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Respiratory/Musculoskeletal > M-Community Acquired Pneumonia > Flashcards

M-Community Acquired Pneumonia Flashcards

1
Q

Pneumonia is the _____ most common cause of death in the US.
_________ adults in the US per year die.
I

A

8th, 4 million

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2
Q

What are the 4 main routes of infection for community acquired pneumonia?
What are the organisms for each route?

A
  1. microaspiration
    - s. pneumoniae
    - h. influenzae
  2. macroaspiration
    - normal flora
    - anaerobes
  3. inhalation
    - mycobacterium
    - mycoplasma
    - chlamydia
    - RSV
    - Influenza
    - legionella
  4. hematogenous spread
    - s. aureus
    - s. typhi
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3
Q

What are the 3 major innate immunity defenses the body uses against pneumonia?
What are the 2 major acquired immunity defenses?

A

Innate

  1. cough reflex
  2. mucus production and ciliary elevator
  3. neutrophils

Acquired

  1. Cell-mediated immunity
  2. antibodies
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4
Q

What are the main diseases and drugs known to decrease the bodies defenses against pneumonia?

A
  1. altered mental status
  2. viral illness
  3. HIV/AIDs
  4. corticosteroids
  5. Tobacco
  6. diabetes
  7. drugs
  8. hypogammaglobinemia
  9. multiple myeloma
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5
Q

What cells line the respiratory tract?

What defenses are presented by these cells?

A

The respiratory tract is lined by:

  1. columnar epithelial cells with cilia
  2. stem cells
  3. mucous cells

This creates a mucus later that traps particulate matter and the cilia beats the foreign object/bacteria/whatever upward, out of the respiratory tract and then we swallow it into GI

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6
Q

What is the most common mode of acquisition for pneumonia by the following pathogens:

  1. S. pneumo
  2. mycoplasma pneumo
  3. H. influenzae
  4. Chlamydia pneumonia
  5. moraxella catarrhalis
  6. Legionella
  7. S. aureus
  8. G- bacilli
  9. viral (RSV, Influenza, metapneumovirus)
  10. GI content (aspiration)
  11. MTb, PCP
A
  1. microaspiration
  2. inhalation
  3. microaspiration
  4. inhalation
  5. inhalation
  6. inhalation
  7. hematogenous spread
  8. massive aspiration
  9. inhalation
  10. massive aspiration
  11. inhalation
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7
Q

What is the most common cause of pneumonia:

  1. under 5
  2. 5-45 yrs
  3. over 45
A
  1. bacterial/viral
  2. mycoplasma/chlamydia
  3. bacterial
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8
Q

Describe the history and physical of someone with pneumococcal pneumonia.

A

previously well individual who RAPIDLY develops:

  1. fever, chills
  2. pleurisy
  3. purulent sputum

Physical exam:

  1. tachycardic- acutely ill
  2. chest exam shows consolidation
  3. pleural friction rub
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9
Q

What would the CXR, labs, and sputum gram stain show for someone with pneumococcal pneumonia?

A

CXR- lobar consolidations, air bronchograms

Labs- leukocytosis, hypoxemia

Sputum G stain : PMNs and G+ diplococci, G+ cocci in chains and pairs

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10
Q

Describe the gram staining, hemolysis pattern, catalase, and sensitivities of S. pneumoniae.

How many serotypes are there?

A

G+ cocci in pairs or chains
Alpha-hemolytic
Catalase negative

Sensitive to:
Optichin and bile lysis

91 serotypes

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11
Q

For CAP, what is the prevalence of pneumonia caused by S. pneumoniae? How does this compare to other causes of CAP?

A

S. pneumoniae has a prevalence of 20-60% which is the greatest of any causes of CAP.

[viruses are 2-15, H. flue and G- are 3-10]

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12
Q

What are the 5 common clinical presentations associated with S. pneumoniae infections?

