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General ID 2019 > pulmonary MAC, Resp Influenza > Flashcards

pulmonary MAC, Resp Influenza Flashcards

1
Q

How do you diagnose NTM lung disease?

A

(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

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2
Q

what are the 2 radiographic types of pulmonary NTM?

A

fibrocavitary disease (cavities, fibrosis, plueral involvement) or nodular bronchiectatic disease (multifocal bronchiectasis with small<5mm nodules)

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3
Q

what is the general initial treatment of MAC lung disease?

A

macrolide (azithromycin/clarifthromycin), rifamycin (rifampin or if hepatoxocitiy, rifabutin), and ethambutol

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4
Q

what is the general treatment for MAC in mild to moderate nodular bronchiectatic disease?

A

azithromycin (500mg 3x/week), rifampin 600mg 3x/week, and ethambutol (25mg/kg 3x/week)

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5
Q

what is the general treatment for MAC fibrocavitary disease/severe disease

A

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)

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6
Q

how would you treat a macrolide resistant infection based on american guidelines?

A

ethambutol, rifampin, clofazimine (synergy with amkiacin) with 2-6 months of amikacin 3x/week

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7
Q

what are the British thoracic guidelines for severe MAC treatment?

A

rifampin, ethambutol, aminoglycoside, + FQ/isoniazid

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8
Q

what do you need to test for prior to initiating therapy in MAC infection?

A

CBC, CMP, EKG (QT interval), audiogram (macrolide/aminoglycoside), opthomalogy (ethambutol), baseline CT scan

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9
Q

how long do you treat MAC lung infection?

A

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

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10
Q

what agent can you use if intolerant to rifampin in MAC infection?

A

clofazimine

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11
Q

when is surgery useful for NTM lung disease?

A

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

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12
Q

MAC patient has GI intolerance tox? ?

A

macroline, ethambutol, rifampin products, FQ or clofazimine

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13
Q

MAC patient with abnormal LFTs tox?

A

macroline, FQ, rifampin products

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14
Q

MAC patient with low WBC tox?

A

rifampin product

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15
Q

MAC patient with decreased auditory function tox?

A

amingolycosides/azithromycin

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16
Q

MAC patient with decreased renal function tox?

A

aminoglycoside

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17
Q

what are the most common MAC species to cause lung disease?

A

m.avium, M. intracelulae, M. chimaera

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18
Q

what are the 5 typical cxr patterns in a pneumonia?

A

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)

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19
Q

what is considered a poor sputum sample?

A

More than 10 squamous epithelial cells per lower power field (more from nasopharynx)

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20
Q

what is considered a good sputum sample?

A

More than 25 PMNs per lower power field (tracheobronchial tree)

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21
Q

what does a predominance of mononuclear cells on sputum gram stain indicate/

A

mycoplasma, chlamydophilia or a viral infection

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22
Q

what viral influenza disease associated with poultry from china?

A

H7N9

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23
Q

Illness script associated with H5N1

A

poultry, 2-8 day incubation, with respiratory failure, bilateral infiltrates, and diarrhea. Clues: Egypt, vietnam, indonesia

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24
Q

how is influenza transmitted?

A

1-4 day incubation, with shedding 5-7 days after illness onset, with large droplets up to 6 feet.

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25
Q

what are the severe complications of influenza?

A
  • 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
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26
Q

when do you prescribe antivirals for influenza?

A

anyone with suspected regardless of the duration of symptoms

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27
Q

key points for influenza antiviral tx for pregnant women?

A

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

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28
Q

key points for influenza antivirals?

A
  • 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
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29
Q

How does oseltamivir occur?

A

specific point mutation H275Y in H1N1 virus including H3N2 and H7N9

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30
Q

what can you use if this is oseltamivir resistant?

A

Can use zanamivir

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31
Q

outside of oseltamivir, what other antivirals for influenza can you use?

A

peravirmir for acute uncomplicated and zanamivir for resistant.

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32
Q

What are key points to remember about zanamivir?

A
  • inhaled zanamivir can exacerbate asthma
  • not approved under 5 years old
  • commercial formulation ahs caused ventilator failure problems
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33
Q

when can you not prescribe influenza PEP?

A

should not be given 48 hours from exposure because prophylaxis can increase selection for resistant viruses.

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34
Q

what can you do if a patient has an egg allergy for influenza vaccine?

A
  • 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
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35
Q

what questions do you need to ask to give influenza vaccine in patient with reported egg allergy?

