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Exam 2 Keystone > L23 - Chronic Pneumonias - mycobacteria & endemic fungi > Flashcards

L23 - Chronic Pneumonias - mycobacteria & endemic fungi Flashcards

1
Q

Which is not a common Feature of Mycobacterial & Fungal Pneumonias?
A. Lung inflammation days to weeks
B. Symptoms: fatigue, weight loss, fever, cough & dyspnea
C. Common pathophysiology: intracellular pathogens of macrophages
D. Histopathologic hallmark: granuloma (necrotizing or non-necrotizing)
E. Diagnosis often delayed & High index of suspicion required

A

A. Days to weeks is more typical of community acquired pneumonia. Myocobacterial and fungal pneumonias last weeks to months

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2
Q 
These are the differential diagnoses of what kind of findings?
	• Lung Cancer 
	• Mycobacterial disease (look similar radiographically)
		○ Tuberculosis (TB) 
		○ Nontuberculous Mycobacteria
	• Fungi 
		○ Histoplasmosis
		○ Blastomycosis 
		○ Coccidiodomycosis 
	• Sarcoidosis
A

Upper Lobe Infiltrate & Adjacent Adenopathy

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3
Q

These labs are done to diagnose what fungi? • Serology
- Complement Fixation – Yeast & Mycelial antigens
- Immunodiffusion – H band shows up earlier (~2 months) than; M band
○ Serum in well with antigens.
Both CF and ID peak @ ~3 months and remain +ve> 2 years
Lung, right, transbronchial biopsy (not shown):
- Granuloma & necrosis with fungal organisms morphologically consistent with this fungi.
- Fungal Cultures negative since this fungi is hard to grow

A

Histoplasmosis

Acute vs convalescent - acute has low titer in yeast & mycelial antigens but convalescent shows 3x titer rise

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4
Q 
What are endemic mycoses mean fungi linked to location.
Where are these commonly located?
1. Cocci
2. Blasto
3. Histo
A
  1. Arizona (desert southwest) - Snow birds (people traveling to warm places for the winter then returning)
  2. Wisconsin (midwest states bordering the great lakes)
  3. SE, mid Atlantic and central US (Mississippi/Ohio river valley)
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5
Q

Histo, blasto or cocci?

  1. Dimorphic process (fungi –> yeast in human host)
  2. Infectious particle is the microconidia which gets inhaled and lodged into the alveoli (yeast then accessible to macrophages)
  3. Incubation period 2 weeks
  4. Histo: multi-uclear giant cell with cytoplasmic shrinking/white spaces
  5. fever in compromised host
A

Histoplasma capsulatum - cytoplasmic shrinking/white spaces (capsulatum - not a real capsule)

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6
Q

T/F Histoplasmosis has a narrow clinical spectrum

A

False - Broad

  1. Acute pulmonary histoplasmosis (localized and diffuse)
  2. Chronic pulm histo
  3. disseminated histo
  4. Others (e.g. pericarditis, fibrosing mediastinitis)
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7
Q

What kind of histo?

  1. CXR may show localized pulmonary infiltrate and adjacent hilar adenopathy
  2. most resolve spontaneously
  3. most common manifestation of histo
A

Localized pulmonary histo/acute pulmonary histo

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8
Q

What kind of histo?
• Indolent process
• Pre-existing lung disease (eg, COPD)
• Upper lobe predominant (sarcoid is like this too)
• Appears cavitary (mimics TB & non-tb mycobacteria)
• Organism can be isolated in sputum, unlike acute pulmonary Histo

A

Chronic pulmonary histo

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9
Q

What kind of histo?
• Immunosuppressed patients (eg, steroids, HIV)
• Chest x-ray changes subtle or absent
• Like TB, TNF essential to defense against H. capsulatum
○ Endemic region (midwest), ⇑ Histo risk a/w TNF inhibitor Rx (eg, Infliximab)…greater than risk for TB
○ Fever on anti-TNF Rx

A

• (Progressive) Disseminated Histoplasmosis

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10
Q

What kind of histo?
• Relentless/excessive inflammatory response to Histo antigen
○ B-cell mediated reaction
• Compresses vital structures such as pulmonary arteries (arrow), SVC, main bronchi, esophagus
• Doesn’t respond to antifungal or other immunosupression
• Intervene with catheters.

