Pulm #4 Flashcards
What is a pleural effusion?
Abnormal accumulation of fluid in the pleural space
What is an empyema?
-Direct infection of the pleural space
What are the two types of pleural effusion?
-Transudate and Exudate
Explain some causes of Transudate pleural effusion
- CHF (MCC)
- Nephrotic syndrome
- Cirrhosis
- Atelectasis
Explain some causes of Exudate pleural effusions
- Any condition associated with infection or inflammation
- Pulmonary embolism
- Malignancy
Symptoms of pleural effusion
- Dullness to percussion
- Decreased fremitus
- Decreased breath sounds
- Pleural friction rub
What is the initial test of choice for pleural effusion? What does it show?
- Lateral decubitus CXR films
- Blunting of the costophrenic angles (meniscus sign)
However, what is the gold standard to diagnose a pleural effusion?
Thoracentesis (can be diagnostic and therapeutic)
What diagnostic is done to confirm an empyema?
CT scan
What is Light’s Criteria?
- If any of these three are present, it is exudative
1) Pleural fluid protein: serum protein > 0.5
2) pleural fluid LDH: serum LDH > 0.6
3) Pleural fluid LDH > 2/3 upper limit of normal LDH
Treatment for pleural effusion
- Treat underlying condition
- Thoracentesis (gold standard)
- Chest tube fluid drainage for empyema
- Pleurodesis (Talc used) if chronic or malignant
What is the pathophysiology of Tuberculosis
After inhalation, Mtb goes to the alveoli, gets incorporated into macrophages and can disseminate from there
Pulmonary Symptoms of TB
- Cough
- Hemoptysis
- Fever
- Night sweats, chills, chest pain
Extrapulmonary symptoms of TB
- Can affect any organ
- -Cervical lymph nodes (Scrofula)
- -Pott’s Disease (TB of the spine)
- -Pericarditis
- -Adrenal gland involvement
- -Genitourinary
What three things do you need to show infected with TB but not infectious?
- PPD
- No symptoms of infection
- No imaging findings of active infection
What is the initial test ordered for TB?
Chest radiograph
Different findings of TB on chest xray
- Reactivation: apical (upper) lobes
- Primary: middle/lower lobe
- Miliary: millet-seed lesions
What other diagnostics can be done for TB?
- Sputum cultures: at least 3 samples on 3 consecutive days
- NAAT: more sensitive than sputum smears
Management of active TB
-Initiate 4 drug therapy: RIPE for 2 months followed by 4 months of RI (6 month duration)
Side effects of TB drugs
- Rifampin: orange colored secretions
- Isoniazid: Hepatitis, peripheral neuropathy
- Pyrazinamide: Hepatitis, Hyperuricemia
- Ethambutol: Optic neuritis, red/green color blindness
What should be given with Isoniazid?
Pyridoxine (B6)
Treatment for Latent TB
-INH + Pyridoxine x 9 months
What drug can be given in TB instead of Ethambutol?
Stretomycin
However, what are the side effects of Streptomycin?
Ototoxicity (CN8)
Nephrotoxicity
Any positive PPD should be followed by a ____ to rule out active disease
CXR
What are the reaction sizes to be positive with a PPD test for TB?
> 5 mm: HIV or immunosuppressed, close contact with person with active TB, CXR with old/healed granuloma
> 10 mm: healthcare workers, all other high risk people
> 15 mm: Everyone else, no known risk factors
What is parrot fever (Psittacosis)?
infection with Chlamydophila Psittaci due to exposure to infected birds
Treatment for Psittacosis
Tetracyclines (tetracycline, doxycycline, minocycline)
What happens in silo filler disease?
It is a hypersensitivity pneumonitis from nitrogen dioxide gas exposure released from plant matter stored in silos as they ferment (gas is converted to nitric acid in the lungs when inhaled)
Management of Silo Filler Disease
- Occupational reduction of exposure
- Entering at the top of the silo
- Use of N95 masks
Risk factors for Berylliosis
- Aerospace
- Electronics
- Ceramics
- Tool and dye manufacturing
- Jewelry making
- Fluorescent light bulbs
(Exposure to nickel, aluminum, and copper)
Treatment for Berylliosis
- Corticosteroids, oxygen
- Methotrexate if corticosteroids fail
Coal Worker’s Lung is a lung disease from inhalation of coal dust particles. What is Caplan Syndrome?
-Coal worker pneumoconiosis + Rheumatoid Arthritis
Diagnostics for coal workers lung
- Chest radiograph: small nodules in upper lung and hyperinflation of lower lobes in an obstructive pattern
- PFT: obstructive pattern
- Lung biopsy: dark, black lungs
Management for coal worker’s lung
Symptomatic management
Risk factors for sarcoidosis
-Females, AA, Northern Europeans
Symptoms of Sarcoidosis
- 50% asymptomatic
- Dry nonproductive cough, dyspnea, rales
- Erythema nodosum (on shins), lupus pernio (on face)
- Hilar LAD (near xiphoid process)
What is Lofgren Syndrome?
-Erythema Nodosum + Bilateral hilar LAD + polyarthralgias with fever
best initial test for sarcoidosis
CXR
What other diagnostics can be done for sarcoidosis?
- PFT: restrictive in pattern
- Tissue Biopsy: Most accurate (noncaseating granulomas)
- Labs: elevated ACE levels
Treatment for sarcoidosis
- Asymptomatic: observation (spontaneous remission in 2 years in most cases)
- Symptomatic: oral corticosteroids
- Methotrexate, Hydroxychloroquine for skin lesions
What two things that are associated with Sarcoidosis are associated with a poorer prognosis?
- Interstitial lung disease
- Lupus pernio
PCP PNA is the most common opportunistic infection in HIV patients with a CD4+ < ____
200
Clinical manifestations of PCP PNA
- Dyspnea on exertion (MC)
- Fever
- Nonproductive cough
- Oxygen desaturation with ambulation!!!
CXR for PCP PNA
-Diffuse bilateral interstitial infiltrates
Labs for PCP PNA
-Increased LDH
What is the definitive diagnostic for PCP
Lung biopsy (rarely done though)
Treatment for PCP PNA
- Bactrim x 21 days
- If HIV + –> add Prednisone if hypoxic
What medications should you give if the patient has PCP and a sulfa allergy?
- Dapsone-Trimethoprim
- Clindamycin-Primaquine
What fungus causes PCP?
Pneumocystic Jirovecii
