Pulm Flashcards
large, centrally located mass with cavitation and mildly enlarged mediastinal lymph nodes
- hypercalcemia
- malignant cells with abundant cytoplasm, intercellular bridges (desmosomes) and keratin pearls, often described as waxy, deeply staining eosinophilic cytoplasmic material
SCC
- can secrete a parathyroid-like hormone as a paraneoplastic syndrome, causing hypercalcemia
MC lung cancer in nonsmokers
- manifests at the periphery of the lungs
- irregular mucin-producing glands invading fibrous stroma
adenocarcinoma
- mutation in EGFR
aggressive subtype of lung cancer that almost always arises in patients with a smoking history and typically as a centrally located mass
- paraneoplastic: Cushings, SIADH, or Lambert-Eaton syndrome
- Malignant cells with scant cytoplasm, nuclear molding, and crush artifact
small cell lung carcinoma
bilateral hilar LAD
- noncaseating granuloma
- elevated ACE and Ca
sarcoidosis
increased airway resistance, which causes decreases in FEV1, FVC, and the FEV1/FVC ratio
- resistance is especially great during expiration, causing an increased RV (air get’s trapped), and increased TLC
obstructive lung disease, COPD
patients have trouble expanding their lungs during inspiration and, as a result, will manifest decreases in TLC, FEV1, FVC
- degree of FEV1 decrease is sometimes less than that of the FVC so FEV1/FVC ratio may be increased/NL
restrictive lung disease, idiopathic pulmonary fibrosis
which TB med is notorious for increasing uric acid levels and causing gout?
pyrazinamide
- antimicrobial that inhibits the fatty acid synthetase I (FASI) enzyme of M. tuberculosis
don’t forget: thiazides, aspirin, and niacin also precipitate gout
does hyperventilation cause respiratory acidosis or alkalosis?
respiratory alkalosis
- less O2 in air (high altitude) -> body increases ventilation -> decreasing the arterial PCO2 (alkalosis)
- kidneys will compensate by excreting more bicarb (low serum bicarb)
what effect does standing up have on ventilation of the lungs?
ventilation decreases at the apex (gravity draws blood downward)
- diameter of the alveoli increases at the apex with standing because gravity causes greater traction on the alveoli
destruction of lung elastic tissue, mostly by neutrophils. This decreases elasticity, and thus increases compliance.
COPD
- the lungs become too compliant; thus, it is difficult to exhale (obstructive)
aerobic, facultative intracellular, Gram-negative rods that infect alveolar macrophages once inside the lungs
legionella
Male in 20-30’s, or female 60-70’s w/acute renal failure, proteinuria, and urinary sediments including dysmorphic RBCs, RBC casts, and granular casts
- also have pulmonary sx! MC alveolar hemorrhage -> hemoptysis
rapidly progressive glomerulonephritis (RPGN)
- crescentic glomerulonephritis and anti-GBM antibodies by immunofluorescence
Necrotizing granulomas are a histopathologic hallmark of what?
granulomatosis with polyangiitis (GPA)
- found in the sinuses, lungs, and kidneys
also TB (sarcoidosis is NONcaseating)
affects medium-sized arteries and is strongly associated with hepatitis B and C
polyarteritis nodosa (PAN)
increased or decreased compliance in emphysema
increased comliance
alpha 1-antitrypsin deficiency?
panlobular emphysema
tx for Q fever?
doxycycline
what organism resides in the phagosomes of alveolar macrophages?
- produces a protein that prevents fusion of the phagosome with lysosomes
TB
- Ghon complex of primary TB favors the upper part of the lower lobe and the lower part of the upper lobe
why does secondary TB prefer the right apex?
it has the highest oxygen pressure of all regions
prodrome of fever and fatigue before the onset of lower respiratory symptoms
- N/V/D, bilateral patchy infiltrates
- hyponatremia, elevated hepatic transaminases, and elevated C-reactive protein
legionella
- charcoal yeast agar
- tx is fluoroqunolone
what are the blood gas levels in emphysema?
decreased ventilation: - decreased P02 - increased PC02 causes prolonged *respiratory acidosis* - metabolic compensation by increasing bicarb production
leukocytosis exceeding 50,000/microL
- will see an increase in early neutrophil precursors and bands in the peripheral blood
leukemoid reaction
- severe infection (left shift)
when would you see neutrophilic leukocytosis following treatment of acute exacerbation of COPD?
