Pathology Respiratory infection Flashcards

Question

xray signs lobar/segmental pneumonia

Answer 1

the infectious process involving the whole lobe or large chunk of one - or sometimes two lobes pathological change when organism lands in the lung (completely solid section) white

Answer 2

**Outcome** - most resolve (if not why not?) * *Complication** - Pleurisy (pleural inflammation), Pleural effusion and empyema (pus in pleural space) - Change of organisation - A mass lesion, COP (cryptogenic organising pneumonia - BOOP) - Lung abscess - Bronchiectasis - Pneumonia is still potentially fatal

Answer 3

**Pleural effusion** sometimes referred to as “water on the lungs,” is the build-up of excess fluid between the layers of the pleura outside the lungs. The pleura are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing.

Answer 4

Pleurisy is a condition in which the pleura — two large, thin layers of tissue that separate your lungs from your chest wall — becomes inflamed. Also called pleuritis, pleurisy causes sharp chest pain (pleuritic pain) that worsens during breathing.

Answer 5

Empyema / purulent pleuritis. It's a condition in which **pus** gathers in the area between the lungs and the inner surface of the chest wall (pleural space)

Answer 6

pathological dilation of bronchi (inappropriate for position in bronchial tree) due to: severe infective episode recurrent infections (many causes) proximal bronchial obstruction lung parenchymal destruction

Answer 7

- 75% start in childhood - Cough, abundant, purulent, fouls sputum haemoptysis coughing of blood from lung (signs of chronic infection) coarse crackles **clubbing**

Answer 8

thin section CT (previously bronchography)

Answer 9

postural drainage antibiotics surgery

Answer 10

severe bronchial haemorrhage which can be fatal

Answer 11

- Localbronchial obstruction - Tumour/foreign body - Local pulmonary damage -bronchiectasis - Generalised lung disease - cystic fibrosis - COPD - Asthma - Non-respiratory disease: Immunocompromised HIV - other Aspiration

Answer 12

- Vomiting - Oesophageal Lesion - Obstetric Anaesthesia - Neuromuscular disorder - Sedation oesophageal disease (reflux)

Answer 13

increased chance of "ordinary" infections - sometimes ones not normally capable of causing infection: **opportunistic pathogens** - usually in immunocompromised pm steroidal therapy, chemotherapy - infection by organisms not normally capable of producing disease in patients with intact lung defences - low-grade bacterial pathogens CMV pneumocystis jirovecil other fungi and yeasts

Answer 14

nose, larynx, pharynx, epiglottis, nose - rhinitis ear -otitis media pharynx - pharyngitis Larynx - laryngitix epiglottis - eppiglotitis

Answer 15

virus - repelled? bacteria 1 pneumococcus, Haemophilus, staph, Moraxella bacteria 2 invasion pertussis, mycoplasma

Answer 16

epithelium

Answer 17

- diarrhoea - oral thrush - nappy thrush - allergic reaction - multi resistance

Answer 18

roughly 1/3

Answer 19

common - fever; antibiotic or not? prodrome to serious illness?

Answer 20

give it time. look hydration and nutrition antipyretic (paracetmol) sugary fluids and time. can review in future.

Answer 21

very common winter months occurs often self-limiting condition prodrome to other illness: pneumonia, bronchiolitis, meningitis, septicaemia review If not sure normal duration symptoms 11-16 days

Answer 22

infection of ear the bulging eardrum can pop and pus comes out common - self-limiting - very red -a primary viral infection - secondary infection with pneumococcus h'flu spontaneous rupture of the ear drum antibiotic treatment usually doesn't help 3-7 days duration normal

Answer 23

**offer regular paracetamol or ibuprofen for pain** **self-care** **consider antibiotic** **reassess if symptoms worsen or signs of more serious illness of condition** refer hospital if severe systemic infection or complication like mastoiditis Mastoiditis is a serious infection in the mastoid process, (hard, the prominent bone just behind and under the ear). Ear infections that people fail to treat cause most cases of mastoiditis.

