pulmonary MAC, Resp Influenza Flashcards
How do you diagnose NTM lung disease?
(1) Clinical criteria (pulmonary symptoms, nodular or cavitary opacities on cxr, high rest CT showing multifoccal bronchiectasis with multiple small nodules AND exclusion of other diagnoses. (2) microbiologic - positive culture from 2 separate exported samples (or AFB smears/cultures) OR BAL positive culture (3) histo features on biopsy + 1 sputum/bal positive for NTM
what are the 2 radiographic types of pulmonary NTM?
fibrocavitary disease (cavities, fibrosis, plueral involvement) or nodular bronchiectatic disease (multifocal bronchiectasis with small<5mm nodules)
what is the general initial treatment of MAC lung disease?
macrolide (azithromycin/clarifthromycin), rifamycin (rifampin or if hepatoxocitiy, rifabutin), and ethambutol
what is the general treatment for MAC in mild to moderate nodular bronchiectatic disease?
azithromycin (500mg 3x/week), rifampin 600mg 3x/week, and ethambutol (25mg/kg 3x/week)
what is the general treatment for MAC fibrocavitary disease/severe disease
azithromycin (250-500mg) daily, rifampin 600mg daily, ethambutol (15mg/kg daily) + amikacin (10-15mg/kg 3x week for the first 8-16 weeks of therapy provided MIC<64)
how would you treat a macrolide resistant infection based on american guidelines?
ethambutol, rifampin, clofazimine (synergy with amkiacin) with 2-6 months of amikacin 3x/week
what are the British thoracic guidelines for severe MAC treatment?
rifampin, ethambutol, aminoglycoside, + FQ/isoniazid
what do you need to test for prior to initiating therapy in MAC infection?
CBC, CMP, EKG (QT interval), audiogram (macrolide/aminoglycoside), opthomalogy (ethambutol), baseline CT scan
how long do you treat MAC lung infection?
until all sputum cultures negative for at least 12 months. Sputum conversion takes 3-6 months for conversion, so typical treatment time is 15-18 months
what agent can you use if intolerant to rifampin in MAC infection?
clofazimine
when is surgery useful for NTM lung disease?
localized disease (especially upper lobe cavity disease), drugs fail to convert sputum cultures after 6 months of treatment, cannot tolerate medical therapy and macrolide-resistant MAC lung disease
MAC patient has GI intolerance tox? ?
macroline, ethambutol, rifampin products, FQ or clofazimine
MAC patient with abnormal LFTs tox?
macroline, FQ, rifampin products
MAC patient with low WBC tox?
rifampin product
MAC patient with decreased auditory function tox?
amingolycosides/azithromycin
MAC patient with decreased renal function tox?
aminoglycoside
what are the most common MAC species to cause lung disease?
m.avium, M. intracelulae, M. chimaera
what are the 5 typical cxr patterns in a pneumonia?
lobar pattern (strep pneumo, HIb, legionella), bronchopneumonia pattern (staph aureus, gram negatives, mycoplasma, chlamydophilia, viral), interstitial pattern (influenza, CMV, pneumocystis, miliary Tb), lung abscess (anaerobes, S.Aureus), and nodular (right sided endocarditis, histo, coccidio, cryptococcus)
what is considered a poor sputum sample?
More than 10 squamous epithelial cells per lower power field (more from nasopharynx)
what is considered a good sputum sample?
More than 25 PMNs per lower power field (tracheobronchial tree)
what does a predominance of mononuclear cells on sputum gram stain indicate/
mycoplasma, chlamydophilia or a viral infection
what viral influenza disease associated with poultry from china?
H7N9
Illness script associated with H5N1
poultry, 2-8 day incubation, with respiratory failure, bilateral infiltrates, and diarrhea. Clues: Egypt, vietnam, indonesia
how is influenza transmitted?
1-4 day incubation, with shedding 5-7 days after illness onset, with large droplets up to 6 feet.
what are the severe complications of influenza?
- Exacerbation of underlying illness: COPD, asthma, CHF
- Ischemic heart disease - ecologic association
- Viral pneumonia: severe hemorrhagic pneumonitis
- Secondary bacterial infection - Strep pneumo, GAS, S.Aureus
- TSS - Staph and GAS
when do you prescribe antivirals for influenza?
anyone with suspected regardless of the duration of symptoms
key points for influenza antiviral tx for pregnant women?
empiric antiviral should be offered up to 2 weeks postpartum and pregnant women
treat for 5 days
initiating treatment within 2 days results in improved outcomes
pregnancy is not a contraindication
key points for influenza antivirals?
- antivirals not effective after 48 hours in outpatient with uncomplicated flu.