A
  • can person eat lightly cooked egg (scrambled) without reaction?
  • after eating eggs, only experience hives?
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36
Q

what is the protocol for reported egg allergy anaphylaxis when giving the influenza vaccine?

A

administer any age-appropriate vaccine, observe for reaction for 30 minute in a setting able to recognize and treat allergic reaction

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37
Q

what suggests a viral pneumonia?

A

gradual onset in the winter affecting older people with wheezing, leukopenia, and cxr showing the interstitial, multilobar picture.

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38
Q

what respiratory viruses can affect mortality in HSC transplant patient?

A

PAIR-Hcr

  • Parainfluenza
  • Adenovirus (cidofovir)
  • Influenza
  • RSV (IVIG, ribavarin)
  • hMPV
  • Coronavirus (?)
  • Rhinvorus (little)
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39
Q

basics of adenovirus?

A
  • DS DNA
  • associated with URI, LTRI, conjunctivitis, gastroenteritis, hepatitis, hemorrhagic cystitis,
  • closed settings
  • no seasonality
  • Cidofovir
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40
Q

What requires droplet precautions?

A

SPIDERMAN

  • Scarlet fever, strep pharyngitis, sepsis
  • paravovirus B19, pneumonia, pertussis
  • Influenza
  • Diptheria
  • Epiglottis
  • Rubella
  • Mumps, meningitis, mycoplasma, meningineal pneumonia
  • An- adenovirus
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41
Q

basics of RSV?

A
  • 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
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42
Q

what are the basics of RSV? (5)

A
  • 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
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43
Q

basics of human metapneumovirus?

A
  • nonsegmented single strand negative sense RNA
  • causes URI, LRTI
  • winter/spring in temperate climates
  • mortality among HSC transplant similar to RSV
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44
Q

basics of parainfluenza virus?

A

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)

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45
Q

vector for MERS coronavirus?

A

the closest relative is bat, camels play role

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46
Q

Hantavirus clue? phases?

A

Yosemite, rodents that transmit through aerosolized excreta, particularly urine

incubation 4-30 days

Febrile phase

Cardiopulmonary phase (pneumonia then ARDS)

diuretic phase

convalescent phase

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47
Q

critical clues to hantavirus cardiopulmonary phase?

A

thrombocytopenia, hemoconcentration, left shift with atypical lymphs, elevated PT, abnormal LFTs

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48
Q

what is chlamydia psittaci microbiology states?

A

Extracellular: infectious elementary body

Intracellular: replicative

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49
Q

how is chlamydia psittaci transmitted?

A

bird feces or respiatory secretions–>aerosol–> human in the elementary body stage

50
Q

what clue is specific to chlamydia psittaci?

A

headache, temperature/pulse dissassociation.

51
Q

what is the preferred/alternative treatment for chlamydia psittaci? how would you diagnose it?

A
  • Preferred: doxycycline
  • Alternatives: macrolides, FQ
  • Dx via sputum is the best
52
Q

what clinical features are useful for C.psittaci?

A

cough, headache, minimal confusion, minimal cxr change, <48 hour response doxycyline

53
Q

what clinical features are useful for C.pnuemoniae?

A

cough, sputum, sore throat, headache, minimal cxr change

54
Q

what clinical features are useful for M.pneumoniae?

A

cough, sputum, cxr more than symptoms, prompt doxycyline response

55
Q

what clinical features are useful for legionella pnuemophilia?

A

sputum, multifocal cxr change, low sodium

56
Q

what are the acute findings of nitrofurantoin pneumonitis?

A

fever, dyspnea, cough, presenting like an atypical pneumoniae

8 days after starting drug

57
Q

what are the lung radiological findings in acute & subacute nitrofurantoin pneumonitis? what does it progress to?

A
  • ground glass findings may have eosinophilia (peripheral or BAL)
  • interstitial pneumonitis, bronchiolitis obliterans, mixed ground glass, fibrosis, conslidation
58
Q

how do you acquire legionella pnuemonia?

A

aerosolization, drinking water (aspiration)

59
Q

where is legionella found?

A

environmental water pathogen, lakes, ponds, AC

60
Q

what can legionella cause?

A

pneumonia (2-10 days after exposure, <5%)

pontiac fever (febrile, flu-like illness 24-28 hours, no infiltrates, epidemic), 90% attac k rate)

61
Q

what do you see on legionella culture and medium?

A

small, pearly white colonies on BCYE agar (agar looks chocolate)

62
Q

What is loefflers syndrome clinical features? cause?

A

fever malaise

mild/none respiratory symptoms

migratory pulmonary infiltrates

peripheral eosinophilia

Caused by the migration of parasites

63
Q

how would you diagnose and tx loffler’s syndrome?