after prednisone administration
- steroids decrease the migration of polymorphonuclear leukocytes
what is the most common type of amiodarone-induced pulmonary toxicity?
interstitial pneumonitis
- restrictive pattern and a low carbon monoxide diffusion capacity
smoker w/ central mass and mediastinal LAD
- malignant cells with scant cytoplasm, nuclear molding and crush artifact, and coarsely dispersed “salt and pepper” chromatin
small cell lung carcinoma
- look out for SIADH -> hyponatremia
- or Chushing’s sx -> high cortisol d/t ACTH
- or Lambert-Eaton myasthenic syndrome (progressive proximal muscle weakness and oculobulbar findings d/t decreased ACh release from presynaptic terminal)
psammoma bodies and Calretinin(+) in lung?
mesothelioma
- Small, dark blue cells
- Chromogranin A +
- Synaptophysin +
small oat cell carcinoma
- Keratin pearls
- Intracellular bridges
- hypercalcemia (d/t PTHrP)
SCC of lung
what is the MC side effect associated with corticosteroid use, especially in diabetic patients?
hyperglycemia
what short-acting muscarinic blocker is used for the tx of acute COPD exacerbation?
ipratropium (M3 antag)
- look for antimuscarinic side effects (dry mouth, urinary retention, elevated HR)
what side affect is associated with inhaled glucocorticoids?
oral candidiasis
when do type II pneumocytes begin to proliferate?
week 20-22
- respiratory tree development by 24 weeks
- levels of surfactant sufficient to support survival by 26-28 weeks
what is the lymphatic drainage system for the lower extremities, pelvis, abdomen, left pleural cavity, left upper extremity, and left head and neck
the thoracic duct
what is responsible for draining the right side of the thorax, upper limb (including right axilla), head, and neck
the right lymphatic duct
- empties into the junction of the right internal jugular and subclavian veins or the right brachiocephalic vein
when would you see interstitial fibrosis with ferruginous bodies?
- stain positive with Prussian blue
asbestosis
Patient presents with acute hypoxia and dyspnea due to diffuse alveolar damage
- CXR shows bilateral diffuse/patchy infiltrates
ARDS
what increases the risk of developing tuberculosis, secondary to macrophage dysfunction?
- CXR demonstrates multiple small nodules throughout the lung fields
silica dust exposure
chronic upper and lower respiratory infections, recurrent middle ear infections beginning in early childhood, infertility, and situs inversus
Kartagener syndrome aka primary ciliary dyskinesia (AR)
- defect in dyenin
- presents similar to CF except for the situs inversus!
what is the MCC of bronchiolitis in children under 2?
- nasal flaring or use of accessory muscles/retractions
RSV
what is the most frequent cause of the common cold?
rhinovirus
MCC of diarrhea in kids under 5?
reovirus (dsDNA)
Kulchitsky cells
- stain positive for neuroendocrine markers including enolase, chromogranin A, and synaptophysin
Small cell lung cancer
- neuroendocrine -> think of ACTH, SiADH…
what is the MOA of ethambutol?
inhibits arabinosyl transferase
- stops mycolic acid synthesis (cell wall synthesis)
what TB med lowers pH to destroy bacteria?
pyrazinamide
- forms pyrazinoic acid
- can cause liver toxicity, muscle weakness, and increase uric acid -> gout !
- Absent breath sounds on the left
- Hyperresonance to percussion on the left
- Reduced tactile fremitus
- Hypotension due to decreased venous return to the heart and external compression of the heart
- Flattened or inhaled diaphragm due to increased intrathoracic pressure on the right side
- Presence of jugular venous distension due to compressed superior vena cava
tension pneumothorax (on left) - would see mediastinal shift to right
how does a tension pneumo differ from a spontaneous pneumo or atelectasis?
a patient with a spontaneous pneumothorax or atelectasis presents with ipsilateral tracheal deviation because the collapsed lung tissues pulls the structures toward it
Milky fluid withdrawn during a thoracentesis
- caused by disruption of lymphatic drainage either as a result of trauma (such as damage to the thoracic duct during thoracic surgery) or from a medical condition such as lymphoma
chylothorax
- the presence of chyle and increased triglycerides within the pleural space
when would you see elevated adenosine deaminase?
