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Pneumonia (Nichols) Flashcards

1
Q

Basic pneumonia definition:

A

inflammation of lung

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2
Q

Almost all acute bacterial pneumonias are _______ before they become pneumonia, and may center around ____ early on

A

multifocal bronchitis

bronchi

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3
Q

Almost all acute bacterial pneumonias

are due to:

A

aspiration of saliva containing pathogen

note: term “apiration pneumonia” = gastroesoph contents

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4
Q

Infiltrate = radiologic manifestation of:

A

pneumonia, edema or hemorrhage –blood, pus or water

Not Specific

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5
Q

Consolidation = radiologic or phys exam manifestation of:

A

alveoli filled with blood, pus or water

(Not Specific!!)

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6
Q

Most types of pneumonia start with:

A

acute inflammation (neutrophilic infiltration)

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7
Q

What are characteristic of subacute bacterial pneumonia?

A 
foamy macrophages
(subacute = macrophages replacing neutrophils--garbage collectors replacing first responders-- starting about day 3)
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8
Q

ALVEOLAR NON-NECROTIZING

Acute Bacterial Pneumonia

A

Pneumococcus
Legionella
Mycoplasma

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9
Q

ALVEOLAR NECROTIZING

Acute Bacterial Pneumonia

A

Staph aureus
Pseudomonas
Klebsiella

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10
Q

INTERSTITIAL NON-NECROTIZING

Acute Bacterial Pneumonia

A

Mycoplasma

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11
Q

Most commonly identified agent of community-acquired pneumonia:
Who is the typical patient?

A

Streptococcus pneumoniae (“pneumococcus”)

older adults with smoking, COPD, alcoholism, preceding viral infection, etc.

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12
Q

Pneumococcus stage 1
Gross?
Micro?

A

day 1:

G–congestion with exudation of serous and frothy, blood-tinged fluid into alveoli

M–engorged septal capillaries, with a few erythrocytes, edema fluid and bacteria in alveoli

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13
Q

Pneumococcus stage 2
Gross?
Micro?

A

days 2-3:

G–red hepatization with drier, granular, dark red consolidation (~ liver)

M–continuing congestion, extravasation of red cells and numerous neutrophils and abundant fibrin in alveoli, infection spreading through pores of Kohn into adjacent alveoli

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14
Q

Pneumococcus stage 3
Gross?
Micro?

A

days 4-7:

G–grey hepatization with continuing consolidation, but color change to grey

M–degenerating dead cells (neuts, RBC, sloughed pneumocytes and bacteria) in the alveoli; fibrin nets extending through pores of Kohn; foamy macrophages replace neutrophils

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15
Q

Pneumococcus stage 4

Gross?

A

day 8 and following: slimy yellowish exudate, resolution without scarring

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16
Q

Pneumococcus symptoms?

A

fever

cough productive of purulent, blood-tinged (“rusty”) sputum

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17
Q

Pneumococcus signs?

A

fever, tachypnea, pulmonary rales and tubular breath sounds, dullness to percussion

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18
Q

Pneumococcus CXR
Rare?
Common?

A

lobar alveolar consolidation with air bronchograms (rare)

segmental or subsegmental alveolar infiltrates without air bronchograms (common)

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19
Q

Pneumococcus diagnostic test results?

A

G+ sputum with lancet-shaped encapsulated diplococci

Urine antigen test

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20
Q

STAPHYLOCOCCUS AUREUS PNEUMONIA

Gross pathology?

A

heavy plum-colored lungs
>exude bloody fluid on sectioning
>develop numerous small abscesses

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21
Q

STAPHYLOCOCCUS AUREUS PNEUMONIA

Micro pathology?

A
  • aggregates of bacteria
  • acute bronchitis (necrotizing)
  • alveolitis and bronchiolitis + abundant degenerating neutrophils, fibrin, edema fluid, hemorrhage and evolving abscesses

(“a b” x3)

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22
Q

STAPHYLOCOCCUS AUREUS PNEUMONIA

CXR?

A

areas of alveolar consolidation in a bronchopneumonia pattern

more commonly than other acute pn: severe, bilateral, abscesses, pleural effusions

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23
Q

Staph aureus pneumonia is characteristically:

A

abscessing

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24
Q

When is a lung abscess drained?

A

it isn’t, unless it becomes an empyema

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25
Q

How do you isolate Staph aureus cultures?

A

primarily seen in stains of microbiology laboratory cultures

NOT clinical specimens of pus, sputum, etc.

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26
Q

Where would you find legionella?