Answer 24

common infection is it viral or bacterial? take throat swab treat with nothing or **10 pays penicillin** Alternative first choices for penicillin allergy or intolerance are clarithromycin or erythromycin. **not amoxicillin -** avoid if there is a possibility of glandular fever (**Epstein Barr virus)**.

Answer 25

children who have strep throat often have scarlet fever - faint pink rash classically pallor (an unhealthy pale appearance.) around the mouth and often not felt right/well for a week or two

Answer 26

treat with nothing or **10 pays penicillin** Alternative first choices for penicillin allergy or intolerance are clarithromycin or erythromycin. **not amoxicillin** - avoid if there is a possibility of glandular fever (Epstein Barr virus). normally lasts 2-3 days but can last over a week

Answer 27

croup (LTB) (larynx), windpipe (trachea) and bronchial tubes (bronchi). Human parainfluenza viruses common generally well coryza (catarrhal inflammation of the mucous membrane in the nose, caused especially by a cold or by hay fever) stridor, hoarse voice "bark" cough **treat oral dexamethasone**

Answer 28

Haemophilus influenzae (H influenzae) type B rare toxic symptoms: stridor, -drooling (partial obstruction oesophagus) treatment - needs intubation and antibiotic. usual duration 1 day.

Answer 29

**trachea - bronchus -bronchioles - lungs - pleura** trachea - tracheitis; bronchus - bronchitis; bronchioles - bronchiolitis lung - pneumonia; pleura - empyema

Answer 30

no infection in an otherwise sterile area infection is the sterile area becomes occupied by an infective agent infection is cleared when the agent is cleared and has left the area sterile again

Answer 31

Haemophilus and pneumococcus

Answer 32

**bacterial;** strep pneumonia, Haemophilus influenzae, Moraxella catarrhalis, mycoplasma pneumonia, chlamydia pneumonia **viral** - RSV, parainfluenza 3, influenza A and B, adenovirus

Answer 33

- make a diagnsis assess the patient oxygenation, hydration, nutrition treat or not treat?

Answer 34

swollen tracheal wall narrowed tracheal lumen luminal debris uncommon "croup which does not get better) LBT fever, sick child staph or strep invasive infection **give augmentin** Amoxicillin/clavulanic acid, also known as **co-amoxiclav**

Answer 35

common ++ endobronchial infection loose rattly cough with URTI post-tussive vomit (glut) chest **free** of crepitations or wheeze Haemophilus / pneumococcus cause mostly self-limiting child very well + parent worried

Answer 36

- disturbed mucociliary clearance (escalator cilia) minor airway malacia (abnormal softening of biological tissue) RSV/adenovirus lack of social inhibition - bacterial infection/ overgrowth is secondary can last 7-10 days can be 25 days.

Answer 37

follows from URTI (rhinovirus) can last up to 4 weeks 60=80% cases respond to antibiotics (sometimes significant side effects) **morbidity:** 1st winter children at nursery high symptoms 2nd winter lapse and but better 3rd winter fine \*\* any winter it's usually pneumococcus and Haemophilus cold\*\*

Answer 38

make diagnosis reassure parents/family do not treat with antibiotic nutrition +hydration

Answer 39

- LRTI of infants affects 30-40% of all infants - usually RSV virus, others include paraflu 3, HMPV nasal stuffiness, tachypnoea, poor feeding crackles +/- wheeze

Answer 40

day 1-2 child is well day 3-5 child worsens day 5-7 child stabilising day 7\> recovery if a child on day 3 is not feeding and o2 low with poor hydration, you would admit to the hospital as you know they will get worse if a child on day 5 you know the child is stabilising and likely to not get worse normal duration about 12 days some more than 16 days Respiratory syncytial virus (RSV)

Answer 41

under 12 months old (infants) one-off infection (not recurrent) treat with maximum observation + minimal intervention

Answer 42

nasopharyngeal aspirate NPA - to identify what the virus is (nurse in the same ward) test spo2 (severity) **no routine need for** a chest x-ray, blood or bacterial culture

