pneumonia

Question 1

granny has acquired a bit of a drinking problem in the nursing home. she presents with a pleuritic chest pain, which kind of pneumonia might she have acquired? How would you treat this?

Answer 1

Aerobic, gram negative bacilli such as Legionella or Pseudomonas aeruginosa are seen in alcoholics and in nursing homes. Also seen with Cardiopulm dz.

Macrolides (Azithromycin) and Fluoroquinolones (Levofloxacin) are good for Legionella

For Pseudomonas, use Aminoglycosides (gentamicin), cephalosporin (3rd gen Cefepime) or carbapenems (Imipenem)

Question 2

A homeless man has a seizure and has poor dental hygiene. What kind of pneumonias may he be at risk for? How would you treat him?

Answer 2

Anaerobes such as Bacteroides, Actinomyces and Fusobacterium.

Anaerobes can be treated with Penicillin (Piperacillin/tazobactam for anaerobes) and Clindamycin

Question 3

A patient who smokes and has COPD may be at high risk for developing which pneumonia? How would you treat this?

Answer 3

Haemophilus Influenza.

This can be treated with 2nd and 3rd gen cephalosporin (Ceftriaxone), TMX/SMP, Quinolone (Levofloxacin), Macrolide (Azithromycin)

Question 4

Granny has gotten her hands on some heroin in her nursing home, and she has just gotten over the cold. She’s at especially high risk for which pneumonia? Treatment?

Answer 4

Staph aureus

treat with Oxacillin, Nafcillin, or Cefazosin

Question 5

someone with structural lung dz, completion of broad spectrum antibiotics, malnutrition or on chronic steroids may get which pneumonia?

Answer 5

Pseudomonas aeruginosa,

this is a gram neg rod so treat with amino glycosides such as Gentamicin, 3th or 4th gen cephalosporins, carbapenems, or extended spectrum penicillin

Question 6

Hospitalized patients are more at risk for which pneumonia?

Answer 6

Legionella

also more at risk for aspirating

Question 7

severe ICU patients more at risk for

Answer 7

S aureus and Legionella

Question 8

Give healthy outpatients these medicines..

Answer 8

macrolides (azithromycin, erythromycin or clarithromycin)

or doxycyline (only covers atypicals to some extent)

Question 9

Which organisms do Macrolides protect against?

Answer 9

Strep pneumo, H flu, atypicals (Legionella, mycobacteria, and chlamydia)

Question 10

Which organisms do doxycycline protect against?

Answer 10

C pneumonia, M pneumoniae, Psuedomonas, H flu

Question 11

What to give an outpatient with underlying comorbities (COPD, CHF, alcoholism) aka at risk for drug-resistant step pneumo

Answer 11

use a respiratory fluoroquniolone (levofloxacin)

OR beta lactam (like 4th gen cefepime) plus macrolide

Question 12

Fluoroquinolones (such as Levofloxacin) are good at covering against which microorganisms?

Answer 12

gram pos (strep pneumo, staph aureus), gram neg (H flu, Klebsiella, legionella, psuedomonas, and e coli), and atypicals

Question 13

Inpatient Non-ICU patients need which medicine?

Answer 13

Beta lactam plus a macrolide. The beta lactam helps protect against the gram negatives such as Klebsiella and Proteus.

Use a second or third generation cephalosporin since they have increased act against gram -

Question 14

severe pneumonia requiring ICU care, which medicine

Answer 14

Beta lactam plus azithromycin

or

beta lactam plus fluuroquinolone

Also use Vancomycin to cover MRSA

To cover psuedomonas, use one of the beta lactams (cephalosporin, pipercillin and carbapenams) plus an amino glycoside (gentamycin)

Question 15

How do you treat an AIDS patient with suspected pneumocystis jiroveci?

Answer 15

TMP/SMX, IV pentamadine, corticosteroids (reduced risk of rep failure and death)

Question 16

Which bacterial pneumonias are AIDS patients at risk for?

Answer 16

S pneumo and H influenzae

Question 17

Which prophylactic therapy should be given to AIDS patients to protect against pneumocystis jirovecii?

Answer 17

Trimethoprim/Sulfa, dapsone, pentamidine

Question 18

How can you make the diagnosis of pneumocystis jirovecii?

Answer 18

visualization on a silver stain, bronchoalveolar lavage

also hypoxemia is prominent

Question 19

Which fungal pneumonia may present as meningitis in AIDs patients?

Answer 19

Cryptoccocus neoformans

Question 20

Do patients with pneumonia have high or low CO2, and why?

