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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
Q

Bacillus anthracis (anthrax)

A 
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
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26
Q

Brucella

A

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

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27
Q

‘Atypical’ bacterial pneumonias

A 
Progressive, fever without rigours
Cough without sputum
Headache, muscle pains
Diffuse chest crackles / diffuse CXR infiltrates
Modest leukocyte sis
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28
Q

Mycoplasma pneumoniae

A

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

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29
Q

Chlamydia psittaci / pneumoniae

A

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

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30
Q

Legionella pneumophila

A

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

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31
Q

Coxiella burnetii

A

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

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32
Q

Risk factor - over 65 years old

A

Streptococcus pneumoniae

33
Q

Institutionalised patients

A

Streptococcus pneumoniae
Gram negative enteric bacilli
Staphylococcus aureus
Anaerobic bacteria (non-ambulatory elderly)

34
Q

Risk factor - alcoholism / living rough

A

Gram-negative enteric bacilli

Legionella

35
Q

Co-morbidities (COPD, heart failure, diabetes, chronic liver/renal failure, recent viral infection)

A

Streptococcus pneumoniae
Gram negative enteric bacilli
Staphylococcus aureus
Haemophilus influenzae

36
Q

Risk factor - hospital admission in previous year

A

Streptococcus pneumoniae

37
Q

Risk factor - hospital admission previous 2-4 weeks

A

Gram negative enteric bacilli

38
Q

Recent antibiotic treatment

A

Streptococcus pneumoniae (resistant organisms)

39
Q

Risk factor - aspiration

A

Gram negative enteric bacilli
Staphylococcus aureus
Anaerobic bacilli

40
Q

Aetiology of common community acquired pneumonias

A 
Streptococcus pneumoniae ~20%
Haemophilus influenzae ~5%
"Atypical" bacteria ~20%
G-ve bacteria and staph aureus ~5%
Viruses ~10%
No organism identified ~40%
41
Q

Blood count in pneumonias

A

Typical pneumonia - neutrophilia

“Atypical” inc mycoplasma, less often leukocytosis, sometimes neutropenia and lymphopaenia

42
Q

Immunofluorescence in pneumonias

A

Urinary antigen in legionella

43
Q

Criteria for hospitalisation

A 
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
Q

Poor prognostic factors

A

> 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
Q

CURB score

A 
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
Q

Treatment

A

Oxygen - aim for sats over 92%
Encourage fluids - may need iv, watch urine
Analgesia
Nutrition
Assess poor prognostic factors and CURB score

47
Q

Iv therapy appropriate if…

A

Disease is severe
Patient obtunded and can’t swallow
Patient confused
Impaired absorption of oral drugs

48
Q

Streptococcus antibiotics

A

Penicillins
macrolides
first generation cephalosporins
Vancomycin

49
Q

Haemophilus antibiotics

A

Clarithromycin
Azithromycin
Third generation cephalosporin

50
Q

Staphylococcus antibiotics

A

Oxacillin
Methicillin
Vancomycin

51
Q

Gram negative gut bacteria antibiotics

A

Aminoglycosides, cephalosporins, aminopenicillins

52
Q

With treatment CRP should fall by…

A

50% in 4-5 days

53
Q

Causes of treatment failure

A

Wrong diagnosis
Secondary complication
Wrong antibiotics
Impaired immunity

54
Q

Follow up

A

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
Q

Influenza A, B

A

Common cause viral pneumonia
Haemagglutsnin and neuraminidase capsule agents re-arrange
At least 50% all viral pneumonia

56
Q

Common viral pneumonias

A

Influenza A/B

Varicella/Zoster (chickenpox)

57
Q

Varicella/Zoster (chickenpox)

A 
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
Q

Less common causes viral pneumonia

A 
Parainfluenza
Respiratory syncytial virus
Measles
Adenovirus
Hantavirus
Cytomegalovirus
59
Q

Parainfluenza

A

Less common cause viral pneumonia
3 stereotypes - 1,2 = croup, 3= pneumonia
Children
Rare in adults unless immunosuppressed

60
Q

Respiratory syncytial virus

A

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
Q

Measles

A

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
Q

Adenovirus

A

5% respiratory infections in children

2% resp. Infections in adults

63
Q

Hantavirus

A

Americas
Rodent reservoir
Caught from faeces - never person-person.

64
Q

Influenza treatment

A

Rimantadine, amantidine 100mg od, 5 days
Zanamivir - blocks viral release, may shorten illness
Watch for secondary bacterial infection

65
Q

CMV treatment

A

Gangciclovir, hyper immune globulin, foscarnet (iv)

66
Q

Varicella treatment

A

Aciclovir

67
Q

SARS

A

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
Q

Nosocomial pneumonia - clinical aspects

A

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
Q

Nosocomial pneumonia - risk groups

A

Old, chronic lung disease, diabetes
Immobility, chest/abdo surgery, nasogastric feeding,
Mechanical ventilation, poor dental hygiene
Steroids, immune suppression

70
Q

Nosocomial pneumonia : organisms

A

Aspiration - anaerobic bacteria, G-ve enterococci
Trauma - streptococcus, haemophilus
Ventilation/ coma - staphylococcus
Prolonged intubation/antibiotics - pseudomonas
MRSA

71
Q

Nosocomial pneumonia treatment

A

Prolonged G-ve cover - cefuroxime plus amino glycoside eg gentamicin
Oxygen, fluids, ventilation, nutrition
If penicillin allergy - clindamycin or ciprofloxacin

72
Q

Nosocomial pneumonia prevention

A

Hand and general hygiene
Infection control measures
Regular equipment sterilisation

73
Q

Lung abscess

A

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
Q

Aspergilloma

A 
Ball of fungus in old cavity
(tb, sarcoidosis, abscess, tumour, cystic fibrosis)
Often asymptomatic
75% present with haemoptysis
Itraconazole can help
75
Q

Invasive aspergillosis

A

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
Q

Allergic bronchopulmonary aspergillosis (ABPA)

A 
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
Q

Histoplasmosis

A

Bat/bird droppings - USA, mycelia inhaled
Mostly asymptomatic
Calcified nodules, extrinsic allergic alveolitis
Chronic progression/cavitation in COPD
Dissemination in immunocompromised

78
Q

Blastomycosis

A

Spores from contaminated soil - USA

Pathology (15 decks)

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