Pleural Disease Flashcards
A 57 year old man presents to hospital with a of week cough, fevers, right sided pleuritic chest pain and is found to have a moderate right sided pleural effusion.
This is aspirated and the fluid sent for microbiological tests. Which of the following is the most likely organism to be grown?
A Enterobacteriacae
B Pseudomonas aerguinosus
C Staphyloccus aureus
D Streptococcus intermedius
E Streptococcus pneumoniae
D Streptococcus intermedius
A 17 year old patient presents feeling generally unwell, with right-sided pleuritic chest pain and fevers. This was preceeded by a sore throat and viral symptoms a couple of weeks ago after which he subsequently noticed a discomfort in his neck.
Which is the most likely causative organism?
A Enterococci spp.
B Fusobacterium necroporum
C Nocardia farcinica
D Staphyloccus aureus
E Streptococcus constellatus
B Fusobacterium necroporum
This is Lemierre’s syndrome caused by Fusobacterium throat infection leading to internal jugular vein septic thrombophlebitis and metastatic infection.
A 69 year old patient who has had a long stay in hospital develops a pleural effusion. He is febrile, breathless and unwell.
Which of the following organisms is most likely to be responsible for his illness?
A Enterobacteriacae
B Pseudomonas aerguinosus
C Staphyloccus aureus
D Streptococcus intermedius
E Streptococcus pneumoniae
C Staphyloccus aureus
A 52 year old presents with progressive weight loss. A chest x-ray reveals a left sided pleural effusion and his inflammatory markers are raised.
Which of the following organisms is most likely to be responsible for his presentation?
A Enterobacteriacae
B Klebsiella pneumoniae
C Staphyloccus aureus
D Streptococcus intermedius
E Streptococcus pneumoniae
B Klebsiella pneumoniae
A 56 year old patient presents with fevers, night sweats and right sided chest pain. They are found to have a unilateral pleural effusion which is subsequently aspirated.
The results of the pleural fluid analysis are as follows:
pH 7.16
glucose 3.0
LDH 1211
protein 51
MCS: turbid fluid, white cells +++, no organisms seen on gram stain, no growth after 72 hours
What is the most appropriate treatment for the patient’s condition?
A Intravenous amoxicillin, metronidazole and gentamicin
B Intravenous co-amoxiclav
C IIntravenous meropenem and vancomycin
D Oral amoxicillin
E Oral co-trimoxazole
B Intravenous co-amoxiclav
Has good anaerobic cover. Aminoglcosides have poor pleural penetration. Meropenem and vancomycin would be appropriate in hospital acquired infectio where MRSA is likely to be a causative organism.
Duration should be at least 2-3 weeks in complex parapneumonic effusion, increased to 4-6 weeks for empyema (purulent pleural fluid).
A patient is being treated for pleural infection is being counselled for intrapleural therapy with fibrinolytics (tPA and DNAse).
Which of the following best describes the benefit?
A Improves resolution of pleural infection but only if the fluid is loculated.
B Lowers chances of needing surgical intervention but slows down the resolution of pleural effusion.
C Reduces the need for surgical intervention but only if given through a larger bore (18-20 Ch) drain.
D Reduces the need for surgical intervention and reduces length of hospital stay.
E Significantly reduces the risk of bleeding.
D Reduces the need for surgical intervention and reduces length of hospital stay.
This is referring to the outcome of the MIST2 trial comparing intrapleural tPA and DNAse to placebo (Rahman et al 2011, NEJM).
The primary outcome was a statistically significant improvement of radiological appearances of pleural effusion (7.9% pleural opacity change over 7 days). This question refers to the secondary outcomes which demonstrate a statistically significant improvement in surgical intervention rates (4% vs 16% in placebo group) and length of hospital stay (11.8 days to 24.8 days in placebo group).
Which of the following treatments is most appropriate?
A Escalate antibiotic therapy.
B Intrapleural fibrinolytics.
C Intrapleural irrigation with 0.9% saline.
D Referral for VATS.
E Replace intercostal drain with wider bore drain.
B Intrapleural fibrinolytics.
Referral to thoracic surgery for consideration of VATS would also be appropriate here but given there is likely to be a delay in transfer as you are working in a DGH, intrapleural fibrinolytics is an appropriate therapy in the interim.
Intrapleural irrigation would be an appropriate alternative in the interim if the patient had a high risk of bleeding.
A patient in your hospital is being treated for pleural infection.
Which of the following is associated with a poor prognosis?
A CRP 320
B Positive microbiology for causative organism
C Underlying respiratory disease
D Urea 8.2
E WCC 18
D Urea 8.2
This refers to the RAPID scoring system to predict outcomes of patients with pleural infection (Rahman et al 2014, Chest).
Other prognostic markers include
(R enal function - urea)
A ge
P urulence of fluid
I nfection source e.g. community or hospital acquired
D ietary factors - albumin
Which of the following may cause an artificially raised pleural fuid pH?
A Air exposure
B Eosinophilic predomoninant
C Hepain contamination
D Lidocaine contamination
E Urinothorax
A Air exposure
Pleural fluid exposed to air following sampling artificially raises the pH. Fluid contaminated with lidocaine, heparin or urine will (artificially) lower the pH. Eosinophils have no effect on pleural fluid pH.
A patient is undergoing investigations for a 5-8 year history of breathlessness. His CT scan is reported as showing symmetrical basal ground glass opacities, parenchymal bands and interlobular septal thickening. It also notes pleural plaques.
What is most likely to be seen on lung biopsy?
A Diffuse alveolar haemorrhage
B Nodular lesions of fibroblasts, collagen and pigmented alveolar macrophages
C Plasma cell infiltration and poorly formed granuloma
D Pleuritis with evidence of fibrosis
E Sparse fibroblastic foci and asbestos bodies
E Sparse fibroblastic foci and asbestos bodies
A 50 year old woman presents with weakness. A CT chest shows a mediastinal mass.
Which is the next most appropriate investigation?
A Autoantibody screen
B Core biopsy
C MRI chest
D Whole body PET CT
E Serum immunoglobulins
E Serum immunoglobulins
A 53 year old patient presents with diplopia and weakness. On examination she has partial ptosis, fatiguability and proximal muscle weakness.
Which is the most sensitive next investigation?
A Acetylcholine esterase autoantibodies
B CT chest
C Electromyography
D Serum immunoglobulins
E Thymic biopsy
A Acetylcholine esterase autoantibodies
This patient has myaesthenia gravis. A biopsy of the thymus should be avoided due to the risk of seeding.
A patient is diagnosed with myaesthenia gravis.
Which of the following treatments should be offered first line?
A Azithromycin
B Physiotherapy
C Pyridostigmine
D Radiotherapy
E Thymectomy
C Pyridostigime
This is first line treatment and can be uptitrated according to response. Steroids can be added. Thymectomy should be offered to all patients <45 years old at presentation however this does not always improve symptoms.
NB. Thymectomy in patients without a proven thymoma can still be helpful in managing symptoms.
https://pn.bmj.com/content/15/3/199
