Respiratory Flashcards
1
Q
Paroxysmal and reversible obstruction of the airways
History of recurrent episodes of wheezes, chest tightness, breathlessness, and/or cough, particularly at
night/early morning
Symptoms may be triggered by specific triggers (e.g. pollens, pets, cold air or perfumes)
Symptoms may worsen after taking beta-blockers, aspirin or NSAIDs (BAN) — Paracetamol is safe
Evidence of variable airflow obstruction seen on tests such as peak expiratory flow measurement
A
Asthma
2
Q
Bronchospasm (smooth muscle spasm narrowing airways)
Excessive production of secretions (plugging airways)
A
Acute asthma
3
Q
Risk Factors for Asthma
A
A combination of genetic & environmental factors
Personal history of atopy (genetic tendency to develop allergic diseases) such as eczema
Family history of asthma or atopy
Inner city environment
Prematurity and low birth weight
Smoking
Maternal smoking
4
Q
Presentation of Acute Asthma
A
Cough
SOB
Wheezes
Chest tightness
5
Q
Slight tachypnea, tachycardia
Classically, expiratory wheeze is
heard (widespread wheeze)
A
Mild Attack
6
Q
o Use of accessory muscles of
respiration
o Inability to complete a sentence
in one breath
o Intercostal retractions
A
Acute Severe Attack
7
Q
Silent chest (no wheeze at all)
Exhaustion
Altered consciousness
Cyanosis
Arrythmia
hypotension
Poor respiratory effort
PEF <33% best or predicted
RR >26
Sp02 <92%
Pa02 <8 kPa
Normal PaCO2 (4.6-6 kPa)
A
Life-threatening Attack
8
Q
SE of Atenolol
A
wheezing
9
Q
SE of Ramipril
A
cough
10
Q
Initial diagnostic tool — Reversible obstructive pattern
A
Pulmonary function tests (SPIROMETRY)
11
Q
Day-to-day peak flow variability showing diurnal cycle
A
Treatment monitoring and adjustment
12
Q
Diagnostic for Asthma
A
Symptoms of Asthma
Post-dilator improvement of >12% in FEV1/FVC
Unexplained peripheral blood eosinophilia
13
Q
- Low dose inhaled steroid (preventer) + SABA when needed (reliever)
A
Asthma in adults
14
Q
- Very low dose inhaled steroid + SABA when needed (reliever)
A
Asthma in children
15
Q
Add LTRA (e.g. Montelukast)
A
Asthma in adults
16
Q
> 5 years — LABA or LTRA // <5 years — LTRA
A
Asthma in children
17
Q
Increase the dose of inhaled steroids OR add
LABA (Salmeterol)
A
Asthma in adults
18
Q
Increase the dose of inhaled steroid
A
Asthma in children
19
Q
In severe cases — Short-term oral steroid
A
Asthma in adults
20
Q
In severe cases — SR Theophylline
A
Asthma in children
21
Q
Immediate treatment [OSTHP]
A
- Start O, if saturation < 92%, aim for 94-98%
- Salbutamol 5mg (or terbutaline 10mg) nebulized with 02
- IV Hydrocortisone 100mg OR oral prednisolone 40-50 mg
22
Q
Where diagnosis is uncertain but with
demonstration of airway obstruction [EEV1/FVC « 0.7),
A
reversibility testing and trial of assessment are suggested
23
Q
Chest X-ray is not a routine assessment
but it’s useful for
A
Exclusion
24
Q
Only benefit for IV hydrocortisone over
oral prednisolone if patient is vomiting or having severe dyspnea where they cannot consume oral medication
A
True
25
If immediate TTT is not working, add
ipratropium - MgS04 — IV aminophylline + IV salbutamal (ICU)
26
In children, tx pf acute exacerbation
OSIPH
IV Salbutamol or IV Aminophylline
Mgs04 comes last
27
Side effect of B2 agonist
Palpitation and Tachycardia
28
If life threatening features are present (SIM)
1. Give salbutamol nebulizers every 15 minutes, or 10 mg continuously
2. Add in ipratropium 0.5mg to nebulizers
3. Give single dose of Mg504 (1.2-2g IV) over 20 minutes
29
If improving within 15-30 minutes (SP)
1. Nebulized Salbutamol every 4 hrs
2. Prednisolone 40-50 mg PO OD for 5-7 days
30
» It's a sign of poorly controlled asthma
» Choice of medication: Short acting beta 2 agonist (used before exercise)
» Review of the regimen including inhaled corticosteroids should be done
Exercise-induced asthma
31
* Patients who are well controlled on inhaled corticosteroids but complains of exercise being the specific problem,
then consider ADDING either:
- Leukotriene receptor antagonist (LTRA) = Montelukast
- Along-acting beta 2 agonist (LABA) = Salmeterol
- Sodium cromoglicate
- An oral beta 2 agonist
- Theophylline