Answer 43

- salbutamol ipratropium bromide adrenalin steroid antibiotic nebulised hypertonic saline

Answer 44

48 hour fever (\>38.5); shortness of breath; cough; grunting - wheeze makes bacterial cause unlikely reduced or bronchial breath sounds often caused by infective agents (virus + commensal bacteria/bacterium) (usually does no harm but if given opportunity then can)

Answer 45

- word causes anxiety be careful signs of pneumonia IF -signs are focal i.e one whole area (left lower zone e.g) you hear crepitations they have a high fever **otherwise, call it a lower respiratory tract infection**

Answer 46

investigate chest cray and inflammatory markers (not routine) **management** nothing if symptoms are _mild_ **(offer review** if things get worse) -Oral amoxicillin first line oral macrolide second choice only for Iv if vomiting

Answer 47

**bronchiolitis** - not indicated (usually RSV, parainfluenza 1, adenovirus) **croup** - not indicated (usually parainfluenza 3, also RSV, adenovirus) **acute lower respiratory tract infection** - not often indicated - child \<2 mild presentations rarely need and have pneumococcal vaccine _however, first-line_ can be amoxicillin **otitis media** - antibiotic not usually indicated - amoxicillin if under age 2 and signs of bilateral infection **pharyngitis/tonsillitis** - not usually indicated - consider penicillin, **not amoxicillin**

Answer 48

whooping cough

Answer 49

it's common vaccine reduces risk vaccine reduces severity symptoms - coughing fits - paroxysm of coughing convulsed vomiting and colour change of skin

Answer 50

- complication of pneumonia extension of infection **into** pleural space includes chest pain and feeling very unwell - give antibiotics +/- drainage - good prognosis in contract to adults

Answer 51

The parietal pleura is sensitive to pressure, pain, and temperature. It produces a well localised pain, and is innervated by the phrenic and intercostal nerves.

Answer 52

**_first sort out oxygenation, hydration and nutrition_** antibiotic? which one? **tracheitis** yes Augmentin **Bronchitis** no **LRTI/pneumonia** optional oral amoxicillin **bronchiolitis** no **empyema** yes iv antibiotics

Answer 53

- acute bronchitis - exacerbation of COPD -pneumonia - empyema - Lung abscess - bronchiectasis

Answer 54

- inflammation of bronchi - temporary \<3 weeks - cough and sputum usually viral requires supportive management

Answer 55

- if cough severe or last longer than 3 weeks high temp for more than 3 days (sign of flu or more serious e.g. pneumonia) cough mucus with blood have underlying heart or lung condition e.g. asthma, heart failure or emphysema becoming more breathless have repeated episodes of bronchitis

Answer 56

- change the colour of sputum -fevers - increased breathlessness - wheeze - cough **caused often by** streptococcus pneumonia Haemophilus influenza Moraxella catarrhalis viral

Answer 57

- steroids antibiotics - amoxicillin doxycycline co-trimoxazole clarithromycin +/- nebulisers

Answer 58

**inflammation of lung parenchyma and consolidation - solidification due to cell exudate impairs gas exchange** **1 in 20 bronchitis develop to pneumonia** (due to damaged cilia unable to escalate products out of lung) Risk factors: smoking; alcohol excess; extremes of age; pre-existing lung disease; chronic illness; immunocompromised; hospitalisation; IVDU; preceding viral illness

Answer 59

**symptoms:** fever; rigours; myalgia muscle pain; cough + sputum; chest pain (pleuritic) increase inspiring; dyspnoea; haemoptysis _rusty brown sputum typical streptococcus pneumonia_ **signs:** tachypnoea (\>RR); tachycardia; reduced expansion chest; dull percussion; bronchial breathing; crepitations; a vocal resonance

Answer 60

**community** - maybe none, chest x-ray if in doubt or not improving (rule out cancer) **Hospital** - bloods (serum biochemistry, Full blood count, CRP, Blood cultures **Chest x-ray** sputum culture, viral throat swab legionella urinary antigen