A

hide inside amoebae in warm water

water heaters, shower heads, air conditioners…

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27
Q

LEGIONELLA PNEUMONIA

gross?

A

bulging firm red or tan areas of consolidation

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28
Q

LEGIONELLA PNEUMONIA

micro?

A
  1. acute non-necrotizing alveolitis
  2. early infiltration by numerous macrophages + neutrophils

(once subacute > all macrophages)

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29
Q

LEGIONELLA PNEUMONIA

symptoms?

A 
cough
high fever, chills, rigors
dyspnea 
headache
diarrhea
confusion
myalgia
CP
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30
Q

LEGIONELLA PNEUMONIA

signs?

A

pulmonary rales, relative bradycardia

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31
Q

LEGIONELLA PNEUMONIA

CXR?

A

initially unilateral bronchopneumonic (alveolar) infiltrate

progresses (in 50%) to pleural effusion

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32
Q

LEGIONELLA PNEUMONIA

high yield dx tests?

A 
urine antigen
CBC: leukocytosis, thrombocytopenia 
Urinalysis: hyponatremia, azotemia, 
liver dysfunction
(must culture on special charcoal medium)
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33
Q

What are the 3 legionella tip-off?

A

diarrhea, confusion, hyponatremia

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34
Q

PSEUDOMONAS AERUGINOSA PNEUMONIA

gross?

A

firm red areas of hemorrhagic consolidation

+/- yellow areas of consolidation with a rim of hemorrhage (target lesions)

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35
Q

PSEUDOMONAS AERUGINOSA PNEUMONIA

micro?

A

> acute necrotizing alveolitis

>Pseudomonas vasculitis (bac invading blood vessels from the adventitia) with associated infarction/hemorrhage

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36
Q

MYCOPLASMA PNEUMONIA usually affects?

A

children and young adults

95% only have URI

37
Q

MYCOPLASMA PNEUMONIA

micro?

A

-lymphoplasmacytic bronchiolitis with ulceration
-neutrophils & fibrin in the lumen
-lymphoplasmacytic interstitial pneumonitis
extending out from the bronchiolitis

38
Q

MYCOPLASMA PNEUMONIA

symptoms?

A

insidious onset of malaise
headache
low-grade fever and chills

followed by **persistent intractable dry cough, pharyngitis, +/- coryza, +/- otitis

39
Q

MYCOPLASMA PNEUMONIA

lab test?

A

cold agglutinins, titer >1:64

40
Q

MYCOPLASMA PNEUMONIA

CXR?

A

patchy areas of consolidation or reticulonodular infiltrate

pl effusion in 20%

41
Q

Classic mycoplasma pneumonia scenario?

A

“walking pneumonia”, outpatient young person with a persistent cough and a chest x-ray looking much worse than the patient

42
Q

Primary TB

symptoms?

A

low-grade fever

(occasionally) chest pain
(rarely) dyspnea from lymph nodes pressing on airways

43
Q

What controls primary TB?

A

type IV immune response

44
Q

What are Ghon complexes?

A
  1. caseating granuloma lesions, usually peripheral and mid lung (primary TB)
  2. enlarged hilar lymph nodes
45
Q

Describe typical reactivation of TB?

A
  • UL

- frequently cavitating

46
Q

Characteristic host response to TB?

A

caseating granuloma with Langhans type giant cells

47
Q

TB diagnosis occurs via…

A

culture with PCR

48
Q

TB gross?

A

tuber lesions + caseation

49
Q

Histoplasmosis is normally from…

A

fecal-enriched soil in caves, chicken coops in

Mississippi (and Ohio) river valleys

50
Q

Histoplasmosis looks like:

A

small yeast

many within phagocytes

51
Q

Histoplasmosis host response?

A

caseating granulomatous (if immunocompetent)

52
Q

Histoplasmosis has many similarities to:

53
Q

Histoplasmosis, radiologically?

A

nodules or masses

note: these resemble lung CA!

54
Q

Histoplasmosis, gross pathologically?

A

nodules or masses

note: these resemble rheumatoid nodules or old TB granulomas!

55
Q

How can you tell if a granuloma = Histo?

A

Methenamine silver stains

sometimes

56
Q

Histoplasmosis, microscopically?

A

alveolar infiltrate of lymphocytes and macrophages, which contain histoplasmosis

57
Q

ASPERGILLOSIS, transmission?

A

airborne transmission, not contagious

58
Q

ASPERGILLOSIS

3 forms of disease?

A
  1. allergy
  2. colonization
  3. invasion (lung nodules or masses; occurs with corticosteroids, immunosuppression, etc)
59
Q

ASPERGILLOSIS

symptoms?

