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► Med Misc 46 > CPC 2 (haemoptysis) > Flashcards

CPC 2 (haemoptysis) Flashcards

1
Q

History of haemoptysis

A 
Source
Volume
Frequency
Admixed or alone
Fresh or old
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2
Q

Investigations for someone with haemoptysis, chest pain, fever, wheeze, crepitations

A

Bloods: FBC, U&Es, LFT, inflammatory markers. Troponin I and D-dimer.
Imaging: CXR, ECG
Special tests: autoimmune screen.

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3
Q

Mechanisms of causes of haemoptysis

A 
Neoplasia
Infection 
Inflammation
Impaired clotting
Raised pulmonary pressure
Aberrant anatomy.
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4
Q

Pulmonary vasculitis is often associated with…

A

necrosis of vessels

systemic vasculitis.

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5
Q

Vasculitides affecting large vessels

A

Giant cell arteritis, Takayashu ateritis, Behcet’s disease.

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6
Q

Churg-strauss syndrome is also called…

A

eosinophilic granulomatosis with polyangiitis

allergic granulomatosis

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7
Q

Vasculitides affecting middle sized vessels

A

Polyarteritis nodosa (rare in lungs), Kawasaki vasculitis.

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8
Q

Vasculitides affecting small vessels

A

Wegener granulomatosis, Churg-Strauss syndroome, microscopic polyangitis.

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9
Q

Vasculitis radiology

A

Can be VERY VARIABLE.

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10
Q

Takayashu ateritis

A

Affects large blood vessels.
Affects mostly young asian women.
Causes intimal proliferation and fibrosis of media and adventitia.
Results in luminal narrowing, occlusion, aneurysms.

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11
Q

Medium vessel arteritis

A

Very rare, uncommon in lungs.

Generally in children under 5 years.

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12
Q

Diffuse alveolar haemorrhage (vasculitis)

A

Generally from small vessel vasculitis.
Results in haemoptysis, with diffuse alveolar infiltrates. Causes a drop in haematocrit.
Can vary in appearance from ground glass to consolidation.

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13
Q

Causes of non-infectious vasculitis

A

Immune complexes
Anti-neutrophil cytoplasmic antibodies (ANCA)
anti-endothelial cell antibodies.

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14
Q

ANCA

A

Antibodies against cytoplasm of neutrophils (probably cross reactive). These activate neutrophils, which show MPO and PR3 on their surface.

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15
Q

Treatment of vasculitis

A

Need to be careful; immunosuppression improves immune-mediated vasculitis but worsens infectious vasculitis.

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16
Q

Origin of cells in granulomatous inflammation of the lungs

A

Bone marrow haematopoietic stem cells become monocytes which become tissue macrophages/histiocytes which try to contain the ineradicable offending material.

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17
Q

Types of granuloma

A

Inert foreign material granulomas

Immune granulomas caused by agents able to induce granulomas (mycobacteria, fungi, parasites).

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18
Q

Differentials for granulomatous disease

A

Infectious

Non-infectious - auto-immune or due to exposure.

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19
Q

Commonest causes of community acquired pneumonia

A

streptococcus pneumonia

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20
Q

Cause of pneumonia in patients with alcoholism

A

Can be Klebsiella pneumonia. Gives a red currant jelly sputum. Can be acutely necrotising. High mortality rate even with treatment (50%).

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21
Q

Risk factors for community acquired pneumonia

A 
Age extremes
Impaired gag-reflex / muco-ciliary escalator. 
Non-functioning spleen
Impaired immunity
Chronic heart/lung/liver conditions
Smoking/alcoholism.
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22
Q

Treatment of choice for community acquired pneumonia.

A

B-lactam antibiotic (amoxicillin) +/- clarithromycin.

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23
Q

Forms of aspergillus lung infections

A

Allergic pulmonary aspergillosis
Aspergilloma in pre-existing lung cavities
Invasive pulmonary aspergillosis in immunosuppression.

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24
Q

S. Aureus pneumonia - associations and effect

A

Associated with PVL

Causes cavitating lesions and lung abscess.