Answer 61

- tuberculosis - lung cancer pulmonary embolism pulmonary oedema pulmonary vasculitis (Wegener's granulomatosis)

Answer 62

right upper zone in pic - will see clear white exudate and consolidation

Answer 63

streptococcus pneumonia h. influenzae viruses less common - legionella, staph aureus, mozzarella catharsis, mycoplasma pneumonia, chlamydia pneumonia, chlamydia psittaci, Coxiella burnetti

Answer 64

* *_Community-acquired_** * *typical** streptococcus pneumonia (gram neg) Haemophilus influenzae mycoplasma pneumonia ``` **atypical** (more systemic symptoms e.g. more dry cough less sputum) legionella pneumophilia (fresh water a/c), chlamydia pneumonia, chlamydia psittaci, Coxiella burnetti, Moraxella catarrhalis, viruses ```

Answer 65

nosocomial (\>48 hours) enterobacteria (aspiration); staphylcoccus aureus; pseudomonas aerigunosa; klebseilla pneumonia - chlostridia - anaerobes - TB

Answer 66

staphylcoccus aureus; klebseilla pneumonia TB

Answer 67

pseudomonas aerigunosa;

Answer 68

to determine whether or not somebody can be treated in the community or needs to come into hospital CURB65

Answer 69

c - confusion u - blood urea \>7mmol/l R - respiratory rate \>30 min B - Systolic bp \<90mmHg diastolic bp \< 60mmHg 65 - age \>65 A score of 0-1 low risk treat community: 2 - moderate risk - usually hospital treat: 3-5 high risk of death need for ITU

Answer 70

- young people they likely wont score on this but doesn't mean they don't have severe pneumonia. they tend to compensate physiologically until they get bad. - hypoxic patients - those with multilobular consolidation

Answer 71

**severity antibiotic penicillin allergy duration** CURB 0-1 AMOXICILLIN Clarythromycin or doxycycline 5 days CURB 2 amoxicillin +clarythromycin Levofloaxin 5-7 days (atypicals) CURB 3-5 Co-amoxiclav Levofluoxacin or +clarithromycin co-trimoxazole 7-10 days (atypicals) \*\* consider route iv vs oral

Answer 72

o2 therapy, fluids (iv or oral) antipyretic (paracetamol), NSAIDS ibuprofen intubation and ventilation

Answer 73

if they cannot swallow, if they are septic or have signs of sepsis (high temp, tachy) if vomiting

Answer 74

staphylococcus aureus secondary infection

Answer 75

stroke, MS, myasthenia, sedation, oesophageal disease (struggling to swallow) **anaerobes are likey** (anaerobes are organisms that do not require energy oxygen for metabolism) treat with - Amoxicillin and metronidazole

Answer 76

haemoglobion malignancy, neutropenia, HIV - fungis usually - aspargillus fumigatus, candida viruses usually - CMV, HSV, VZV pneumocystis jiroveci pneumonia treat cotrimoxazole MRSA treat vancomycin

Answer 77

- Sepsis - AKI (acute kidney injury) - Adults respiratory distress syndrome - Parapneumonid effusion (fluid pleural space) - empyema - lung abscess - disseminated infection (bacteremia which can cause sceptic emboli in other organs) **signs of these:** swinging fever, sweats, persistently high WBC count/CRP, weight loss, failure to improve

Answer 78

thoracic ultrasound +/- aspirate - fluid parameter simple ph \>7.2 complicated \<7.2 empyema pus/culture +ve May need drain and prolonged antibiotic surgery/intrapleural tPA + DNAse Tissue plasminogen activator (tPA) is a protein involved in the breakdown of blood clots.

Answer 79

more likely with staph aureus pseudomonas, anaerobes - purulent sputum, haemoptysis - screen for TB CT scan +/- bronchoscopy prolonged antibiotic

Answer 80

recovery can take weeks repeat chest x-ray 6 weeks if over 50 years old and smokers recommend smoking cessation **recurrent pneumonia** ? immunocompromised underlying structural lung disease ?aspiration

Answer 81

would give recurrent LRTI havin dilated distal bronchi - tend to produce sputum in thickened/inflames airways. = airway becomes narrow due to inflammation regardless of dilated airway = obstructive change on spirometry.