* This would be taken 2h before an exercise and will prevent symptoms for approximately 12h
32
» History of smoking and progressive dyspnea
» Evidence of irreversible airflow obstruction on spirometry
- FEV1 < 80% predicted
- FEV1/FVC < 0.7 (Post-dilator)
» All spirometry findings are increased (TLC, RV) except for DLCO & VC
COPD
33
Presentation of COPD
* Cough + sputum production
* Dyspnea
* low-grade fever (mostly afebrile)
* Wheezes
34
Investigations of COPD
Raised hematocrit
Chest X-ray is not recommended but if ordered
- Hyperinflated lung fields
- Flattened diaphragm
- Prominent posterior ribs markings (>7 posterior ribs seen)
- Small heart
- May see bullae
35
Productive cough (TABLESPOON of mucus)
that lasts for three months or more per year
for at least two years
Chronic Bronchitis
36
is now the preferred term for patients
with airflow obstruction who were
previously diagnosed with chronic bronchitis
or emphysema
COPD
37
Asthma Vs COPD
Reversibility distinguishes asthma from
COPD
COPD is almost refractory to medication
Almost all COPD patients do smoke or have
smoked in the past
COPD tend to be in old age (>35 years)
» Asthma patients can develop COPD later in life
» Venturi mask doesn't create +ve pressure
unlike non-invasive ventilation
38
MAanagement of COPD
* Antibiotics — If sputum is purulent or clinical signs of pneumonia
* Prednisolone 30mg/day for 7-14 days
* Nebulized normal saline — to clear out mucus
* Inhaled or nebulized bronchodilators
* Controlled 02 therapy 24% via Venturi face mask, with oximetry Maintain saturations between 88% and 92%
* |V aminophylline Beneficial if the patient is wheezy and has not improved with nebulizers alone
* Non-invasive ventilation — RR> 30, pH< 7.34, falling Pa02 or rising PaC0O2 despite medical treatment
39
Invasive mechanical ventilation
Indications
* Failed NIV
* Contraindicated NIV in scenarios such as: respiratory arrest, high aspiration risk or impaired mental status
40
Complications
Invasive mechanical ventilation
¢ Pneumonia
* Barotrauma
* Failure to wean to spontaneous ventilation
41
A respiratory stimulant, given IV
Used to drive respiratory rate if >20 breaths/minute
Been replaced by NIV
Doxapram
42
amount of air in the lungs after maximal inspiration
TLC
43
amount of air that remains in the lungs after maximal expiration
RV
44
amount of air that is pushed out of the lungs after maximal inspiration
VC
45
amount of air pushed out of the lungs after forced maximal expiration
FVC
46
amount of air pushed out of the lungs in 1sec during maximal expiration
FEV1
47
FEV1 - decreased
Less than 80% of predicted
Obstructive
48
FEV1 - decreased
Less than 80% of predicted
Restrictive
49
FvC N
More than 80% of predicted
Obstructive
50
FvC - decreased
Less than 80% of predicted
Restrictive
51
FEV1/FVC decreased
Less than 0.7
Obstructive
52
FEV1/FVC - N
0.7-0.8
OR
increased
More than 0.8
Restrictive
53
Obstructive Lung Disease
vs
Restrictive Lung Disease
54
Long-term oxygen therapy (LTOT)
Prescribed to patients with COPD and severe chronic hypoxemia
7 Once started, it's likely to be life-long
# Usually given over a minimum of 15h a day
Add-ons to improve breathlessness = Prednisolone or Nebulized normal saline
55
Possible candidates
* Very severe airflow obstruction — FEV] < 30% predicted
* Polycythemia
* (Cyanosis
* Peripheral swelling
* Raised JVP
* Oxygen saturation 92% or less on room air
56
Conditions for assessment
® Patient should be stable and >5 weeks have passed since last exacerbation of COPD
® (On a fully optimized treatment for COPD
* 2 sets of ABG are taken 3 weeks apart to ensure the patient is sufficiently hypoxic
57
Indications
* p02<7.3kPa
* p02 =7.3kPa+ one of the following:
- 2ry polycythemia (raised hematocrit)
- Peripheral edema
- Pulmonary hypertension
58
Non-invasive ventilation
Indications
1. Acidosis (pH <7.35)
2. Rising PaCO2
3. Falling Pa02
4. RR=30
All of these despite medical management (steroids, nebulized bronchodilators & standard 02 therapy) is an
indication of non-invasive ventilation
59
Risk Factors for Pulmonary Embolism
60
is suspected with normal X-ray & normal chest examination
Pulmonary embolism
61
Respiratory alkalosis + Hypoxia =