- They are effective in hospitalized patients
- Double dose oseltamivir not effective
- Influenza B viruses have intrinsic resistance to rimantidine and amantadine
How does oseltamivir occur?
specific point mutation H275Y in H1N1 virus including H3N2 and H7N9
what can you use if this is oseltamivir resistant?
Can use zanamivir
outside of oseltamivir, what other antivirals for influenza can you use?
peravirmir for acute uncomplicated and zanamivir for resistant.
What are key points to remember about zanamivir?
- inhaled zanamivir can exacerbate asthma
- not approved under 5 years old
- commercial formulation ahs caused ventilator failure problems
when can you not prescribe influenza PEP?
should not be given 48 hours from exposure because prophylaxis can increase selection for resistant viruses.
what can you do if a patient has an egg allergy for influenza vaccine?
- can still give the vaccine
- Can also give recombinant influenza vaccine (RIV, Fluboc) that does not contain egg protein
- Those with anaphylaxis to egg, consultation with allergist no longer recommended
what questions do you need to ask to give influenza vaccine in patient with reported egg allergy?
- can person eat lightly cooked egg (scrambled) without reaction?
- after eating eggs, only experience hives?
what is the protocol for reported egg allergy anaphylaxis when giving the influenza vaccine?
administer any age-appropriate vaccine, observe for reaction for 30 minute in a setting able to recognize and treat allergic reaction
what suggests a viral pneumonia?
gradual onset in the winter affecting older people with wheezing, leukopenia, and cxr showing the interstitial, multilobar picture.
what respiratory viruses can affect mortality in HSC transplant patient?
PAIR-Hcr
- Parainfluenza
- Adenovirus (cidofovir)
- Influenza
- RSV (IVIG, ribavarin)
- hMPV
- Coronavirus (?)
- Rhinvorus (little)
basics of adenovirus?
- DS DNA
- associated with URI, LTRI, conjunctivitis, gastroenteritis, hepatitis, hemorrhagic cystitis,
- closed settings
- no seasonality
- Cidofovir
What requires droplet precautions?
SPIDERMAN
- Scarlet fever, strep pharyngitis, sepsis
- paravovirus B19, pneumonia, pertussis
- Influenza
- Diptheria
- Epiglottis
- Rubella
- Mumps, meningitis, mycoplasma, meningineal pneumonia
- An- adenovirus
basics of RSV?
- nonsegmented Single-stranded negative sense RNA virus
- MCC of LRTI in children
- a common cause of URI in adults
- transmitted by droplet and contact
- December - April
what are the basics of RSV? (5)
- long incubation period 2-8 days
- Dx by antigen (DFA, PCR)
- no indication for palivizumab
- inhaled ribavarin controversial
- anecdotal use of oral ribavarin in transplant patients
basics of human metapneumovirus?
- nonsegmented single strand negative sense RNA
- causes URI, LRTI
- winter/spring in temperate climates
- mortality among HSC transplant similar to RSV
basics of parainfluenza virus?
spring and fall seasonality
causes URI, bronchiolitis, croup, pneumonia in children
adults have URI, cough, and viral pneumonia
parainfluenza 3 is more severe
can be associated with COP (all resp. viruses in transplant)
vector for MERS coronavirus?
the closest relative is bat, camels play role
Hantavirus clue? phases?
Yosemite, rodents that transmit through aerosolized excreta, particularly urine
incubation 4-30 days
Febrile phase
Cardiopulmonary phase (pneumonia then ARDS)
diuretic phase
convalescent phase
critical clues to hantavirus cardiopulmonary phase?
thrombocytopenia, hemoconcentration, left shift with atypical lymphs, elevated PT, abnormal LFTs
what is chlamydia psittaci microbiology states?
Extracellular: infectious elementary body
Intracellular: replicative
how is chlamydia psittaci transmitted?
bird feces or respiatory secretions–>aerosol–> human in the elementary body stage
what clue is specific to chlamydia psittaci?
headache, temperature/pulse dissassociation.
what is the preferred/alternative treatment for chlamydia psittaci? how would you diagnose it?
- Preferred: doxycycline
- Alternatives: macrolides, FQ
- Dx via sputum is the best
what clinical features are useful for C.psittaci?
cough, headache, minimal confusion, minimal cxr change, <48 hour response doxycyline
what clinical features are useful for C.pnuemoniae?
cough, sputum, sore throat, headache, minimal cxr change
what clinical features are useful for M.pneumoniae?
cough, sputum, cxr more than symptoms, prompt doxycyline response
what clinical features are useful for legionella pnuemophilia?
sputum, multifocal cxr change, low sodium
what are the acute findings of nitrofurantoin pneumonitis?
fever, dyspnea, cough, presenting like an atypical pneumoniae
8 days after starting drug
what are the lung radiological findings in acute & subacute nitrofurantoin pneumonitis? what does it progress to?