Answer 82

- wider bronchi than corresponding blood vessels - signet ring sign - bronchi look like a ring - tree bud change in the structure

Answer 83

- idiopathic - Childhood infection - pertussis,/whooping cough - Ciliary dyskinesia - Hypogammaglobulinaemia - Cistic Fibrosis - Allergic broncho-pulmonary aspergillosis (ABPA)

Answer 84

- Chronic productive cough - breathlessness - recurrent LRTI -Haemoptysis - Finger clubbing -crepitations (coarse) - Wheeze - Obstructive spirometry

Answer 85

exacerbations: staph aureus ; h influenzae; pseudomonas aerigonsa need: sputum, chest x-ray (including AAFB) - seen by chest physio - mucolytics - prolonged antibiotic course 10-14 days vaccinations consider prophylactic antibiotic

Answer 86

a constant presence and/or prevalence of a disease/infectious agent in a population within a geographical area e,g, chickenpox UK: malaria Malawi

Answer 87

increase, often sudden, in number of cases of a disease above what is normally expected in population in a certain area

Answer 88

carries the same definition of. epidemic (sudden increase number of cases of a disease above normal ina population area(s) but it often used for a more limited geographical area

Answer 89

an epidemic that has spread over several countries or continents, usually effecting a large number of people

Answer 90

alpha and beta (most common for infection humans) source mainly bats gamma - mainly comes from birds Delta - comes porcine so pigs

Answer 91

Incubation period days - 1-14 days median 5-55 days for symptoms infectious peak 24 hours pre symptoms. reproduction number - people acquiring infection from infected 2.2 - 3.3 1.4 Scotland

Answer 92

1 viral entry+early infection: 2 host immune response - immune cells early macrophages + dendritic - late phase cytotoxic cells 3. hyperinflammatory phase infects t cells and macrophages = more cytokine release that is infected 4 multiple organ dysfunction - lungs reduce the capacity of airways alveoli reduced capacity spreads to other organs and poor o2 shut down need ventilation - death

Answer 93

- rhinorrhoea (runny nose) -general malaise (unwell pale) - headache - sore throat - cough fever

Answer 94

covid can cause pneumonia and acute respiratory distress syndrome - lots of white patches

Answer 95

**brain** headache dizziness, confusion, epilepsy. ataxia,ansomia, ageusia: systemic inflammation _ cerebral edemam pulmonary hypoxia, matebolic acidosis **heart** elevated cardiac troponin elevated nt-probnp, bnp: myocarditis - stress-induced cardiomyopathy **kidney** elevated serum creatinine, increase urea, proteinuria: direct infection, systemic inflammation **blood** - increased: prothrombin time, d-dimer, fibrinogen, aPTT: SARS COV 2 MEDIATED ENDOTHELIAL DYSFUNCTION systemic inflammation (e.g. cytokine, complement pathway) **body** increased: ferritin, c reactive protein, esr + lymphopenia, fever: systemic inflammation

Answer 96

Handwashing social distancing mask wearing isolation **vaccines** PPE

Answer 97

if you are well to stay at home - 10 days if unwell (e.g. admitted to hospital) 14 days if very unwell and needed ITU or immunocompromised - 21 days

Answer 98

**pzifer/niontech moderna aztrazenca** **vaccine type** mRNA vaccine mRNA vaccine attenuated virus **efficacy 95% 94% 70%** **Authorised dose** doses 3 weeks 2 doses 4 weeks 2 doses 12 weeks apart apart apart

Answer 99

anti-pyretic (paracetamol) steroids supportive therapy clinical trials 02 therapy 6mg dexamethasone once a day for 10 days for anyone who needs o2 therapy.