A

fever
hemoptysis
pleuritic CP
(cough, dyspnea)

60
Q

ASPERGILLOSIS

microscopically?

A

regular septate hyphae with dichotomous acute angle branching
-invades bronchus

61
Q

What is particularly bad about the progression of ASPERGILLOSIS infection?

A

angioinvasive = causes hemorrhage and infarction

62
Q

Diagnostic tests for Aspergillosis?

What would confirm the dx?

A
  1. serum test for galactomannan (limited usefulness)
  2. culture or biopsy (also not awesome)

Aspergillus fruiting body

63
Q

CRYPTOCOCCUS

Where do you find this?

A

yeast found in soil and pigeon poop

64
Q

CRYPTOCOCCUS

transmission?

A

airborne transmission, not contagious

65
Q

CRYPTOCOCCUS
Most common form of infection?
Second most common?

A
  1. meningitis
  2. lung nodules/masses
    (occ. interstitial pneumonia)
66
Q

CRYPTOCOCCUS

Primary virulence factor?

A

anti-phagocytic capsule

67
Q

CRYPTOCOCCUS

Primary host defense?

A

cell-mediated immunity

macrophage response, sometimes with discrete granulomas or giant cells

68
Q

CRYPTOCOCCUS

microscopically?

A

faintly basophilic or translucent yeast with large surrounding clear space in H&E-stained tissue

69
Q

CRYPTOCOCCUS

Diagnosis?

A

morphology
antigen test
culture

70
Q

CRYPTOCOCCUS

Histologic confirmation?

A

mucicarmine stain

red = +

71
Q

PNEUMOCYSTIS JIROVECII PNEUMONIA

2 main characteristics?

A
  1. fungus which behaves like a protozoan
  2. opportunistic pathogen in patients with
    deficient cell-mediated immunity (AIDS, etc.)
72
Q

PNEUMOCYSTIS JIROVECII PNEUMONIA

Symptoms?

A

insidious onset of dyspnea, fever, and non-productive cough

73
Q

PNEUMOCYSTIS JIROVECII PNEUMONIA

Signs?

A

tachypnea with no rales or rhonchi

74
Q

PNEUMOCYSTIS JIROVECII PNEUMONIA

CXR?

A

bilateral hazy interstitial infiltrates which become dense alveolar infiltrates

75
Q

PNEUMOCYSTIS JIROVECII PNEUMONIA

Gross?

A

heavy, diffusely consolidated, tan lungs

76
Q

PNEUMOCYSTIS JIROVECII PNEUMONIA

Micro?

A

foamy eosinophilic, sparsely cellular, centro-alveolar “honeycomb” exudate

+/- lymphoplasmacytic interstitial pneumonia

77
Q

PNEUMOCYSTIS JIROVECII PNEUMONIA
Diagnosis?
What would you NOT use?

A

Demonstration of helmet-shaped org in biopsy, smear, aspirate or lavage using:

  1. cyst stains (e.g. Grocott, methenamine silver)
  2. trophozoite
  3. immunostains

Cannot culture this–it doesn’t grow!

78
Q

Type 2 pneumocyte hyperplasia is seen in what 2 conditions?

A

interstitial pneumonias

acute lung injury

79
Q

Chronic pneumonias tend to be (etiology):

A

fungal, mycobacterial, toxic, autoimmune or idiopathic

80
Q

Chronic pneumonias tend to be (lung pattern):

A

interstitial
nodular
both

81
Q

What two causes of chronic pneumonia are often chronic and nodular?

A

fungal

mycobacterial

82
Q

INTERSTITIAL chronic pneumonias (3):

A

Pneumocystis
Sarcoidosis
Toxoplasmosis

83
Q

NODULAR chronic pneumonias (6):

A 
TB
Histoplasmosis
Aspergillosis
Cryptococcosis
Coccidioidomycosis
Blastomycosis

“BITCHY Nodules = Blasto, asperg-i-llosis, Tb, Coccidio, Histo, crYpto

84
Q

Most common causes of viral pneumonia?

A

influenza

RSV

85
Q

What virus causes interstitial pneumonias in immunocompromised patients?

A

Cytomegalovirus (CMV)

86
Q

What virus causes nodular pneumonias in immunocompromised patients?

A

Herpes simplex virus (HSV)

87
Q

Viral pneumonias tend to be (interstitial/nodular)

A

interstitial

88
Q

What are Ghon focuses?

A

grey/white caseating granulomas (necrotic centers)

FYI: “complex” = this + hilar lymphadenopathy

Pulmonary (31 decks)

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