- ground glass findings may have eosinophilia (peripheral or BAL)
- interstitial pneumonitis, bronchiolitis obliterans, mixed ground glass, fibrosis, conslidation
how do you acquire legionella pnuemonia?
aerosolization, drinking water (aspiration)
where is legionella found?
environmental water pathogen, lakes, ponds, AC
what can legionella cause?
pneumonia (2-10 days after exposure, <5%)
pontiac fever (febrile, flu-like illness 24-28 hours, no infiltrates, epidemic), 90% attac k rate)
what do you see on legionella culture and medium?
small, pearly white colonies on BCYE agar (agar looks chocolate)
What is loefflers syndrome clinical features? cause?
fever malaise
mild/none respiratory symptoms
migratory pulmonary infiltrates
peripheral eosinophilia
Caused by the migration of parasites
how would you diagnose and tx loffler’s syndrome?
Dx: larvae in respiratory specimen, stool O&P
tx: anti-helminths, corticosteroids
what helminthic causes of acute or chornic eosinophilic pneumonia?
Migration (lofflers):
- Ascaris
- hookworms
- strongyloides
Lung invasion - paragonimiasis
what are the tropical pulmonary eosinophilia causes?
- wucheria bancrofti
- brugia malayi
what is ABPA minimal criteria?
The presence of asthma and/or cystic fibrosis,
a positive skin test to Aspergillus sp., an IgE > 417 IU/mL (or kU/L),
an increased specific IgE or IgG Aspergillus sp. antibodies
presence of infiltrates on a chest X-ray
what is ABPA?
exaggerated response of the immune system (a hypersensitivity response) to the fungus Aspergillus
characteristics of mycoplasma pneumoniae?
“walking pneumonia” - CXR looks worse than patient
Extrapulmonary manifestations
- SJS
- Erythema multiforme
- Hemolytic anemia
- hepatitis
- CNS: encephalitis, meningitis
How would you diagnose mycoplasma pneumoniae on diagnostics?
Culture is gold standard
cold agglutin titers (50-70%)
molecular and serology
what are risk factors for TB infection (latent)?
- Exposure to TB
- TB endemic area
- homelessness/incarceration
- healthcare/corrections work
- IVU
RIsk factor for progression to TB disease (active)?
- Recent TB infection (latent)
- HIV infection
- TNF-alpha inhibitors
- immunosuppresion
- DM2/ESRD
- Silicosis
- Cancers
Extrapulmonary manifestations of active TB?
BCLAP
- Bone and joint (vertebral)
- CNS (meningitis, focal tuberculomas)
- Lymphadenitis
- Abdominal/pelvic
- Pleural
what tests can diagnose active TB?
NAAT (negative does not rule out)
Mycobacterial culture (slow 3-6 weeks, gold standard)
what is first line treatment for active TB disease?
- daily RIPE
- RIPE x 2 months (induction)
- then, RI for 4 months (continuation)
- Add pyridoxine (vitamin b6) to prevent INH neurotoxicity
- Daily tx more efficacious than intermittent
- in HIV positive, intermittent tx associated with RIF resistance
When do you extend TB treatment post 6 months?
pulmonary cavitary disease with sputum cultures + 2 months (add 3 months, total 6-9)
Bone and jonit (add 3 months, total 6-9)
CNS (total 9-12)
which TB drug is least associated with liver toxicity?
Ethambutol
what special considerations do you need to keep in mind with active TB disease and HIV positive patients?
- lung cavitation may be absent in advanced immunosuppression
- Risk for smear-negative pulmonary TB
- extrapulm TB and dissemination
- do not use rifampin with PIs
when to start ART in patient with active TB disease?
CD4<50 - within 2 weeks of starting TB tx
CD4>50, within 8 weeks of starting TB tx
Pregnant women - start immediately (maternal health and PMTCT)
when do you start TNF alpha inhibitors in a patient that tests positive for latent TB?
If LTBI, initiate treatment prior to starting anti-TNF
optimal duration of delay unknown (some say 2-8 weeks)
what are the 3 treatment regimens for LTBI?
- isoniazid daily for 9 months (9 INH)
- Isoniazid plus rifapentine once weekly x 3 months
- alternative if cannot tolerate INH or suspicion for INH-resistance, rifampin daily x 4 months
what are the complications of BCG immunotherapy for bladder cancer? tx?
- granulomatous prostatitis, pneumonitis, hepatitis,
- Tx: inherent resistance to PZA, treat with rifampin + INH+ ethambutol
In which patients would a greater/equal be considered positive in LTBI than 5mm?
- HIV
- recent TB contact
- CXR with fibrotic changes
- organ transplantation
- TNF alpha antagonists
- prednisone>15mg x 1 month
In which patients would a greater/equal be considered positive in LTBI than 10mm?