A
  1. Respiratory tract (upper- sinisitis, otitis media, lower- bronchitis, pneumonia, pleural effusion, empyema, bacteremia)
  2. Endocarditis
  3. Meningitis
  4. Arthritis
  5. Spontaneous bacterial peritonitis
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13
Q

What are the 2 upper respiratory tract infections associated with S. pneumonia?

A
  1. sinusitis

2. otitis media

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14
Q

What are the lower airway infections associated with S. pneumoniae?

A
  1. bronchitis

2. pneumonia (pericarditis, pleural effusion, empyema, bacteremia)

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15
Q

S. pneumonia colonizes ___ to ____% of adults and ______% of children in the nasopharynx.

Rates of ____% are detectable in the first year of life and ______with age.

A

5-10% of adults and 40% of children.

In the first year of life 70% are colonized but the rate decreases with age.

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16
Q

When do most s. pneumonia infections occur during the year?
How do most patients that get colonized present?
What does the infection usually follow?

A

Most infections occur in the winter and spring.
Most patients that are colonized are asymptomatic
The infection usually follows a viral URI

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17
Q

What are the major risk factors for getting a S. pneumoniae infection? (8)

A
  1. Younger than 2 or older than 65
  2. asplenia
  3. alcoholism
  4. diabetes
  5. antecedent influenza *****
  6. HIV
  7. new virulent strain of s. pneumonia
  8. defective humoral immunity
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18
Q

What are the 5 major virulence factors of s. pneumoniae? Which is the “major virulence determinant”?

A
  1. Polysaccharide capsule (major virulence determinant)
  2. pneumolysin
  3. PspA (pneumococcal surface protein A)
  4. PsaA (pneumococcal surface antigen A)
  5. IgA protease
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19
Q

What is the major virulence determinant of s. pneumoniae?

How many types are there?

A

Polysaccharide capsule- 91 types

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20
Q

There are smooth and rough strains of s. pneumoniae.
Which has a capsule?
Which is more virulent?
What are the functions of each?

A

Smooth- capsule, increased virulence, decreases phagocytosis in tissue and bloodstream invasions

Rough- no capsule- decreased virulence but promotes adherence to epithelium in respiratory tract

Spontaneous variation can occur between the 2 forms!

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21
Q

What does the highly negative charge of the s. pneumoniae capsule allow it to inhibit?

A
  1. interactions between CR3 and iC3b (neutrophil adhesive molecules)
  2. interactions with Fcgamma receptors and Fc portion of IgG to prevent phagocytosis
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22
Q

What are the 4 functions of the s. pneumoniae virulence factor, pneumolysin?

A
  1. pore forming cytotoxin released by autolysis that is lytic to the host cell.
  2. inhibits ciliary action of epithelial cells
  3. impairs respiratory burst of phagocytes
  4. induces inflammatory cytokines
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23
Q

What are the 2 functions of pneumococcal surface protein A?

Why is this surface protein relevant?

A

PspA:

  1. blocks binding of C3b to factor B
  2. binds to epithelial membranes

There are anti-PspA antibodies that are protective in animal models for infection

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24
Q

What are the 3 functions of pneumococcal surface antigen A?

A
  1. mediates metal ion uptake
  2. protects against oxidative stress
  3. binds GlcNac-B-1,3 Gal on respiratory epithelial cells
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25
Q

Basically, the four steps of pathogenesis of s. pneumoniae are colonization, evasion of mechanical barriers, evasion of immune mechanisms, and invasion.

How is the pathogen able to evade mechanical barriers?

A
  1. Aspiration below the larynx-
    - chance increases with decreased conciousness (opiates, alcohol, barbiturates, benzodiazepine)
    - chance increases with neurological disease (absence of gag reflex)
  2. lack of mucociliary clearance
    - smoking, COPD, bronchiectasis
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26
Q

What are the host defenses against s. pneumonia colonization?

