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Pathology > Pneumonia > Flashcards

Pneumonia Flashcards

1
Q

Pneumonia definition

A 
An infection (usually bacterial)
Symptoms and signs of consolidation of parts of lung parenchyma
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2
Q

CAP

A

Community acquired pneumonia
Commonest infectious cause of death
40% require hospital, 10% ICU
Hospital mortality approx 10%

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3
Q

Common CAP bacteria

A

Streptococcus pneumoniae / pyogenes
Haemophilus influenzae
Staphylococcus
Anaerobes (aspiration)

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4
Q

Uncommon CAP bacteria

A

Gram negative bacilli from bowel - (Klebsiella pneumoniae, e.coli, pseudomonas auruginosa, acintobacter)
Nocardia asteroides/brasiliensis
Actinomyces
Moraxella catarrhalis

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5
Q

Very uncommon CAP bacteria

A 
Yersinia pasteurella / pestis (Plague)
Pasteurella multocida
Francisella tularensis
Bacillus anthracis (Anthrax)
Brucella (Brucellosis)
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6
Q

Streptococcus pneumoniae

A

Common CAP
Easily activated in debilitated
Intense fever, rigours, pleuritic pain, tachycardia, tachypnoea, rusty sputum
Crackles, then consolidation
Fever breaks 8th day
Medical emergency
Complications common - empyema, meningitis, septicaemia

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7
Q

Rust coloured sputum

A

Streptococcus pneumoniae

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8
Q

Streptococcus pyogenes

A

Uncommon pneumonia
Often post-viral in young
Complications frequent - pleural effusion, empyema, pneumothorax

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9
Q

Haemophilia influenzae

A

Common cause pneumonia
Often followed URTI
Not very invasive

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10
Q

Typical features bacterial pneumonias - general

A

Distress, pain, fever, rigours, tachycardia, tachypnoea, cough with rusty sputum
On examination - Local crackles early, later consolidation
Fever, hypoxia, high neutrophil count, ESR, CRP
Culture before antibiotics!

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11
Q

Staphylococcal pneumonias

A

Can be antibiotic resistant
V. Invasive - bullae rupture into pleura, septicaemia
Causes - inhalation / aspiration, from blood, post- viral
Complications frequent

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12
Q

Staphylococcal CXR

A

Central/segmental consolidation
Modular infiltrates with fluid levels
Often access, pleural effusion, empyema

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13
Q

Anaerobic pneumonia - causes

A

Aspiration
Alcohol, coma, seizure, anaesthesia
Chronic dental / ENT infection

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14
Q

Anaerobic pneumonia - signs/symptoms

A

Typical pneumonia with pleuritic pain
Lower lobes, especially right lower lobe
Fever, breathless
Access, empyema

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15
Q

Gram negative bacilli

A

Typically nosocomial
Co-morbidities common
Inc. klebsiella pneumoniae, e-coli, pseudomonas aeruginosa

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16
Q

Klebsiella pneumoniae

A 
Unusual, G-ve pneumonia
Elderly men, co-morbidities
Thick, bloody sputum
Multiple upper lobe consolidation
Bulging fissures and cavitation
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17
Q

Pseudomonas pseudomallei

A

G-ve aerobe found in soil and water in tropics

Original infection through skin

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18
Q

E-coli, pseudomonas aeruginosa, acinetobacter

A 
Gram negative bacilli
Chronically ill people
Haemoptysis rare
Lower lobes
Abscesses and empyema frequent
Can progress very quickly
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19
Q

Nocardia asteroides/brasiliensis

A

Aerobic, G+ve bacilli from soil, uncommon pneumonia esp immunocompromised
Subacute fever, lethargy, weight loss, productive cough, pleuritic pain, skin abscesses, focal neurological signs
CXR - consolidation, cavities, nodules, abscesses

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20
Q

Actinomyces Israeli

A 
Anaerobic, branching bacilli - mistaken for fungus
Commensal of pharynx 
Bad dentition, bronchiectasis, COPD
Males
Sub-acute symptoms
Cavitation pustules open on chest wall
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21
Q

Moraxella catarrhalis

A

Gram negative diplococcus
Commensal of pharynx
COPD, congestive heart failure

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22
Q

Yersinia pestis (plague)

A

Gram negative rod
Disease of rodents, also human-human transmission
V. Infectious, starts as URTI
Bubonic - large suppurating lymph nodes
Pneumonic - pain, cough, SOB, haemoptysis, LL infiltrates, pleural effusion

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23
Q

Pasteurella multocida

A

Rare G-ve bacilli pneumonia
Oropharynx commensal - mammals
Cutaneous infection after animal bites
Can be complicated by pneumonia if co-morbidity

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24
Q

Francisella tularensis

A

G-ve bacillus, rare cause pneumonia
Infects mammals and insects of northern hemisphere
Tularaemia caused by animal bite
Local bite site - purulent with lymphadenopathy
Abrupt pneumonia with fever, rigours, malaise, cough and chest pain