A

Dx: larvae in respiratory specimen, stool O&P

tx: anti-helminths, corticosteroids

64
Q

what helminthic causes of acute or chornic eosinophilic pneumonia?

A

Migration (lofflers):

  • Ascaris
  • hookworms
  • strongyloides

Lung invasion - paragonimiasis

65
Q

what are the tropical pulmonary eosinophilia causes?

A
  • wucheria bancrofti
  • brugia malayi
66
Q

what is ABPA minimal criteria?

A

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

67
Q

what is ABPA?

A

exaggerated response of the immune system (a hypersensitivity response) to the fungus Aspergillus

68
Q

characteristics of mycoplasma pneumoniae?

A

“walking pneumonia” - CXR looks worse than patient

Extrapulmonary manifestations

  • SJS
  • Erythema multiforme
  • Hemolytic anemia
  • hepatitis
  • CNS: encephalitis, meningitis
69
Q

How would you diagnose mycoplasma pneumoniae on diagnostics?

A

Culture is gold standard

cold agglutin titers (50-70%)

molecular and serology

70
Q

what are risk factors for TB infection (latent)?

A
  • Exposure to TB
  • TB endemic area
  • homelessness/incarceration
  • healthcare/corrections work
  • IVU
71
Q

RIsk factor for progression to TB disease (active)?

A
  • Recent TB infection (latent)
  • HIV infection
  • TNF-alpha inhibitors
  • immunosuppresion
  • DM2/ESRD
  • Silicosis
  • Cancers
72
Q

Extrapulmonary manifestations of active TB?

A

BCLAP

  • Bone and joint (vertebral)
  • CNS (meningitis, focal tuberculomas)
  • Lymphadenitis
  • Abdominal/pelvic
  • Pleural
73
Q

what tests can diagnose active TB?

A

NAAT (negative does not rule out)

Mycobacterial culture (slow 3-6 weeks, gold standard)

74
Q

what is first line treatment for active TB disease?

A
  • 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
75
Q

When do you extend TB treatment post 6 months?

A

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)

76
Q

which TB drug is least associated with liver toxicity?

A

Ethambutol

77
Q

what special considerations do you need to keep in mind with active TB disease and HIV positive patients?

A
  • lung cavitation may be absent in advanced immunosuppression
  • Risk for smear-negative pulmonary TB
  • extrapulm TB and dissemination
  • do not use rifampin with PIs
78
Q

when to start ART in patient with active TB disease?

A

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)

79
Q

when do you start TNF alpha inhibitors in a patient that tests positive for latent TB?

A

If LTBI, initiate treatment prior to starting anti-TNF

optimal duration of delay unknown (some say 2-8 weeks)

80
Q

what are the 3 treatment regimens for LTBI?

A
  1. isoniazid daily for 9 months (9 INH)
  2. Isoniazid plus rifapentine once weekly x 3 months
  3. alternative if cannot tolerate INH or suspicion for INH-resistance, rifampin daily x 4 months
81
Q

what are the complications of BCG immunotherapy for bladder cancer? tx?

A
  • granulomatous prostatitis, pneumonitis, hepatitis,
  • Tx: inherent resistance to PZA, treat with rifampin + INH+ ethambutol
82
Q

In which patients would a greater/equal be considered positive in LTBI than 5mm?

A
  • HIV
  • recent TB contact
  • CXR with fibrotic changes
  • organ transplantation
  • TNF alpha antagonists
  • prednisone>15mg x 1 month
83
Q

In which patients would a greater/equal be considered positive in LTBI than 10mm?

A
  • Recent arrival from TB endemic area
  • IVU
  • HCW
  • children<5 years olds
  • Medical conditions: transplant, cancer, ESRD, DM2, gastrectomy or small bowel bypass
84
Q

what can cause a false positive T-IGRA?

A

M.kanasii and M.Marinum

85
Q

NTM disease for pulmonary organisms?

A
  • MAC
  • M.Kansasii
  • M.xenopi
  • M.abscessus
  • M.malmoense
86
Q

NTM disease that hits skin and soft tissue?

A
  • MAC
  • M.marinum
  • M.Abscessus
  • M.chelonae
  • M.fortuitum
  • M.Kansasii
  • M.ulcerans
87
Q

what organisms can be disseminated MAC disease?

A
  • MAC
  • M.kansasii
  • M.abscessus
  • M.chelonae
  • M.haemophilum
88
Q

Mycobacterial Association of corneal disease and post-plastic surgery?