TB
- an ADA level >40 IU/L in a lymphocytic-predominant effusion has a 92% sensitivity and 90% specificity for tuberculosis
when would you see ipsilateral diaphragm elevation and ipsilateral tracheal deviation?
resorption (obstructive) atelectasis
- history of recent surgery, fever, and dyspnea within 48 hours post-op
- absent tactile fremitus ipsilaterally
- inspiratory lag caused by a collapsed lung that does not expand on inspiration
when would you observe increased tactile fremitus?
conditions that consolidate the lung tissue like pneumonia will increase the transmission of sound waves
when would you observe decreased tactile fremitus?
- conditions that decrease sound wave transmission, like pleural effusion and pneumothorax
- conditions that eliminate sound wave transmission, such as obstructive (resorption) atelectasis
cytokine involved in survival, activation and proliferation of CD4 and CD8 T cells
IL2
- Helper T cells secrete IL-2 and interferon (IFN)-γ that allow for the activation of both macrophages and CD8-positive cytotoxic T cells
delayed separation of the umbilical cord, increased circulating neutrophils, and recurrent bacterial infections that lack pus formation
leukocyte adhesion deficiency
- caused by a defect in integrins, proteins used by leukocytes to adhere to a vessel wall during an infection
defect in transportation of proteins
- increased risk of pyogenic infections, giant granules in leukocytes
- albinism, peripheral neuropathy
Chediak-Higashi syndrome
recurrent infections with catalase-positive organisms, including Staphylococcus aureus, Pseudomonas aeruginosa, Burkholderia cepacia, Aspergillus, and Nocardia
Chronic granulomatous disease
- occurs because of a NADP-oxidase deficiency
- patients have poor oxygen-dependent killing systems
what is the tx for anthrax poisoning?
dual antibiotic therapy plus antitoxins such as raxibacumab
why does Lambert-Eaton syndrome cause weakness?
antibodies develop against voltage-gated calcium channels required for ACh release
- leads to proximal muscle weakness, depressed tendon reflexes, and autonomic changes
multisystem granulomatous disorder of unknown etiology
- noncaseating granulomas
- MC in African Americans
- hilar lymphadenopathy, parenchymal lung disease, and/or pulmonary fibrosis
- erythema nodosum (tender nodules on the shins), skin nodules, arthralgias, or uveitis
- elevated ACE
sarcoidosis
- constellation of dyspnea, hypoxia, eye involvement, possible erythema nodosum, and an elevated ACE level is most concerning for sarcoidosis
broad-based budding yeast most likely found in the Southeastern and South-central United States, as well as states along the Mississippi and Ohio River basin
Blastomycosis
acute angle branching mold
- ground glass attenuations surrounding a halo sign in the lungs
aspergillus
found in the Southwestern United States and can cause pneumonia and meningitis
- histology will reveal large spherule with multiple, round endospores
Coccidioides immitis
opportunistic fungal infection that may cause meningitis
- more likely to be found in an immunocompromised host
- narrow-based budding yeast
- commonly associated with pigeon droppings
- india ink staining
Cryptococcus neoformans
one of the fungal mycoses that may cause pneumonia and pneumonitis
- commonly found in the Mississippi and Ohio River valleys (cave spalunking)
- icroscopically, the Histoplasma can be seen within macrophages
histoplasmosis
small vessel vasculitis characterized by positive p-ANCA
- occurs primarily in the lung and heart, resulting in severe asthma attacks -> seen in pts w/hx of asthma
- massive eosinophil invasion of the vessel walls and surrounding tissues
Churg-Strauss aka eosinophilic granulomatosis with polyangiitis
does surfactant increase or decrease surface tension?
decreases surface tension, increasing compliance
- surfactant keeps small alveoli open by decreasing surface tension
is asthma obstructive or restrictive?
obstructive
what type of HsRxn is reactive TB ?
delayed type hypersensitivity reaction (type IV)
- T-cells and macrophages initiate granulomatous inflammation
what is a sign of reactivated tuberculosis?
cavitary lesions
- due to erosion of the granuloma
what are the most common trigger of asthma exacerbations in both children and adults
Respiratory viral infections
when would you see transudate in the lungs?
- clear fliud, low protein, low LDH
Transudate can result from congestive heart failure, nephrotic syndrome, and hepatic cirrhosis
when would you see exudate in the lungs?