Answer 100

mild - nasal cannula 1-6L moderate nasal cannula or simple facemask (sm) 5-10L severe - simple facemask or reservoir mask 15L very severe nasal high-flow o2 (up tp 70L) or Cpap (15L) for airway maintenance - venturi mask suitable for resp type 2 failure 2-15L non-invasive ventilation 0-15L

Answer 101

those from high prevalence countries - 70% non-UK born most aged between 15 and 44 HIV positive or immunocompromised elderly, neonates and diabetics **homeless, alcohol dependency, idvu, those with mental health problems and those in prisons approximately 1 in 10 cases**

Answer 102

numerous species - ubiquitous in the soil and water few species responsible for human disease tuberculosis )m.tuberculosis, m africanum, m bovis (bovine tb is bcg strain) non-tuberculosis - mycobacteria NTM infection/atypical mycobacteria leprosy (m leprae) non-motile bacillus, slow-growing (disease slow but treatment is long) aerobic (predilection for apices or lungs) uniquely thick fatty cell wall - resistant to acids, alkalis and detergents resistant to neutrophil and macrophage destruction **not all AAFB are tb (aafb= alcohol and acid fast bacilli)**

Answer 103

airborne (pulmonary and laryngeal tb) someone with tb in lungs if they cough, sneeze, yell, sing tb bacteria attaches to aerosol droplets someone breathing these bacteria in through droplets - required prolonged close contact outdoors - mycobacteria usually eliminated by UV radiation and dilution **not by shaking hands, sharing food, touching surfaces, sharing toothbrushes or kissing** exception to rule is mycobacterium bovis can be spread by consumption of unpasturised infected cows milk (uncommon in UK)

Answer 104

False – this describes an epidemic. An endemic disease is maintained at a consistent and predictable level in a given population, for example chickenpox in the UK.

Answer 105

False – secondary bacterial infection after flu is usually due to damage to the mucociliary escalator, which results in bacteria and mucus accumulating in the lower respiratory tract.

Answer 106

True – pneumonia caused by atypical organisms classically presents slightly differently to typical pneumonia. Features include diarrhoea and vomiting, headache, myalgia (muscle ache) and dry cough.

Answer 107

False – vocal resonance is used as part of clinical examination to detect areas of consolidation in the lung. Consolidated lung transmits sound more effectively than aerated lung, so the voice of the patient is heard more clearly over abnormal lung, i.e. vocal resonance is **increased.**

Answer 108

False – not necessarily. CURB 65 does not account for hypoxia, and young patients with a good capacity to compensate physiologically may not have a high respiratory rate or low blood pressure until they are very unwell. Hypoxia is an important feature indicating **severe illness** regardless of CURB 65 score

Answer 109

False – opportunistic infections generally occur in people with severely compromised immune systems, for example from untreated HIV. However, people with some neuromuscular disorders are at higher risk of aspiration pneumonia, through impaired swallowing mechanism.

Answer 110

True – Croup – or laryngotracheobronchitis – is a common childhood illness, most commonly caused by the Parainfluenza I virus. It causes a barking cough and stridor (sound caused by upper airway obstruction). Treatment, when required, is with dexamethasone (a steroid) to reduce inflammation.

Answer 111

True – if a person is recurrently developing lung infections, this indicates that one or more parts of their body’s defence mechanism are not working. Examples include diseases such as COPD, cystic fibrosis, or bronchiectasis; localized obstruction such as a tumour or a foreign body; or immunocompromise due to HIV or medications.

Answer 112

False – this patient would have a CURB 65 score of 1, for their age. Remember: C = confusion U = blood urea \>7mmol/L R = respiratory rate over 30 B = systolic BP \<90mmHg, diastolic BP \<60 and 65 = age over 65. Each component scores 1 point. Patients with a CURB 65 score over 3 have a significant risk of death and require critical care input.

Answer 113

False – if the child is eating and drinking well, and their oxygen levels are normal, it is reasonable to keep a close eye on them and do nothing.

Answer 114

## Footnote True – this is a recognized side effect of ethambutol, so patients will routinely have their vision monitored during treatment.

