorder? What is a major acute restrictive disorder?
Guillian Barre or ALS etc.// ARDS
Can a person with redness and swelling have a positive PPD?
NO, there must be induration (swelling)
T/F hypersensitivity pneumonitis is IgE mediated
ABSOLUTELY FALSE, it is IgG and presents initially as type III and progresses to Type IV (granulomatous)
What was the first antibiotic that was ever created to Tx TB?
Streptomycin in 1944
Which 3 states have the highest rates of TB?
Hawaii, Alaska, and California
What is the difference in the use of isoniazid for Tx of latent TB vs. rifampin?
Isoniazid is to be given 300 mg for NINE MONTHS while rifampin can be given instead at 600 mg for 4 MONTHS (most ppl pick rifampin b/c it shaves off 5 months)–also, they cannot be jailed for not taking meds if they are latent, but if the reactivate, then they go on the 4 drug regimen and can be jailed
Where was TB first documented?
A cemetary in Heidelberg, Germany. Skeletal remains demonstrated Pott’s disease
Why did TB become so common during the industrial revolution?
Because a major risk factor for TB is living in close quarters
In whom is a PPD >10 mm considered positive?
Patients with clinical conditions that increase odds of reactivation (silicosis, renal failure etc), ppl born in foreign country with an incidence of >25/100,000 cases. Foreign born, and healthcare employees
What is the ratio of CD4/CD8 in a bronchoalveolar lavage of hypersensitivity pneumonitis?
low
What are 3 likely lab findings with sarcoidosis?
Hypercalcemia/Hypercalciuria from the increase in 1,2 dihydrocalciferol; elevated ACE levels
A woman is hypercalcemic with elevated ACE levels and bilateral hilar lymphadenopathy, what do they probably have?
Sarcoid
What respiratory issue is sildenafil used for?
Pulmonary HTN
With respect to nosocomial pneumonia why are many hospitals concerned with GI prophylaxis (i.e. for Tx of stress ulcers)?
Because the increased pH of the gastric acid allows more microbes to live there and increases risk of aspiration pneumonia
What is the most common type of tuberculosis infection you will likely see as a physician?
Latent Tuberculosis infections, far mor common than acute
What is the infection that you can have a person incarcerated for over not being compliant with medications?
TB
What is the major risk factor for pseudomonas pneumonia?
STRUCTURAL LUNG DZ esp. CF and COPD
Which fungal pneumonia is associated with erythema nodosum?
Coccidiodes immitis
What is Hammond-Rich Syndrome?
Acute interstitial pneumonia
T/F: bronchoscopic biopsy is the definitive Tx for idiopathic pulmonary fibrosis
FALSE it would not yield a large enough sample, you need to do a surgical Bx; ALSO, along w/ surgical Bx you need the CLINICAL PICTURE
What is the difference in Tx of RBILD and DIP?
Both require cessation of smoking but only DIP requires steroids
What is the hallmark of acute interstitial pneumonia?
Diffuse alveolar damage
Which interstitial lung diseases involve a Hx of smoking?
Desquamative interstitial pneumonia and Respiratory Bronchiolitis intersitial pneumonia
What are the effects of interstitial lung disease on PFT’S?
Decreased CO diffusing capacity, decrease TLC and FEV1 as well as decreased compliance
What are the first line Tx for aspergillosis?
Azoles over amphotericin B? Although in micro, Keller said allergic aspergilloses should be given corticosteroids, and non-invasive aspergillomas should be surgically removed, ONLY hematogenous aspergillosis should be Tx’d with voriconazole
Where is the consolidation if the aortic knob is obliterated on CXR?
Left upper lobe
Which pneumonia may have “multiple nodules” on CXR?
Staph
Aside from idiopathic pulmonary fibrosis, where else can usual interstitial pneumonia be seen?
Collagen vascular disease, Asbestosis + other occupationals, drug induced lung disease
What is the Tx of miliary TB?
Same as that of pulmonary (active) TB–isoniazid, rifampin, pyrazinamide, and ethambutol
What is the best information you can get from an Acid Fast stain?
Information about how infective a patient is, overall the acid fast (Ziehl-Neelsen) stain is rather insensitive but IF it does detect red snappers, you know that person is rather infectious. If not, it doesn?t r/o TB but it probably does mean that they arent very infectious if they do have it
What kind of inflammation occurs in hypersensitivity pneumonitis?
Granulomatous
What is the prognosis for idiopathic pulmonary fibrosis?
Poor. Respiratory failure and death in 3-8 years, also there is cor pulmonale 2ndary to PHTN
What is the Tx of desquamative interstitial pneumonitis?
Tx is to QUIT smoking and STEROIDS
In whom is a PPD >15 mm considered positive?
A healthy person w/o any real risk factors for TB
What is another name for bronchiolitis obliterans w/ organizing pneumonia? What is causing the “obliterans”?
Cryptogenic organizing pneumonitis; granulation tissue (LCT) is obliterating the airways
In whom is a PPD > 5 mm considered positive in (4)?
HIV infection, Close contact with active contagious disease, abnormal CXR with fibrotic changes consistent with old TB, and any immunosuppressed pt (TNF-alpha blockers- etanercept and infliximab, glucocorticoids, organ transplant)
What is the difference in the Tx of an HIV (+) pt for TB vs. a HIV (-) pt?
NONE aside from the fact that you give them ART as well and try to balance it
What is similar and different about respiratory bronchiolitis interstitial lung disease and Desquamative interstitial pneumonitis?
RBILD is also assoc w/ smoking and accumulation of macros (AND fibro’s) in UPPER AIRWAY whereas DIP was lower airway (in alveoli)
Who invented the stethoscope? Who proved that TB had an infectious etiology?
Laennec; Robert Koch
What are the risk factors for multidrug resistance?
Antibiotic Tx in past 3 months 2) Hospitalized greater than 5 days 3) high freq. of ATB resistance in community and 4) immunosuppressive Dz or Tx
What kind of granulomas are present in sarcoid and where are they in the lung?
Non-caseating and in the SUBMUCOSA OF BRONCHIOLES
Which organism is notable for forming a “fungal ball” by colonizing a pre-existing pulmonary cavity such as a healed granuloma?
Aspergillus
Interstitial lung disease is probably a sequela, largely, of what kind of disease?
Vascular disease
Describe stage 0-3 for sarcoidosis:
0: normal 1: bilateral hilar lymphadenopathy 2: bilateral lymphadenopathy w/ pulmonary infiltrates and 3) parenchymal infiltrates w/o BHL–the worse the disease, the more lymph nodes are lost
What are the 3 (Rowane) options for Tx of CAP in the general medical ward?
Beta lactam with a macrolide OR high dose amoxicillin OR high dose amoxicillin + clavulanate AND a macrolide
What is the pathological hallmark of Idiopathic pulmonary fibrosis?
Usual interstitial pneumonia
T/F interstitial lund diseases only affect the interstitium?
False, they begin in interstitium but can involve alveolar airspace, blood vessels, and distal airways