- Cloudy fluid with high protein and LDH
Exudate can result from malignancy, pneumonia, collagen vascular disease, and trauma
fungus with rounded, single-celled, tuberculate macroconidia formed on short, hyaline, undifferentiated conidiophores
- hilar LAD
- immunocompromised pts may present with fever, headache, malaise, myalgia, abdominal pain, and chills, progressing to severe dyspnea resulting from diffuse pulmonary involvement
histoplasma
- seen within macrophages (small bois)
soil fungus native to the San Joaquin Valley of California
coccidiomycosis
hypercapnia
retention of CO2 -> respiratory acidosis
In addition to a SABA, what is the next additional medication for the chronic management of asthma and allergic symptoms?
montelukast
- leukotriene receptor antag blocks LTD4 and LTC4
what is tx for preterm neonate with RDS?
exogenous surfactant
- CPAP, or intubatation/mechanical ventillation
college student presents with malaise, headache, and muscle pain
- nonproductive cough and sore throat
- extensive diffuse infiltrates in both lungs
atypical pneumonia caused by Mycoplasma pneumoniae
what is first-line treatment for mild persistent asthma?
inhaled steroid: beclomethasone
- can also add montilukast
MCC of community-acquired pneumonia?
strep pneumo
currant jelly sputum and Maconkey agar?
klebsiella
Recurrent pulmonary infections in patients with CF are most likely due to what?
Pseudomonas aeruginosa
- aerobic, oxidase-positive, Gram-negative rod noted for its ability to produce a green pigment
asthma, chronic rhinosinusitis with nasal polyps, and acute upper and lower respiratory tract reactions following aspirin ingestion
- what is it called and what could have prevented a flare up?
aspirin-exacerbated respiratory disease
- Aspirin-induced hypersensitivity results from poorly regulated arachidonic acid metabolism leading to enhanced leukotriene production -> give leukotriene antags (montelukast, zafirlukast, pranlukast)
NOTE: albuterol is short acting (rescue med), will never be the answer to what med could have prevented
what is the MC manifestation of Q fever?
endocarditis
- look out for pt w/ weakened immune response, preexisting condition (rheumatic heart dz)
what is the virulence factor of Yersinia pestis that is antiphagocytic and keeps the alveolar macrophages from phagocytizing the organisms when delivered to the lungs?
protein capsule
what virulence factor helps Yersinia resist phagocyte killing and suppresse cytokine production by white blood cells to lower the immune reaction?
type III secretion system
what virulence factor binds to another bacterial protein, called protective antigen, that helps it evade the immune system by killing macrophages?
- is a Zn2+-dependent endoprotease that clips off the N-terminus of mitogen-activated protein kinase kinases
- Inhibiting these host cell kinases leads to altered signaling pathways and apoptosis of the host cells
lethal toxin of B. anthracis
functional spleen increases the risk for infections with encapsulated bacteria, including what?
Streptococcus pneumoniae and Neisseria meningitidis
- also Salmonella typhi
what is the drug class of choice for COPD?
Muscarinic antagonists: ipratropium, tiotropium
- Methylxanthines (theophylline, aminophylline) are not widely used anymore d/t adverse effects: cardiac arrhythmia, CNS stimulation, GI distress (structure is similar to caffeine)
what two bacteria are associated with hot tubs?
legionella and pseudomonas
NOTE: legionella causes pulmonary problems (inhaled water droplets), white pseudomonas causes skin infections (folliculitis)
what is the growth medium for pseudomonas?
Maconkey agar
what is the growth medium for bordatella pertussus?
Bordet-Gengou agar
what is the growth medium for Mycoplasma pneumoniae?
eaton agar
blood pH at high altitude?
respiratory ALKALOSIS -> increased pH
- low atmospheric O2 -> increased ventilation -> decreases PaCO2 = alkalosis
what effect does hypoxia have on the lungs
causes pulmonary vasoconstriction
young child, 3-5 days of high fever, strawberry tongue, lymphadenopathy, and desquamation of hands and feet
Kawasaki
- treated with high dose aspirin and IV IgG
what effect does CO poisoning have on O2 levels?
CO outcompetes O2 for Hgb binging spot
- less O2 -> cells shift to anaerobic metabolism -> making H+ (lactic acidosis)
what is the normal V/Q ratio in the lung apex?