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25
Q

Host factors affecting TB risk

A 
Previous exposures
Extremes of age
Nutritional status
Living conditions
Other underlying medical conditions
Immunosuppression
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26
Q

Environmental factors affecting TB risk

A

Endemic infection
Homelessness
Drug and alcohol misuse
Imprisonment

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27
Q

Pathogenesis of TB

A

Bacilli taken up by macrophages, which then go to lymph nodes resulting in Type 1 cytokines which lead to accumulation of macrophages/histiocytes and granuloma formation. This leads to necrosis, with some of the bacilli dying, extensive tissue necrosis, cavitation and spread.

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28
Q

Diagnosis of TB

A

Microscopy, culture, molecular methods (PCR, DNA probes).

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29
Q

Treatment of TB

A

2 months of pyrazinamide ad ethambutol, 6 months of isoniazid and rifampicin.

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30
Q

Rifampicin action

A

Blocks mRNA synthesis

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31
Q

Isoniazid action

A

Inhibits mycolic acid synthesis

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32
Q

Pyrazinamide action

A

Inhibits mycolic acid synthesis.

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33
Q

Ethambutol action

A

Inhibits polymerisation oof arabinoglycan.

34
Q

Causes of haemoptysis

A

Can be airways disease (common), pulmonary parenchymal diseases, or pulmonary vascular diseases.

35
Q

Airways causes of haemoptysis

A

Inflammatory
Neoplasm
Foreign body
Fistula

36
Q

Pulmonary parenchymal causes of haemoptysis

A

Inflammatory
Coagulopathy
Iatrogenic
(Cocaine induced, catamenial)

37
Q

Pulmonary vascular causes of haemoptysis

A

PE
pulmonary AV malformation
Elevated capillary pressure
Iatrogenicc

38
Q

Stain to show fungi

A

Grocott stain

39
Q

Stain to show mycobacteria

A

Ziehl-Neelson stain

40
Q

How much fluid does the pleural space typically contain?

41
Q

Imaging signs of pleural effusion

A

Meniscus sign. Homogenous density, density in dependent portion, loss of normal silhouette, with/w’out mediastinal shift.

42
Q

50 ml in the pleural space - appearance on plain film

A

Loss of CP angles in lateral view

43
Q

175 ml in the pleural space - appearance on plain film

A

Loss of lateral CP angle in PA view

44
Q

500 ml in the pleural space - appearance on plain film

A

Ipsilateral hemidiaphragm PA view.

45
Q

Types of pleural effusion

A

Subpulmonic
Pleural fluid in fissure
Encysted pleural fluid
Loculated effusions (usually haemothorax or empyema)

46
Q

Imaging for pleural effusions

A

CXR, US and CT

47
Q

Ultrasound for pleural effusion; which type gives echogenic image?

A

Exudate, haemorrhage, empyema, chylothrorax

48
Q

Ultrasound for pleural effusion; which type gives anechoic image?

A

Transudate or more rarely, exudate

49
Q

Effusion secondary to heart failure (appearance)

A

Bilateral or right-sided, improves with diuresis.

50
Q

Malignant effusions - appearance on CT

A

unilateral pleural effusion with nodular irregular pleural thickening.

51
Q

Main primary sites causing metastatic pleural effusions to the pleura

A

Lungs > breast > lymphoma or leukaemia.

52
Q

What is the main primary malignancy of the pleura?

A

Malignant pleural mesothelioma (mostly caused by asbestos exposure)

53
Q

Presentation of mesothelioma

A

Chest pain and dyspnoea
Bloody pleural effusion
May be locally invasive

54
Q

Types of mesothelioma

A

Epitheloid, sarcomatoid, biphasic, desmoplastic

55
Q

Prognosis of mesothelioma

56
Q

Benign lung tumour

A

Hamartoma - usually an incidental finding.

57
Q

Broad types of lung cancer

A

Non-small cell lung cancer, endocrine and rarities.