A

IgA directed against capsular antigens

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27
Q

What are the host defenses against s. pneumoniae in the lungs? (3 things)`

A
  1. Alveolar macrophages (IgG, C3b for opsonization)
  2. PMN recruitment (IL8, TNFa)
  3. Th1 cytokines (IL12, TNF, IFNg)
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28
Q

What are the 3 main host defenses against s. pneumoniae in the blood?

A
  1. IgG2, C3
  2. C-reactive proteins
  3. splenic clearance
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29
Q

Starting with microaspiration, how does the progression of pneumonia with s. pneumonia occur?

A
  1. aspiration from nasopharynx
  2. failure of tracheobronchial clearance (mucus/cilia)
  3. intra-alveolar spread via pore of Kohn in small airways
  4. Congestion
  5. Red Hepatization
  6. Grey hepatization
  7. resolution
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30
Q

How does the lung appear during:

  1. congestion
  2. red hepatization
  3. grey hepatization
A
  1. edema and bacteria in alveoli
  2. PMNs, RBCs and fibrin in alveoli
  3. degeneration of cellular infiltrates and reabsorption
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31
Q

A patient comes to you saying that they felt fine and then all of a sudden, they had chills, fever (>38.5) and felt crappy.
They have been coughing up rust-colored sputum. They are having pleuritic chest pain, exacerbated by movement.
There is also referred abdominal pain.
What is the likely cause?

A

pneumococcal pneumonia due to:

  1. rapid onset
  2. rust sputum
  3. pleurisy
  4. ab pain (lower lobe infiltrate)
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32
Q

In someone with pneumococcal pneumonia, what do you notice on physical exam of the lungs?

A
  1. Toxic looking with tachycardia and fever
  2. Splinting on affected side
  3. Fremitus
  4. Auscultation - inspiratory crackles, E->A, pectoriloquy
  5. Pleural effusion- dullness to percussion, decreased breath sounds
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33
Q

What do you see on lab work for pneumococcal pneumonia?

A

CXR- lobar infiltrate, air bronchograms, (maybe pleural effusion)

WBC >15,000/mm3
Hypoxemia with VQ mismatch

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34
Q

What are the 4 major complications of pneumococcal pneumonia?

A
  1. Pleural effusion (uncomplicated, empyema 1%)
  2. Pericarditis
  3. Bacteremia- increased mortality, DIC, endocarditis, meningitis
  4. Meningitis
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35
Q

What are the 7 biggest risk factors for MORTALITY from pneumococcal pneumonia?

A
  1. Age (50% mortality over 70)
  2. impaired humoral immunity (mult. myeloma, hypogammaglobinemia, complement deficiency, lymphoma)
  3. Asplenia (HgSS, autosplenectomy, chronic hemolytic anemias, surgical)
  4. chronic disease (alcoholism, diabetes, cigs, COPD, cancer)
  5. multiple lobe involvement/pleural effusions
  6. leukopenia
  7. S. pneumoniae serotype 3 (50% mortality)
36
Q

What are the 4 tests for diagnosis of s. pneumoniae?

A
  1. blood/pleural fluid cultures - definitive but often (-)
  2. Sputum cultures- not sensitive or specific bc of upper respiratory contamination
  3. Gram staining of sputum- over 25 pmns, less than 10 squam. epithelial cells, predominance of G+ cocci in chains or pairs (80% sensitive, highly specific)
  4. antigen test- used in urine for diagnosing pneumonia and CSF for dianosing meningitis
37
Q

What deems an adequate specimen when doing a sputum gram stain for s. pneumoniae?

A

> 25 PMNs
<10 SECs
Predominance of G+ cocci is 80% sensitive and highly specific for pneumococcal pneumonia

38
Q

What is the treatment for pneumococcal pneumonia?

A

Immediate therapy with antibiotics decreases mortality from 30% to 5%

  1. penicillin (sensitive, intermediate, highly resistant)
  2. ceftriaxone (sensitive, intermediate, highly resistant)
  3. fluoroquinolones
  4. macrolides
  5. trimethoprim sulfa
39
Q

What is thought to be the mechanism of resistance of pencillin resistant S. pneumoniae (PRSP)?
Where was it first described?
What is the prevalence in Dallas?
What are the 2 biggest risk factors?