3
what is the normla V/Q ratio in the lung base?
.6
how would a PE change the V/Q ratio in the lungs?
it would increase the V/Q ratio
- perfusion (Q) decreases
- when the denominator gets smaller, ratio gets higher
what is the treatment for an acute asthma attack?
- supplemental oxygen
- short acting β-2 agonists (albuterol)
- IV steroids (methylprednisolone)
what asthma med is only used for maintenance of persistent asthma?
long acting β-agonist (salmeterol)
what are all the inflammatory mediators essential in recruiting leukocytes to the site of an infection?
TNF-a, IL1, IL8, bacterial products
what causes RSV in a premie?
less surfactant -> more surface tension -> instability of the lung during expiration -> less compliance
pt has trasudative plural effusion
- you’ve ruled out kidney and liver causes, what test do you need to confirm CHF dx?
echo
young/college student with malaise, HA, muscle pain, sore throat, non productive cough
- CXR shows extensive diffuse infiltrates
ALWAYS think M. pneumoniae (atypical pneumonia)
- mild sx can last up to 4 weeks
what lung lobe silhouettes the right heart border
- onlateral radiograph is confirmed to be anteriorly locate
right middle lobe
- right lower lobe is more posterior than the right middle lobe*
what is the correct placement for a needle decompression for tension pneumo?
second intercostal space along the midclavicular line
NOTE: needle decompression is always followed by chest tube placement as soon as the patient is stabilized
what is the correct placement for a chest tube?
fourth intercostal space along the midaxillary line
bacterium that resist decolorization by acids
- military opacities on CXR
TB
what does a B6 deficiency lead to?
muscle weakness, peripheral neuropathy, uncoordinated movements
what do mast cells contain?
basophilic granules
mast cell stabilizer used to control inflammation in asthma and to prevent exercise-induced bronchospasm
- inhibits the degranulation of mast cells, which prevents the release of inflammatory modulators such as histamine and leukotrienes
cromolyn sodium
- used to prevent bronchoconstriction and inflammation, but it does not provide relief for acute symptoms
large, round, densely staining nucleus with minimal amounts of pale cytoplasm
lymphocytes (B cells, T cells, NK cells)
what antineoplastic is known to cause dilated cardiomyopathy
- inhibits topoisomerase II (causing DNA strand breaks)
- tx for Hodgkin’s lymphoma, breast/lung/ovary tumors, and sarcomas and myelomas
doxorubicin
vasopressin receptor antagonist which prevents the action of ADH in the collecting duct
- used to treat SiADH in small cell lung carcinoma
conivaptan
what is erythema nodosum and when would you see it?
tender nodules on bilateral shins
- seen in sarcoidosis, TB and IBD
what two meds can be given to kid with croup in severe respiratory distress?
- corticosteriods
- racemic epinephrine -> utilized to reduce upper airway swelling until the corticosteroids can kick in
what causes hypervitaminosis D?
sarcoidosis
- noncaseating granulomas have the ability to secrete 1,25 vitamin D, potentially causing hypercalcemia and hypervitaminosis D in affected individuals
what does low partial pressure of oxygen in the lung cause?
hypoxic vasoconstriction
- shifts blood away from poorly ventilated regions of the lung to well-ventilated regions of the lung
dipalmitoylphosphatidylcholine (lecithin) is a major component of what?
surfactant
how do you know when a fetus’ lungs have reached maturity?
the amniotic fluid lecithin/sphingomyelin ratio reaches 2:1 (around 36 weeks)
fever, night sweats, and cheese-like material in hilar lymph nodes?
TB
- cheese in LN = caseous necrosis
what is the MCC of tuberculosis-like symptoms in patients with AIDS the CD4 count drops below 50 cells/mm3
M. avium
industrial exposure
- eggshell calcifications
- small round nodules in upper lobes
silicosis
industrial exposure
- ferruginous bodies
- interstitial fibrosis in lower lobes
asbestosis
young pt w/ cough, weight loss, fine crackles
- XCR shows interstitial reticular opacities
- restrictive pattern
- **lymphocytic infiltrate with NONcaseating granulomas*
hypersensitivity pneumonitis- similar to idiopathic pulmonary fibrosis, but pt is younger, and has granulomas