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25
Bacillus anthracis (anthrax)
``` G+ve rod, spores in soil Infects animals Contaminated dung, milk transmits Cutaneous - black, swollen pustule Intestinal - severe bowel upset Pneumonic - cough, pain, stridor, cyanosis, oedema neck and chest wall ```
26
Brucella
Gram negative coccobacilli GU tract of cows, pigs, goats, dogs contact or milk Fever, malaise, headache, hepatosplenomegaly, low back pain CXR - nodules, miliary infiltrates, mediastinal lymphadenopathy
27
'Atypical' bacterial pneumonias
``` Progressive, fever without rigours Cough without sputum Headache, muscle pains Diffuse chest crackles / diffuse CXR infiltrates Modest leukocyte sis ```
28
Mycoplasma pneumoniae
Atypical bacteria Small epidemics, closed populations 10-20 days incubation Cough, fever, malaise, arthralgia, middle ear infection, d&v, anaemia, lymphadenopathy, meningitis, hepatitis, pericarditis CXR - lower lobe infiltrates resolve over 4-6 weeks
29
Chlamydia psittaci / pneumoniae
Ornithosis in domestic fowl Atypical pneumonia with 7-14 day incubation Fever, arthralgia, headache, myalgia, chest pain, pleuritic pain Splenomegally Macular rash CXR lower lobe infiltration
30
Legionella pneumophila
Atypical bacterial pneumonia Breeds in air conditioning NOT human-human Ranges from mild, to fever, rigours, pneumonia, headache, haemoptysis, chest pain Loads of extra pulmonary symptoms - abdo, hyponatraemia, myalgia, confusion, skin rash, oliguria, protein urea, fits Hepatitis, neutropenia, lymphopaenia CXR dense general consolidation, often unilateral, pleural effusion
31
Coxiella burnetii
Rickettsiaceae: Q fever Tick vector - wild / domesticated animals - often asymptomatic Multiplies in placenta so risk - calving Atypical pneumonia, 2-4 week incubation period Abrupt onset fever, chills, myalgia, headache Hepatosplenomegaly CXR dense nodular infiltrates
32
Risk factor - over 65 years old
Streptococcus pneumoniae
33
Institutionalised patients
Streptococcus pneumoniae Gram negative enteric bacilli Staphylococcus aureus Anaerobic bacteria (non-ambulatory elderly)
34
Risk factor - alcoholism / living rough
Gram-negative enteric bacilli | Legionella
35
Co-morbidities (COPD, heart failure, diabetes, chronic liver/renal failure, recent viral infection)
Streptococcus pneumoniae Gram negative enteric bacilli Staphylococcus aureus Haemophilus influenzae
36
Risk factor - hospital admission in previous year
Streptococcus pneumoniae
37
Risk factor - hospital admission previous 2-4 weeks
Gram negative enteric bacilli
38
Recent antibiotic treatment
Streptococcus pneumoniae (resistant organisms)
39
Risk factor - aspiration
Gram negative enteric bacilli Staphylococcus aureus Anaerobic bacilli
40
Aetiology of common community acquired pneumonias
``` Streptococcus pneumoniae ~20% Haemophilus influenzae ~5% "Atypical" bacteria ~20% G-ve bacteria and staph aureus ~5% Viruses ~10% No organism identified ~40% ```
41
Blood count in pneumonias
Typical pneumonia - neutrophilia | "Atypical" inc mycoplasma, less often leukocytosis, sometimes neutropenia and lymphopaenia
42
Immunofluorescence in pneumonias
Urinary antigen in legionella
43
Criteria for hospitalisation
``` Risk factors for pneumonia Failure of first line antibiotics Signs of immediate severity - chest pain, confusion, hr >125, temp 40, resp rate >30, cyanosis, low b.p Suspected complication Home management appears impossible ```
44
Poor prognostic factors
>65 years old Co-morbidities Confusion, raised resp rate, low b.p, hypoxaemia Urea >7mM, albumin <35g/l, WBC over 20, under 4 CXR - multilobar involvement Positive blood culture
45
CURB score
``` Confusion (AMTS 8 or less) Urea (>7mM) Respiratory rate (>30/min) Blood pressure (<60 diastolic) Mortality with all 4 is 80%, 3 is 33%, 2 23%, 1 8% ```
46
Treatment
Oxygen - aim for sats over 92% Encourage fluids - may need iv, watch urine Analgesia Nutrition Assess poor prognostic factors and CURB score
47
Iv therapy appropriate if...
Disease is severe Patient obtunded and can't swallow Patient confused Impaired absorption of oral drugs
48
Streptococcus antibiotics
Penicillins macrolides first generation cephalosporins Vancomycin
49
Haemophilus antibiotics
Clarithromycin Azithromycin Third generation cephalosporin
50
Staphylococcus antibiotics
Oxacillin Methicillin Vancomycin
51
Gram negative gut bacteria antibiotics
Aminoglycosides, cephalosporins, aminopenicillins
52
With treatment CRP should fall by...
50% in 4-5 days
53
Causes of treatment failure