What measurement makes it “highly resistant” and what does this mean for treatment?

A
  • PRSP have chromosomal mutations of penicillin-binding proteins.
  • First described in Africa and Spain
  • 40% of Dallas county
  1. prior antibiotic therapy or hospitalization
  2. children in day care

Highly resistant is MIC >2micrograms/mL and it means that in addition to penicillin, it will often be resistant to other antibiotics too.

40
Q

What strains of s. pneumoniae are thought to have macrolide resistance?
What are the 3 major drugs they are resistant to?

What are the 2 genes that are thought to be mutated in macrolide resistance? Do they have a high level of resistance or low?
Which mutation is in 75% of resistant strains?

A

PRSP is also thought to be resistant to macrolides.

Erythromycin, azithromycin, clarithromycin

  1. ermB gene - ribosomal methylation, high level of resistance (MIC>64)
  2. mefE gene - efflux pump, low level of resistnace (MIC
41
Q

With antibiotic treatment of pneumococcal pneumonia, fever and tachycardia resolve in _______. Chest radiographs in healthy people resolve in _______ and in chronically ill patients resolves in ________.

A

fever, tachycardia- 48 hours

CXR of healthy - 3 wks

CXR of chronically ill - 4 months

42
Q

How many serotypes are in the pneumococcal vaccine?

What is the protective efficacy in healthy young adults?

A

23 serotypes with a protective efficacy of 80%

43
Q

What does the pneumococcal vaccine protect against?
Who is the vaccine less protective in?
Who is the vaccine ineffective in?

What are the 3 major indications for receiving the vaccine?

A

It protects against bacteremia NOT pneumonia

Less protective in the elderly and immunosuppressed and ineffective in children under 2.

Use the vaccine for:

  1. patients >65
  2. immunocompromised
  3. chronically ill (COPD, diabetes, smokers, CHF, renal disease)
44
Q

What pneumococcal vaccine is available for children under 2?

A

13 valent protein polysaccharide conjugate vaccine

45
Q

Influenza vaccines can also protect against ________.

A

pneumococcal pneumonia

46
Q

What are 3 likely causes of macroaspiration of normal oropharyneal flora?
What bacteria are most likely to cause pneumonia from macroaspiration?

A

Decreased consciousness or absent gag reflex:

  1. drug overdose, opiates, alcohol
  2. anesthesia
  3. neuromuscular disease affecting swallowing

Anaerobic organisms like:
1. fusobacterium
2. bacteroides spp
Mixed with aerobic and microaerophilic strep and normal oral flora.

47
Q

What organism would make you suspicious as the cause of hospital acquired CAP type II (macroaspiration)?

48
Q

What would the history of present illness look like for a patient with macroaspiration?

What would be noted on physical exam?

A
  1. reason for impaired consciousness (leading to aspiration)
  2. insidious onset of low grade fever, purulent foul-smelling sputum, weight loss
  3. poor dentition, cachexia, +/- pulmonary consolidation
49
Q

What would the CXR show for someone with macroaspiration pneumonia?

A

focal infiltrates, upper lobes with cavities

50
Q

What is treatment for macroaspiration pneumonia?

A

***Clindamycin for several months (or a penicillin derivative)

51
Q

Where would the following size droplets likely land in the respiratory tract?

  1. > 10 micrometers
  2. 1-5 micrometers
  3. <1 micrometer
A
  1. upper respiratory tract
  2. bronchi, alveoli
  3. remains airborne
52
Q

Why are “atypical” pneumonia agents considered to be atypical?

A

Cultures and stains were negative and the clinical course was much more gradual than a typical pneumonia.

Typical pneumonia (s. pneumo) - abrupt onset, rapid progression, lobar distribution

Atypical pneumonia (mycoplasma, chlamydia, legionella) hae gradual onset, insidious progression, patchy distribution

53
Q

What are the 6 “common causes” of atypical pneumonia?