A

Fibrosing mediastinitis

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11
Q

Diagnosis of what kind of histoplasmosis is best done (has highest sensitivity) by urine antigen testing?

A

Disseminated histo mostly - acute pulmonary histo may also be sensitive, but NOT helpful for sub-acute or chronic pulmonary histo

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12
Q

Antigen testing has highest sensitivity for diagnosing which type(s) of histo?

A

Disseminated histo

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13
Q

Serology testing has highest sensitivity for diagnosing which type(s) of histo?

A

Chronic and acute pulmonary histo

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14
Q

Fungal stain testing has highest sensitivity for diagnosing which type(s) of histo?

A

Not very helpful in general (additive test for diagnosing disseminated)

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15
Q

Culture testing has highest sensitivity for diagnosing which type(s) of histo?

A

Chronic pulmonary histo (additive test for diagnosing disseminated as well)

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16
Q

Is antifungal treatment indicated here?

  1. Acute pulmonary disease with hypoxia
  2. acute pulmonary symptoms >1 month
  3. Chronic pulmonary disease
  4. Esophageal compression/ulceration
  5. mediastinal granuloma w/obstruction or tissue invasion
  6. disseminated disease
A

Treatment IS indicated

17
Q

Is antifungal treatment indicated here?

  1. Acute self-limited syndromes
  2. Acute pulmonary disease, mildly ill
  3. Joint complaints
  4. pericarditis
  5. histoplasmoma
  6. fibrosing mediastinitis
  7. broncolithiasis
  8. Sarcoidosis-like syndrome
A

Treatment IS NOT indicated

18
Q

T/F Acute/Chronic Histo: ID & CF Serology not helpful bc…
○ possible false-negatives
○ Cross reactions
○ Index of suspicion

A

False - it is helpful, but be aware of these possibilities of false neg, cross reactions and have an index of suspicion

19
Q

T/F Histopath/culture & urine antigen for diagnosis of acute cases of histo

A

False - severe cases

  • disseminated
  • diffuse pulm histo
20
Q

Histo, blasto, or cocci treatment?

  • severe: lipo-AmphoB
  • Other: Itraconazole
A

Histo

21
Q

Histo, blasto, or cocci treatment?

  • severe: AmphoB
  • Other: Itraconazole
A

Blasto

22
Q

Histo, blasto, or cocci treatment?

  • severe: AmphoB
  • Other: Itraconazole and fluconazole
A

Cocci

23
Q

Which is false regarding TB?
A. This is a leading cause of death and disability with 8 million new cases each year.
B. 1/3 of the world’s population is actively infected with M tuberculosis
C. Co-infection with HIV increases rate of progression
D. Resistance to standard TB drugs are rising
E. M tb is transmitted by aerosol route (person-to-person) ONLY due to sustained, close contact w/infected person

A

B. Latently infected - and at risk of developing active TB

24
Q

Isoniazid and rifampin are among the first line drugs that are classified as ______ in treating TB

A

Multi-drug resistant (MDR TB)

25
Q

All first line & key second line drugs (quinolones, injectable drugs) are among the drugs that are classified as ______ in treating TB

A

Extensively drug resistant (XDR TB)

26
Q

Active or latent TB?

both within macrophages and extracellularly, in caseous granulomas

A

Latent - 5% progress after 2 years to active (10% if there is a concurrent HIV infection)

27
Q

Active or latent TB?

chronic, progressive disease, primarily in the lungs

A

Active

28
Q

Infectious TB particles (droplet nuclei) are small (1-2 µm) & deposit in the (upper/lower) airways

A

Lower

29
Q

Which is true regarding the pathophysiology of TB?
A. Following aerosol infection, M tuberculosis evades adaptive immune defenses of alveolar macrophage
B. Late dissemination through hematogenous and lymphatic routes
C. Provokes a humoral immune response that results in granulomatous inflammation
D. Tissue destruction largely due to the host’s inflammatory response

A

D
A. evades innate immune
B. Early dissemination
C. Provokes a cell-mediated immune resp

30
Q

Active or latent TB?

