Pulmonology and ABX

Question 1

What is a COPD exacerbation and what can cause it?

Answer 1

Exacerbation- increased SOB or cough, change in sputum color/quantity, wheezes, prolonged expiration, and use of accessory muscles.

It can be triggered by a URI, physical exertion, and air pollution.
—Infectious causes are H flu, M Catarrhalis, and Strep Pneumo

Question 2

Treatment for COPD exacerbations

Answer 2

—Oxygen
—Nebulized albuterol + Ipratropium
— Oral glucocorticoids

ABX:
—Azithromycin, Levofloxacin/Moxifloxacin, Augmentin, or Doxycycline for 5-7 days

Question 3

Community Acquired Pneumonia Sx and Causative organisms

Answer 3

Fever, productive cough, and infiltrates on CXR

Strep Pneumoniae most commonly
H. Flu
M. Catarrhalis

Question 4

Community Acquired PNA Treatment

Answer 4

Outpatient:
—Macrolide or Doxycycline first line
—FQN only used as first line if comorbid conditions or recent ABX use

Inpatient:
—Beta lactam + either Macrolide (pref) or Doxycycline
OR
—A broad spectrum FQUN

Question 5

Atypical PNA cause and presentation

Answer 5

Caused by Mycoplasma.

Young pt with viral prodrome (Fever, HA, malaise, pharyngitis) + persistent dry cough

Non focal lung exam— scattered wheezes or crackles

Question 6

Atypical PNA Chest X ray findings

Answer 6

Atypical pattern:
—Reticulonodular pattern most common
—Diffuse, patchy, or interstitial infiltrates

Question 7

Atypical PNA treatment

Answer 7

Macrolides
—Azithromycin or Clarithromycin—

Or Doxycycline

**Mycoplasm lacks a cell wall so its naturally resistant to Beta Lactams

Question 8

Macrolides MOA, Clinical use, and ADRs

Answer 8

PO and IV= erythromycin and azithromycin
PO only= Clarithromycin

MOA: Inhibits bacterial protein synthesis by blocking 50S ribosomal subunit

Clinical Use:
—CAP, atypical PNA, pertussis, MAC infections
—Gastroparesis
—Strep throat and AOM if PCN allergy

ADRs:
—GI distress
—QT Prolongation
—Rash
—Relative contraindication in pregnancy

Question 9

What causes Pertussis and how does it present?

Answer 9

Caused by Bordatella pertussis (Gram -)

Catarrhal phase:
—URI sx lasting 1-2 weeks. MOST CONTAGIOUS during this period

Paroxysmal phase:
—Severe paroxysmal coughing fits with inspiratory whooping sound after coughing.
—May have post cough emesis
—often lasts 2-4 weeks

Convalescent phase:
—Resolution of the cough (coughing stage may last for up to 6 weeks)

Question 10

Diagnosis of Pertussis

Answer 10

Clinical diagnosis

When available order both throat cultures and PCR
—Throat culture: most sensitive during first 2 weeks of illness
—PCR of nasopharyngeal swab: sensitive up to 4 weeks of illness

Question 11

Is lymphocytosis common in pertussis?

Answer 11

Yes

Question 12

Management of Pertussis

Answer 12

Supportive is mainstay of treatment:
—oxygenation, nebulization, mechanical ventilation as needed

Antibiotics are used to decrease contagiousness of pt:
—Macrolides are DOC: Azithromycin, erythromycin
—TMP SMX second line

Post exposure prophylaxis for all close contacts regardless of vaccine status

Question 13

What abx is better tolerated and preferred in children <1 month of age?

Answer 13

Azithromycin

Question 14

How is Pertussis transmitted?

Answer 14

Respiratory droplets during coughing fits. If pt is admitted should be on droplet precautions

Question 15

Complications of pertussis

Answer 15

Pneumonia, encephalopathy, otitis media, sinusitis, and seizures.

Increased mortality in infants d/t apnea/cerebral hypoxia associated with coughing fits

Question 16

Pertussis prevention

Answer 16

In the US, 5 doses of DTaP is typically recommended at 2 months, 4 months, 6 months, 15-18 months, and 4-6 years of age.

Booster dose is administered between 11-18 years of age

Question 17

What is the cause and pathophysiology of a Tuberculosis infection?

Answer 17

Infection of the respiratory system by Mycobacterium tuberculosis.

After inhalation of airborne droplets, Mtb goes to the alveoli, gets incorporated into the macrophages and can disseminate from there

Question 18

What are the outcomes of infection with tuberculosis?

Answer 18

1. Primary TB
   —the outcome of initial infection (usually self limiting)
   —Primary Rapidly Progressing TB—> active initial infection with clinical progression. Common in children <4yo in endemic areas. These pts are contagious
2. Chronic Latent Infection
   —About 90% of pts control the initial primary infection via caseating granuloma formation
3. Secondary Reactivating TB
   —Reactivation of latent TB with waning immune defenses
   —5-10% lifetime incidence
   —Most commonly localized in APEX/UPPER LOBES with CAVITARY LESIONS
   —These pts are contagious

Question 19

What 3 criteria need to be met to be non infectious with a chronic (latent) TB infection?

Answer 19

1. (+) PPD skin test
2. So sx of infection
3. no imaging findings of active infection

Question 20

What are caseating granulomas in TB infections?

Answer 20

Caseating=necrosis

These granulomas may become caseating= central necrosis and acidic with low oxygen, making it hostile for Mtb to grow

Question 21

Clinical Manifestations of TB

Answer 21

Pulmonary:
—Cough (productive or not)
—hemoptysis
—Fever, chills, night sweats and chest pain

Extrapulmonary: can affect any organ
—Cervical lymph nodes Scrofula
—meningitis
—Potts disease (vertebrae)
—Miliary TB
—Adrenal gland involvement
—Genitourinary

Question 22

Chest Radiographs in TB infections

Answer 22

Primary TB:
—Middle/Lower Lobe consolidation
—Granuloma=residual evidence of healed primary TB
—Ghon complex= calcified primary focus + lymph node
—Rankes complex=healed fibrocalcific Ghon complex

Reactivation:
—Apical upper lobe fibrocavitary disease most common

Miliary TB:
—small millet seed like nodular lesions 2-4mm