Answer 115

## Footnote False – Amoxicillin does not have much activity against atypical organisms. When pneumonia is severe or atypical infection is suspected, treatment should include a macrolide antibiotic like clarithromycin, or an alternative like doxycycline, levofloxacin or co-trimoxazole.

Answer 116

False – while pulmonary TB will often give a positive Acid Alcohol Fast Bacilli smear, not all positive AAFB smears are TB, and a negative AAFB smear does not rule out TB.

Answer 117

1 activates macrophages recognising TB - ingests bacteria - t helper cells activated and come from lymph nodes secreting cytokines - develop into epithelioid cells and Langhans giant cells 2 create granulomas for the immune system to fend off infection 3 causes ventral necrosis which may later calcify

Answer 118

- no preceding exposure or immunity - mycobacteria spread via lymphatics to draining hilar lymph nodes usually, no symptoms can have fever malaise (generally unwell pale) erythema nodosum (Erythema nodosum is swollen fat under the skin causing bumps and patches that look red or darker than surrounding skin.) rarely chest signs for the majority, 85% of initial lesion +local lymph node (primary complex) health without scar may calcify associated with the development of immunity to tubercoloprotein

Answer 119

progressive disease contained latent (in granulomas contained) cleared/cured

Answer 120

Tuberculosis bronchopneumonia - primary focus continues to enlarge (cavitation) - enlarge hilar lymph compress bronchi, lobar collapse, enlarge lymph node discharges into bronchus = poor prognosis

Answer 121

(look like millet seeds on autopsy) develops with hematogenous spread of bacteria to multiple organs fine mottling on x-ray widespread granulomata CNS TB in 10-30%

Answer 122

only in humans. most animals succumb to primary TB and never develops to post-primary TB two hypothesis 1. tb bacteria entering a dormant stage with low or no replication over long periods of time 2. balances state of replication and destruction by immune mechanisms

Answer 123

- cough - fever - sweats (mainly at night) - weight loss **crp normal in 15% esr normal in 21%**

Answer 124

tb likes oxygen - apices soft fluffy/nodular upper zone cavitation 10-30% lymphadenopathy rare

Answer 125

if you have a normal chest x-ray but clinical suspicion - military TB cavitation and nother differential lymphadenopathy, alternative diagnosis

Answer 126

Chest x-ray mediastinal lymphadenopathy (mainly unilateral 15% bilateral) pleural effusion miliary (haematogenous spread 1-3%) \*\* if pt short history (few weeks) unwell and looks lobar pneumonia (usually pneumococcal cause) **+** large hilar lymph nodes _think tb could be primary \*\*_

Answer 127

if a patient has a short history (few weeks) of feeling unwell and xray looks like lobar pneumonia and xray shows large hilar lymph nodes **think tb** as it could could be primary TB

Answer 128

get the bug - get 2 sputum samples 8-24 hour gap at least one early morning sample - induced sputum - saline to encourage cough - bronchoscopy with BAL (bronchial alveolar lavage) endobronchial ultrasound (EBUS) with biopsy - lumbar puncture in CNS TB - urine in urogenital tb aspirate/biopsy from tissue (lymph-node, bone, joint, brain, access Mantoux or IGRA (interferon-gamma release assays) are NOT routinely used in diagnosing active TB (mainly dormant or latent TB)

Answer 129

- **isoniazid (h)** **pryazinamide (z)** **Riampicin (r)** **ethambutol (e)**

Answer 130

- multiple drug therapies essential - Therapy must continue for at least 6 months - single-agent treatment leads to drug resistance organisms within 14 days - TB therapy is a job for specialists only - legal requirement to notify all cases - test for HIV, Hep b and Hep C also

Answer 131

4:2/2:4 = **4** drugs treat for **2** month / **2** drugs treat for **4** month = 6 months total R/H/Z/E = Rafimpicin (R), Isoniazid (H), Pyrazinamide (Z), Ethambutol (E) **_2 months_** R/H = Rafimpicin (R), Isoniazid (H), **_4 months_** _standard 70kg patient takes 12 tabs daily_ give 2-9 month if monoresistance 12 months for cns tb, h monoresistance extensive disease 9-12 or 18-20 months for MDR, TT TB

Answer 132

risk of isoniazid induced retinopathy - add vitamin b6 to reduce risk steroids (sometimes) vitamin - D substitution?