A

M.chelonae

89
Q

Mycobacterial Association of healthcare/hygiene associated outbreaks?

A
  1. M.chelonae
  2. M.fortuitum
  3. M.abscessus
90
Q

Mycobacterial Association of line infection?

A

M.mucogenicum

91
Q

Mycobacterial Association of HIV?

A
  • MAC
  • M.kansasii
  • M.genavense
  • M.haemophlium
92
Q

Mycobacterial Association of tropical setting?

A

M.ulcerans (buruli ulcer)

93
Q

Mycobacterial contaminant

A

M.gordonae

94
Q

noncommunicable NTM exception?

A

M.massilense in CF

95
Q

Mycobacterium associated with pseudo-outbreaks?

A
  • M.immunogenum
  • M.simiae
96
Q

Mycobacteria that cross-reactions with IGRA?

A
  • M.szulgai
  • M.kansasii
  • M.marinum
97
Q

Mycobacterium associated with aspiration?

A

M.fortuitum

98
Q

Mycobacterium associated with fish and fish tanks?

A

M.marinum

99
Q

what are the two types of MAC pulmonary disease presentations?

A
  • 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
100
Q

what are pulmonary NTM risk factors?

A
  • Underlying structural abnormalities
  • exposure/transmission - soil, hot tubs
  • Immunosuppressives
101
Q

how would you treat pulmonary M.kansasii therapy? key characteristics?

A
  • like TB
  • thin-walled upper lobe cavities
  • treat with RIF, INH, EMB with RIF as key drug
  • treat 12 months from culture negativity
102
Q

How do you generally treat pulmonary M.abscess? (no specific agents)

A

3-4 drugs for 18-24 months with 4-6 months suppressive therapy

cure is rare

more rapid progression than MAC

103
Q

How do you specifically treat for M.abscessus?

A
  • parenterally with tigecycline, amikacin, imipenem, cefoxitin
  • oral agents: clofazimine, linezolid, moxifloxacin
  • Surgical resection
104
Q

how do you treat post-plastic surgery M.chelonae?

A
  • remove foreign body
  • 4-6 months of therapy based on susceptibilities
    *
105
Q

how do you treat M.marinum?

A
  • 2 agents x 3-4 months
  • Macrolides, sulfonamides, doxycycline, rifampin, ethambutol
106
Q

how do you treat nail salon furunculosis? most common mycobacterium?

A
  • M.fortuitum
  • 4 months of FQ and/or doxycycline
107
Q

how do you treat tattoo associated M.chelonae?

A
  • 2-3 months of oral therapy based on susceptibilities
  • 1-2 agents, almost always a macrolide
108
Q

what is the best drug used to treat M.chelonae?

A

tobramycin

109
Q

what is the best drug used to treat M.fortuitum?

A

bactrim, doxy

110
Q

what is the length of treatment for disseminated M.chelonae and M.fortuitum?

A

3 drugs (including 1 IV) x 4-6 months

111
Q

what parenteral drugs do you use for M.chelonae and M.fortuitum?

A

aminoglcyosides, imipenem, cefoxitin, tigecycline

112
Q

what oral drugs are used for M.chelonae and M.fortuitum treatment?

A

macrolides, FQ. Use linezolid for M.chelonae

113
Q

what are the two types of leprosy disease?

A

Paucibacillary and multibacillary

114
Q

characteristics of paucibacillary leprosy disease?

A
  • MC form - tuberculoid
  • bacillary load<1 million
  • Skin biopsy: AFB negative
  • <5 skin lesions
115
Q

Characteristics of multibacillary leprosy disease?

A
  • lepromatous
  • massive bacillary load
  • skin biopsy: floridly positive for AFB
  • >5 skin lesions
116
Q

what is PB leprosy treatment?

A
  • dapsone 100mg daily
  • rifampin 600mg once monthly
117
Q

what is MB leprosy treatment?

A

12 months of

  • Dapsone daily
  • clofazimine daily
  • Rifampin OR clofazimine 1x monthly
118
Q

footbaths and plastic surgery mycobacterium?

A
  • Footbaths - M.Fortuitum or other RGM
  • Plastic surgery - M.chelonae or orther RGM
  • RGM = Mycobacterium abscessus, Mycobacterium fortuitum, Mycobacterium chelonae
119
Q

HIV disseminated MAC that doesn’t grow

A

think M.genvense

120
Q

inducible macrolide resistance (erm gene)

A

M.abscessus

121
Q

equatorial Africa mycobacterium

A

M.ulcerans

General ID 2019 (19 decks)

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