- Recent arrival from TB endemic area
- IVU
- HCW
- children<5 years olds
- Medical conditions: transplant, cancer, ESRD, DM2, gastrectomy or small bowel bypass
what can cause a false positive T-IGRA?
M.kanasii and M.Marinum
NTM disease for pulmonary organisms?
- MAC
- M.Kansasii
- M.xenopi
- M.abscessus
- M.malmoense
NTM disease that hits skin and soft tissue?
- MAC
- M.marinum
- M.Abscessus
- M.chelonae
- M.fortuitum
- M.Kansasii
- M.ulcerans
what organisms can be disseminated MAC disease?
- MAC
- M.kansasii
- M.abscessus
- M.chelonae
- M.haemophilum
Mycobacterial Association of corneal disease and post-plastic surgery?
M.chelonae
Mycobacterial Association of healthcare/hygiene associated outbreaks?
- M.chelonae
- M.fortuitum
- M.abscessus
Mycobacterial Association of line infection?
M.mucogenicum
Mycobacterial Association of HIV?
- MAC
- M.kansasii
- M.genavense
- M.haemophlium
Mycobacterial Association of tropical setting?
M.ulcerans (buruli ulcer)
Mycobacterial contaminant
M.gordonae
noncommunicable NTM exception?
M.massilense in CF
Mycobacterium associated with pseudo-outbreaks?
- M.immunogenum
- M.simiae
Mycobacteria that cross-reactions with IGRA?
- M.szulgai
- M.kansasii
- M.marinum
Mycobacterium associated with aspiration?
M.fortuitum
Mycobacterium associated with fish and fish tanks?
M.marinum
what are the two types of MAC pulmonary disease presentations?
- Older male, smoker, COPD with an apical cavity or fibronodular disease, more rapidly progressive
- Older female, “lady windermere” where you see scoliosis, nodular and interstitial nodular infiltrate, bronchiectasis RML, bronchiolitis, slow and progressive
what are pulmonary NTM risk factors?
- Underlying structural abnormalities
- exposure/transmission - soil, hot tubs
- Immunosuppressives
how would you treat pulmonary M.kansasii therapy? key characteristics?
- like TB
- thin-walled upper lobe cavities
- treat with RIF, INH, EMB with RIF as key drug
- treat 12 months from culture negativity
How do you generally treat pulmonary M.abscess? (no specific agents)
3-4 drugs for 18-24 months with 4-6 months suppressive therapy
cure is rare
more rapid progression than MAC
How do you specifically treat for M.abscessus?
- parenterally with tigecycline, amikacin, imipenem, cefoxitin
- oral agents: clofazimine, linezolid, moxifloxacin
- Surgical resection
how do you treat post-plastic surgery M.chelonae?
- remove foreign body
- 4-6 months of therapy based on susceptibilities
*
how do you treat M.marinum?
- 2 agents x 3-4 months
- Macrolides, sulfonamides, doxycycline, rifampin, ethambutol
how do you treat nail salon furunculosis? most common mycobacterium?
- M.fortuitum
- 4 months of FQ and/or doxycycline
how do you treat tattoo associated M.chelonae?
- 2-3 months of oral therapy based on susceptibilities
- 1-2 agents, almost always a macrolide
what is the best drug used to treat M.chelonae?
tobramycin
what is the best drug used to treat M.fortuitum?
bactrim, doxy
what is the length of treatment for disseminated M.chelonae and M.fortuitum?
3 drugs (including 1 IV) x 4-6 months
what parenteral drugs do you use for M.chelonae and M.fortuitum?
aminoglcyosides, imipenem, cefoxitin, tigecycline
what oral drugs are used for M.chelonae and M.fortuitum treatment?
macrolides, FQ. Use linezolid for M.chelonae
what are the two types of leprosy disease?
Paucibacillary and multibacillary
characteristics of paucibacillary leprosy disease?
- MC form - tuberculoid
- bacillary load<1 million
- Skin biopsy: AFB negative
- <5 skin lesions
Characteristics of multibacillary leprosy disease?
- lepromatous
- massive bacillary load
- skin biopsy: floridly positive for AFB
- >5 skin lesions
what is PB leprosy treatment?
- dapsone 100mg daily
- rifampin 600mg once monthly
what is MB leprosy treatment?
12 months of
- Dapsone daily
- clofazimine daily
- Rifampin OR clofazimine 1x monthly
footbaths and plastic surgery mycobacterium?
- Footbaths - M.Fortuitum or other RGM
- Plastic surgery - M.chelonae or orther RGM
- RGM = Mycobacterium abscessus, Mycobacterium fortuitum, Mycobacterium chelonae
HIV disseminated MAC that doesn’t grow
think M.genvense
inducible macrolide resistance (erm gene)
M.abscessus
equatorial Africa mycobacterium
M.ulcerans