Wrong diagnosis Secondary complication Wrong antibiotics Impaired immunity
54
Follow up
CXR takes 6-12 weeks to resolve Repeat CXR advised at 6 weeks if persistent symptoms or underlying lesion (smoking) 10-20% older smokers with CAP have underlying carcinoma Vaccination - influenza, pneumococcal
55
Influenza A, B
Common cause viral pneumonia Haemagglutsnin and neuraminidase capsule agents re-arrange At least 50% all viral pneumonia
56
Common viral pneumonias
Influenza A/B | Varicella/Zoster (chickenpox)
57
Varicella/Zoster (chickenpox)
``` Rash on face then body Erythema thus Macules then vesicles, crust Pneumonia within 5 days of rash Epidemics in winter and spring Pneumonia almost exclusively in adults Miliary calcification CXR ```
58
Less common causes viral pneumonia
``` Parainfluenza Respiratory syncytial virus Measles Adenovirus Hantavirus Cytomegalovirus ```
59
Parainfluenza
Less common cause viral pneumonia 3 stereotypes - 1,2 = croup, 3= pneumonia Children Rare in adults unless immunosuppressed
60
Respiratory syncytial virus
Uncommon cause viral pneumonia Leading cause respiratory tract infection in children Cough, cold, pharyngitis, fever, LRT involved 50% cases Pneumonia or bronchiolitis Immunosuppressed Induces IgE response, predisposing to asthma
61
Measles
Uncommon cause viral pneumonia Prodrome one week before rash (fever, URTI, malaise, anorexia) 50% pneumonia Face, neck, extremeties Leukopenia Reticulonodular pulmonary infiltrates, hilar lymphadenopathy, pleural effusion, Immunosuppressed
62
Adenovirus
5% respiratory infections in children | 2% resp. Infections in adults
63
Hantavirus
Americas Rodent reservoir Caught from faeces - never person-person.
64
Influenza treatment
Rimantadine, amantidine 100mg od, 5 days Zanamivir - blocks viral release, may shorten illness Watch for secondary bacterial infection
65
CMV treatment
Gangciclovir, hyper immune globulin, foscarnet (iv)
66
Varicella treatment
Aciclovir
67
SARS
Guangdong province china, spread though Middle East Novel corona virus, probable animal reservoir Person-person spread, most nosocomial Fever 2-3 days, cough, SOB, resp failure, diarrhoea and lung infiltrate Diagnosed by PCR
68
Nosocomial pneumonia - clinical aspects
Infection with CXR infiltrate, abscess and impaired gas exchange At least 72hr following hospital admission 15% hospital acquired infection Gram negative bacteria ITU / mechanical ventilators / nebulisers highest risk
69
Nosocomial pneumonia - risk groups
Old, chronic lung disease, diabetes Immobility, chest/abdo surgery, nasogastric feeding, Mechanical ventilation, poor dental hygiene Steroids, immune suppression
70
Nosocomial pneumonia : organisms
Aspiration - anaerobic bacteria, G-ve enterococci Trauma - streptococcus, haemophilus Ventilation/ coma - staphylococcus Prolonged intubation/antibiotics - pseudomonas MRSA
71
Nosocomial pneumonia treatment
Prolonged G-ve cover - cefuroxime plus amino glycoside eg gentamicin Oxygen, fluids, ventilation, nutrition If penicillin allergy - clindamycin or ciprofloxacin
72
Nosocomial pneumonia prevention
Hand and general hygiene Infection control measures Regular equipment sterilisation
73
Lung abscess
High mortality Alcoholic men >50 years old Most from aspiration pneumonia - dental disease, impaired consciousness, diabetes, bronchial carcinoma, secondary to staph. Pneumonia, immunocompromised, septic embolism in iv drug users Cough, haemoptysis, fevers, night sweats, weight loss, malaise, foul sputum
74
Aspergilloma
``` Ball of fungus in old cavity (tb, sarcoidosis, abscess, tumour, cystic fibrosis) Often asymptomatic 75% present with haemoptysis Itraconazole can help ```
75
Invasive aspergillosis
Fungal hyphae invade tissue Usually immunosuppressed eg. Chronic oral corticosteroids Fever, chest pain, cough, haemoptysis, dyspnoea Spread to sinuses, brain, eyes, skin, endocarditis Fungal hyphae in sputum - transbronchial biopsy Amphotericin B, itraconazole
76
Allergic bronchopulmonary aspergillosis (ABPA)
``` IgE, IgG response Positive skinprick rest Bronchiectasis, flitting lung infiltrates Hyphae and spores in sputum Dark mucus plugs - airway casts Poorly controlled, severe chronic asthma Itraconazole ```
77
Histoplasmosis
Bat/bird droppings - USA, mycelia inhaled Mostly asymptomatic Calcified nodules, extrinsic allergic alveolitis Chronic progression/cavitation in COPD Dissemination in immunocompromised
78
Blastomycosis
Spores from contaminated soil - USA

Pathology (15 decks)

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