What are the 2 less common causes of atypical pneumonia?

A

Common:

  1. mycoplasma pneumonia
  2. chlamydia pneumonia
  3. legionella pneumophila
  4. RSV
  5. metapneumovirus
  6. adenovirus

Less common:

  1. chlamydia psittaci
  2. coxiella burnetti (Q fever)
54
Q

What makes mycoplasma pneumoniae difficult to culture? What is unique about the bacteria?

A
  1. slow growth on cell-free media
  2. mulberry/fried egg growth
  3. no cell wall
  4. aerobic and anaerobic growth
55
Q

How does mycoplasma pneumoniae cause atypical pneumonia?

A
  1. The terminal organelle at one end of the mycoplasma binds to sialylated glycoproteins on respiratory epithelial cells
  2. Adheres to the base of the cilia producing hydrogen peroxide to induce damage.

INHIBITION OF CILIARY ACTION, SLOUGHING OF CILIATED CELLS

56
Q

A 23 year old comes in to see you and has fever, malaise, coryza, headache, cough.
He doesn’t appear very ill. When you inspect his throat you see pharyngeal erythema without adenopathy.
His chest seems clear despite an abnormal CXR.
What is the likely cause of his illness?

A

He has walking pneumonia so a likely cause is mycoplasma pneumonia.

57
Q

What is the incubation period of mycoplasma pneumonia?
How does the patient typically present?
What does their CXR look like?

A

Incubation: 2-3 wks

Patient will be an ambulatory young person with fever, malaise, coryza (:a cold), headache, cough. They won’t appear ill but may have pharyngeal erythema without adenopathy.

They CXR will be abnormal but chest will be clear.

58
Q

Who gets unusually severe pneumonia from mycoplasma pneumoniae? Why?

A

Sickle cell anemia patients because an extrapulmonary manifestation of mycoplasma pneumoniae is cold agglutinins which precipitate in the vasculature and in sickle cell can cause distal necrosis to the vasculature occlusion.

59
Q

What are the extrapulmonary manifestations of mycoplasma pneumoniae?

A
  1. Reversible cold agglutinins- IgM antibodies to I antigen on RBCs
  2. hemolysis can lead to Reynaud’s
  3. aseptic meningitis
  4. transverse myelitis
    5 Guillen-Barre
60
Q

How is the diagnosis of mycoplasma pneumonia made?

A
  1. Direct antigen testing
  2. Cold agglutinin titer >1:32
  3. Serology: anti-mycoplasma IgM, IgG

NOT culture because difficult, time consuming
NOT PCR because accurate but not readily available

61
Q

Describe Chlamydophila.
What are the 2 forms?
Which is metabolically active?

A

They are obligate intracellular parasites.

  1. Elementary bodies- infectious form, inert
  2. Reticulate bodies- form inside host cell, metabolically active and can persist for a long time
62
Q

Chlamydia pneumonia infects almost everyone by the age of _______.
Most infectious are asymptomatic but if there are symptoms they are __________, _____, and _______.
The progression of the disease is ________.

A

30.
sore throat, hoarseness, cough
Progression is slow

63
Q

What seasons are people more likely to be affected by chlamydia pneumonia?

A

There is no seasonal variation

64
Q

How is chlamydia pneumonia diagnosed?

A

Microimmunofluoresence antibody test

65
Q

A bird handler comes in with a systemic infection and atypical pneumonia. They have fever, pharyngeal erythema, rales, and hepatomegaly.

What do you suspect they have?
How would you diagnose it?

A

Chamydia psittaci- diagnosed by serology (CF or microimmunoflorescence)

66
Q

What are the antimicrobial treatment options for chlamydia psittaci/ pneumonia?

A
  1. doxycycline, macrolides

2. quinoline

67
Q

What are the 2 diseases caused by legionella pneumophila?
What is the relative presentation of each?
Which is more fatal?