58
Q

Types of endocrine lung cancer

A

Small cell, large cell neuroendocrine, carcinoid

59
Q

Common causes of haemoptysis

A

Bronchiectasis, bronchial carcinoma, pulmonary infarction, bronchitis and infections.

60
Q

Common causes of massive haemoptysis

A

Bronchiectasis, TB or cancer.

61
Q

Use of 5% saline neb

A

Encourage productive coughing if sputum hard to obtain.

62
Q

Top 4 causes of haemoptysis

A
  • Bronchiectasis (including cystic fibrosis)
  • Acute or chronic bronchitis
  • Malignancy
  • Infections
63
Q

Probable cause of haemoptysis with history of chronic cough and sputum production extending back many years

A

Bronchiectasis

64
Q

Probable cause of haemoptysis with history of smoking, shortness of breath on exertion, wheeze, cough and sputum

A

Bronchitis

65
Q

Probable cause of haemoptysis with smoking history, asbestos exposure or weight loss. May also have a history of background shortness of breath or wheeze if co-existing COPD. History of recurrent pneumonias.

A

Malignancy

66
Q

Probable cause of haemoptysis with history of fevers, sweats, cough and sputum production.

A

Bacterial pneumonia

67
Q

Probable cause of haemoptysis with night sweats, fevers, cough, sputum and weight loss often over a period of many weeks. History of immune deficiency or high risk behaviours (e.g. sexual history, iv drug use).

68
Q

Probable cause of haemoptysis with history of COPD or TB.

A

Aspergilloma

69
Q

Probable cause of haemoptysis with history of immobility or long distance travel, painful/swollen legs or shortness of breath.

70
Q

Probable cause of haemoptysis with history of epistaxsis or other ENT disease, fevers, night sweats.

A

Wegener’s granulomatosis

71
Q

Probable cause of haemoptysis with history of recurrent bruising or bleeding, use of anti-coagulants.

A

Coagulopathy

72
Q

Probable cause of haemoptysis with history of rheumatic fever, shortness of breath

A

MV disease, LVF

73
Q

Connective tissue disorders associated with pulmonary vasculitis

A

Rheumatoid arthritis
SLE
systemic sclerosis

74
Q

Vasculitides associated with presence of anti-neutrophil cytoplasmic antibodies

A

Churg-Strauss syndrome, microscopic polyangiitis and Wegener’s granulomatosis.

75
Q

Probably cause of haemoptysis with clubbing

A

Bronchiogenic carcinoma or bronchiectasis.

76
Q

Probable cause of haemoptysis with lymphadenopathy

A

Bronchogenic carcinoma.

77
Q

Why should you check the nasal passage in an examination for haemoptysis

A

Ulcerations are seen there in Wegener’s granulomatosis.

78
Q

What bloods would you do and why for haemoptysis

A

FBC - infection, inflammation, blood loss.
CPR, ESR - infection/inflammation
U&Es - dehydration and renal impariment. Also hyponatraemia in some bronchogenic malignancies.
ANCA - Wegener’s granulomatosis.
Blood cultures - if infection suspected.
Coag screen.

79
Q

Local complications of lung cancer

A

Recurrent laryngeal nerve palsy, phrenic nerve palsy, SVC obstruction, Horner’s syndrome, rib erosion, pericarditis, AF.

80
Q

What does the following case suggest?
A 48-year-old male presents with a 8 week history of epistaxis and nasal stuffiness. On examination there is evidence of nasal crusting. A chest x-ray demonstrates multiple cavitary lesions.

A

Granulomatosis with polyangiitis (Wegener’s granulomatosis)

81
Q

What are the features of granulomatosis with polyangiitis?

A

upper respiratory tract: epistaxis, sinusitis, nasal crusting
lower respiratory tract: dyspnoea, haemoptysis
rapidly progressive glomerulonephritis (‘pauci-immune’, 80% of patients)
saddle-shape nose deformity
also: vasculitic rash, eye involvement (e.g. proptosis), cranial nerve lesions

► Med Misc 46 (31 decks)

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