Answer 20

Low CO2 because the hyperventilate due to the low V/Q ratio. The ventilation is low bc the alveoli are full of inflammatory cells.

Question 21

what is the radiology of aspiration?

Answer 21

bilateral opacities with air bronchograms

Question 22

how would a patient with typical pneumonia present?

Answer 22

rapid onset, ill appearing, high fevers, chest pains, rigors, consolidation/rales, leukocytosis

Question 23

organisms for typical pneumonia

Answer 23

S pneumo, S aureus, H flue, Klebsiella, Legionella

Question 24

what are the risk factors for drug resistant S pneumo

Answer 24

age>65, Beta lactam therapy within 3 months, exposure to child in daycare

Question 25

when might sputum samples be useful for diagnostics? What can't it detect?

Answer 25

when there's a large number of bacteria with a single morphology, when there are many PMNs and few squamous epithelial cells no recent antibiotic admin can't detect legionella, mycoplasma, viruses, chlamydia

Question 26

blood cultures are used in _____ patients and are ______, but not _____

Answer 26

hospitalized specific, not sensitive

Question 27

if someone has CAP, and they still have a fever and cough 2 days after treatment started, were they misdiagnosed?

Answer 27

no. median duration of fever is about 3 days on appropriate Rx. fatigue, dyspnea, cough often lasts 7-14 days.

Question 28

treatment for HAP is based on..

Answer 28

local hospital flora HAP more likely to be polymicrobial

Question 29

a patient with a splenectomy is at higher risk for

Answer 29

encapsulated organisms like S. pneumo, H. flu, N. meningitides

Question 30

a patient with a neutropenia is at higher risk for

Answer 30

bacteria, aspergillus, candida

Question 31

what is the most likely diagnosis in a symptomatic HIV+ patient with abnormal CXR

Answer 31

bacterial pneumonia (S pneumo and H flu)

Question 32

An HIV+ patient with a low CD4 count has an atypical pneumonia presentation, with lower zone infiltrates and mediastinal adenopathy. Whats top of ddx?

Answer 32

M. tuburculosis

Question 33

What fungal infection are HIV+ patients susceptible to when the CD4 gets as low as 50

Answer 33

invasive aspergillosis

Question 34

when do you see red hepatization and what causes it?

Answer 34

days 3-4 of pneumococcal pneumonia intraalveolar accumulation of neutrophils and erythrocytes

Question 35

when do you see grey hepatization and what causes it?

Answer 35

days 5-7 of pneumococcal pneumonia intra-alveolar organization and macrophages

Question 36

Which filamentous bacteria is AFB stain negative? What is distinct about these abscesses?

Answer 36

Actinomyces israelii sulfur granules

Question 37

Which filamentous bacteria is AFB positive and often in immuocompromised hosts?

Answer 37

Nocardia asteroides

Question 38

What is typical walking pneumonia? What does this look like histologically? Treatment?

Answer 38

Mycoplasma pneumoniae treat with azithromycin you would see acute inflammation in the wall and lumen of the bronchiole

Question 39

which lung lobe does secondary pneumonia usually show up?

Answer 39

granulomas in apical/posterior of upper lobes

Question 40

air crescent sign on radiology is indicative of

Answer 40

Aspergilloma

Question 41

What does Histoplasma capsulatum look like histologically?

Answer 41

necrotizing granulomatous inflammation distinguish from TB with silver stains or culture

Question 42

what does Coccidioides Immitis look like? where is it located in US?

Answer 42

looks like spheres with endospores southwestern US and San Joaquin valley

Question 43

Which stain can you use for the caseating granulomas of cryptococcus neoformans? What does a cryptococcoma look like?

Answer 43

mucicarmine cryptococcoma looks like a single dominant mass, may look like a neoplasm

Question 44

what is Type I invasive aspergillosis characterized by?

Answer 44

organisms invade blood vessels, leading to infarction and thrombosis esp in immunocompromised hosts

Question 45

what is Type II aspergilloma characterized by?

Answer 45

mycetoma fungus ball in pre-existing cavity

Question 46

what is Type III aspergillosis characterized by? What will you see in blood and sputum?

Answer 46

Allergic Bronchopulmonary Aspergillosis (ABPA) most patients are asthmatics who develop immune reactions to Aspergillis eosinophilia

Question 47

If you look under a microscope and see filling of alveolar airspaces w/ organisms and proteinaceous fluid in an immunosuppressed patient, which fungi may come to mind?

Answer 47

pneumocystis jiroveci