A
  1. Legionnaire’s disease (pneumonia/fatal)

2. Pontiac Fever (influenza-like/ non-fatal)

68
Q

Describe legionella pneumophila.
What is the structure?
What are the oxygen needs?
How does it G stain?

A

It is an aerobic G- rod, but does not stain well on gram stain. It stains better with silver stain.
It needs fastidious growth to be grown in vitro culture.

69
Q

What serogroup of legionella is most prominent in human cases of disease?

A

serogroup 1

70
Q

Where does legionella live? How is it spread to humans?

What are the 3 biggest risk factors for getting infected?

A

It lives in fresh water and in free living ameoba (NOT in humans)
It spreads via aerosol (not person-to-person)

  1. age
  2. smoking/drinking
  3. immunocompromised
71
Q

What is the incubation period, symptoms and recovery for Pontiac Fever?

A

Incubation : 20-48 hours
Symptoms: myalgia, fever, dry cough
Recovery: 2-5 days, no treatment

72
Q

What is the incubation period for Legionnaire’s disease?

What are the symptoms? What is the recovery?

A

Incubation :2-10 days
Symptoms: myalgia, headache, fever, cough, diarrhea, pulmonary consolidation, nodular bilateral infiltrates
Recovery: case fatality is 10%

73
Q

Which bacteria causes diarrhea with pneumonia like symptoms?

A

legionella pneumophila in legionnaires

74
Q

What is the pathogenesis of legionella pneumophila?

A
  1. inhaled droplets reaching alveoli and small bronchioles
  2. infection of alveolar macrophages
  3. phagosome is surrounded by ER, membrane is lost
  4. legionella multiply in ER-derived sac
  5. destroy the cell and spread to more
75
Q

What is the most important natural immunity against legionella infection?

A

Cell-mediated immunity!! (antibodies are NOT important)

IFNg activates macrophages which allows them to kill legionella

76
Q

How is legionella diagnosed?

A

***Urine antigen test: legionella pneumophila serotype 1

NOT gram stain–> silver stain
Culture on special media
Serology
Direct FA of sputum, PCR of sputum or bronchalveolar lavage

77
Q

How can we prevent the spread of legionella?

A
  1. keep cool water towers clean: biocides, flush with hot water in cleaning
  2. disinfect water supply: heat, chlorine, copper-silver ionization
78
Q

How is legionella treated?

A

Use a drug that concnetrates in the phagolysosome!!!!

  1. Macrolides (azithromycin)
  2. fluoroquinolones
  3. rifampin (with other drugs)
79
Q

What 2 antibiotics do NOT work on treating legionella?

A
  1. beta-lactams

2. aminoglycosides

80
Q

What are the 4 main things that lead to hematogenous spread of pneumonia causing bacteria?

A
  1. infective endocarditis of tri/pulm valves
  2. intravascular infections
  3. primary extravascular infections
  4. course of bacteremia
81
Q

What bacterial strain is associated with infective endocarditis of the tricuspid and pulmonary valves?

How will this pneumonia present?

A

S. aureus will cause focal pneumonia with nodules and small cavities.
Multiple lesions at the same time

82
Q

What is Lemierre’s syndrome?

A

It is septic thrombophlebitis of the jugular vein caused by intravascular infections (fusibacterium)

83
Q

What is a prime example of how an extravascular infection causes bacteremia and pneumonia?

A

Y. pestis–> bubonic plaque–> bacteremia–< pneumonia

84
Q

What infectious agents are most likely to cause pneumonia in an AIDS patient with CD4<400?

A

MTb
S. pneumoniae
S. aureus/ H. flu

85
Q

What infectious agents are most likely to cause pneumonia in AIDS patients with CD4 <200?

A

pneumocytis jiroveci

86
Q

What infectious agent is most likely to cause pneumonia in an AIDS patient with CD4 <50-100?

A 
P. aureginosa
MTb
non-Tb mycobacteria
cryptococcus neoformans
CMV

Respiratory/Musculoskeletal (36 decks)

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