Answer 133

rifampicin - orange 'irn bru' tears/urine/lenses. induces liver enzymes, prednisolone, anticonvulsants. all hormonal contraceptive ineffective, hepatitis Isoniazid - hepatitis, peripheral neuropathy (pyridoxine b6) pyrazinamide - hepatitis, gout ethambutol - optic neuropathy (check visual activity) + all 4 drugs can cause rash

Answer 134

screen - contact of people aged \<65 (hepatotoxicity increased with age) - new entrants from high endemic areas pre-biologics (TNF alpha inhibitors) - are of outbreaks asymptomatic with normal chest x-ray and examination **and** positive either Mantoux test or IGRA

Answer 135

where the immune system controls the TB infection and bacteria are still viable in the body but don't cause disease.

Answer 136

**always rule out active TB** - rifampicin + isoniazid for 3 months **_or_** isoniazid only for 6 month * *_or**_ Rifampicin only for 6 months _**or_** rifapentine and isoniazid once weekly for 12 weeks (underserved population)

Answer 137

False – rusty brown sputum is classically seen with pneumonia caused by Streptococcus pneumonia.

Answer 138

False - the cut-off is at least 48 hours after admission to hospital.

Answer 139

False – TB is an airborne pathogen, and is not spread by physical contact.

Answer 140

False – C. burnetti is classically associated with exposure to farm animals. Bird owners are classically prone to pneumonia from Chlamydia psittaci.

Answer 141

False – high flow nasal oxygen can be delivered up to 70L/min! The oxygen is warmed and humidified, otherwise this would be prohibitively drying and uncomfortable. It is important to be aware that this is classed as an aerosol-generating procedure.

Answer 142

False – the primary infection (i.e. the point at which the person becomes infected; the first exposure to TB) is often asymptomatic, and in the majority of people it will either be cleared completely or contained within a granuloma as latent TB. Most symptomatic presentations of TB result as a reactivation of latent TB.

Answer 143

True –Most upper respiratory tract infections are self-limiting. However, rarely, the epiglottis can become inflamed from a bacterial infection (such as Haemophilus influenzae) and this can lead to airway obstruction and even death. This used to be more common in children than it is now, but fortunately incidence is falling due to the Hib vaccine.

Answer 144

False – it is usually caused by a respiratory syncytiovirus, and is most common in babies.

Answer 145

False – latent TB (positive Mantoux or IGRA test in a person who has had contact with TB, but is asymptomatic and has a normal CXR) is treated to reduce the chance of developing active TB. The same antibiotics are used, for a slightly shorter course, usually 3 to 6 months.

Answer 146

False – secondary bacterial infection after flu is usually due to damage to the mucociliary escalator, which results in bacteria and mucus accumulating in the lower respiratory tract.

Answer 147

True – pseudomonas infection is typically seen in cystic fibrosis and other bronchiectatic disease. It causes copious, green, foul-smelling sputum.

Answer 148

True – a reservoir or “non-rebreathe” mask uses a bag to create a reservoir of oxygen and increase the concentration of oxygen being delivered to around 60-90%.

Answer 149

True – this involves the wide dissemination through the bloodstream of TB granulomata, and commonly involves spread to the brain and meninges.

Answer 150

True – Intravenous drug users are at higher risk of S. aureus bacteraemia (as S. aureus is a common skin commensal) and S. aureus pneumonia. It is also classically seen following influenza infection.

Answer 151

False – the key cells in the respiratory system’s innate defence mechanism are macrophages. They participate in the macrophage-mucociliary escalator, and clear debris from the lungs by phagocytosis.