  1. M tuberculosis within macrophages w/o clinical symptoms or signs
  2. reservoir for development of disease, & diagnosed by a tuberculin skin test (TST)
A

Latent

31
Q

A positive diagnosis of latent TB involves:

  1. TST greater than ____ and negative CXR in regular population
  2. TST of ____ for HIV, immunosuppresed, and close contacts of active cases
  3. TST of ____ for patients in very low TB incidence areas (e.g. rural IA)
  4. Neg CXR and this new blood test that is replacing TST bc it is more specific and is unaffected by prior BCG immunization
A
  1. 10mm
  2. 5-10mm
  3. greater than or equal to 15mm
  4. Interferon gamma release assay (IGRA)
32
Q

Which is false regarding active TB?
A. Develops from LTBI
B. Months – decades after initial infection: fever, chills, night sweats, cough, wt loss
C. Develops most often under conditions that suppress cell-mediated immunity (e.g HIV infection, anti-TNF Rx, Steroids, aging, diabetes, chronic renal failure, malignancy)
D. 85% occur in extra-pulmonary sites soley (LN, spleen, liver, bones, joints, kidneys) or concurrent with lung disease

A

D. False - 85% occur in lungs

33
Q

Which is false regarding diagnosis of active TB?
A. High index of suspicion is key
B. CXR, Sputum acid-fast stain x 3, & mycobacterial culture & susceptibilities (3-6 weeks)
C. Nucleic acid amplification testing on sputum was standard of diagnosis but is now being replaced by newer tests
D. Tuberculin skin test misleading due to delayed result (3 days) & can be falsely negative

A

C. ○ Target: unique M tuberculosis sequences
○ Latest update: mutation sequences a/w drug resistance
○ Advantage: immediate identification & susceptibility data

34
Q

Which is false regarding principles of therapy for TB:
A. Start treatment only once diagnosis is confirmed to prevent negative side effects of therapy
B. Multiple drugs: Prevent resistance
C. Long treatment: 6 months
D. Directly Observed Therapy (DOT): Improves adherence
E. Monitor for toxicity: Multiple drugs have SE and interactions, especially in patients with liver disease (alcoholism, chronic hepatitis)

A

A. Prevent further TB transmission: Start treatment when suspicion high even prior to secure diagnosis

35
Q 
Which 2 first line antimycobacterial agents are used during the first 2 months of active TB treatment?
A. Pyrazinamide (PZA)
B. Rifampin (RMP)
C. Isoniazid (INH)
D. Ethambutol (EMB)
A

A and D

Isoniazid and rifampin are major components of active TB regimens. Isoniazid is also in LTBI treatments

36
Q

This is used to treat (pulmonary & extrapulmonary TB OR LTBI)?

INH, RMP, PZA, EMB- 2 months, then INH + RMP for 4 months

A

pulmonary & extrapulmonary TB

37
Q

This is used to treat (pulmonary & extrapulmonary TB OR LTBI)?
INH x 9 months

A

LTBI

38
Q

Which is not unique to TB:
A. Person-to-person transmission
B. Latent form diagnosed by tuberculin skin test or IGRA
C. Upper lung involvement
D. Active (reactivation) disease diagnosed by sputum AFB smear & culture
E. Prolonged Rx: Active x 6 months; Latent x 9 months

A

C - seen with lung cancer, mycobacterial diseases (TB, nonTB mycobacteria), fungi (histo, cocci, blasto), sarcoidosis

Exam 2 Keystone (13 decks)

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