Pulmonary embolism
62
Respiratory alkalosis + NO hypoxia =
Panic attack
63
Symptoms of PE
Dyspnea
Pleuritic chest pain or retrosternal chest pain
Cough and hemoptysis
64
Signs of PE
* Tachypnea, tachycardia
* Hypoxia, anxiety, restlessness, agitation and impaired consciousness
® Pyrexia
* Elevated JVP
* Gallop heart rhythm, a widely split-second heart sound, tricuspid regurgitant murmur
* Pleural rub
* Systemic hypotension and cardiogenic shock
65
Diagnosis of Pulmonary Embolism
CTPA (CT pulmonary angiogram) — Gold standard
66
Management of Pulmonary Embolism
Immediate administration of LMWH once PE is suspected (even prior to CTPA)
67
Results in hyperventilation which causes a respiratory alkalosis
There would be no metabolic compensation as panic attacks resolve rapidly
We would not expect any metabolic compensation as it takes the kidneys days to conserve acid
Pa02 would be normal
Panic attacks
68
Pulmonary embolism in pregnancy
Chest X-ray should be requested first before deciding whether a V/Q scan or CTPA should be done, in order to
exclude other pulmonary diseases such as pneumonia, pneumothorax or lobar collapse
Abnormal X-ray + clinical suspension of PE = CTPA
Normal X-ray + clinical suspicion of PE = V/Q sean
69
Pulmonary embolism in pregnancy
70
Pulmonary embolism in pregnancy
71
Pulmonary embolism in pregnancy
72
Pneumocystis carinii pneumonia (PCP) (Pneumocystis jiroveci pneumonia)
» HIV patient + desaturation on exercise while normal during rest
» HIV is an important risk factors especially if CD4 <200/mm? — should receive PCP prophylaxis (co-trimoxazole)
73
Pneumocystis carinii pneumonia (PCP) (Pneumocystis jiroveci pneumonia)
Features
* Exertional dyspnea
* Gradual onset of dry cough
* Fever
* Tachypnea
* May be signs of AIDS (e.g. Thrush)
* Chest examination is typically normal
* Could present with Herpes labialis
74
Pneumocystis carinii pneumonia (PCP) (Pneumocystis jiroveci pneumonia)
Investigation
* Sputum
* Bronchoscopy with bronchoalveolar lavage
75
Pneumocystis carinii pneumonia (PCP) (Pneumocystis jiroveci pneumonia)
Management
Co-trimoxazole (trimethoprim-sulfa) in severe cases
Atovaquone in mild to moderate cases
76
HIV + dry cough
PCP
77
HIV + productive cough
TB
78
Prophylaxis in HIV with mycobacterium avium & CD4<50
Azithromycin
79
Think of flu like symptoms in an
Immunocompromised patients
80
Caused by Legionella pneumophila
Acquired by droplet inhalation of contaminated water
Severe, potentially fatal acute pneumonia
Legionnaires disease
- they often mention hints like travelling, hotel spas or hot tubs [millionaire]
81
Features of
Legionnaires disease
Flu-like symptoms
Cough: dry — productive
Fever, diarrhea, vomiting, confusion, coma
82
Investigations of
Legionnaires disease
Sputum — Black currant jelly
Chest X-ray (should be arranged as a follow uo around 6 weeks after discharge — Bi-basal consolidation
Specific blood results:
Low sodium
Lymphocytopenia (low WBCs)
Low albumin
Elevated Liver enzymes
83
Management of
Legionnaires disease
Clarithromycin/Azithromycin +/- rifampicin or fluoroquinolone
Clarithromycin + statin may lead — rhabdomyolysis = pause/decrease statins OR give Doxycycline
instead
Clarithromycin + salbutamol can cause — hypokalemia
84
Features of
Mycoplasma (atypical pneumonia)
* Young adults (living in dorms)
* Dry cough
* NoSOB
* Joint pain + rash (erythema multiform — target lesions on the back of the hand)
* low grade fever + flu-like symptoms
85
Chest X-ray of
Mycoplasma (atypical pneumonia)
perihilar shadowing + bilateral patchy consolidation
86
Management of
Mycoplasma (atypical pneumonia)
Erythromycin
87
Commonest causative organisms — Staph, Strept, H. influenza
Aspiration pneumonia
88
risk factors for predicting mortality
CURB-65
89
CURB-65
* Confusion
* Urea >7mmol/L (>19 mg/dl)
* Respiratory rate >30/min
* BP <90/60mmHg
® Age265
Score is also used in case of community acquired pneumonia
90
* A complication of pneumonia as well as invasive procedures of the thorax
* Pneumonia — Parapneumonic effusion — Pleural empyema
* Suspected when pneumonia does NOT improve with antibiotics
* Empyema usually starts in the lower lobe where sound would be absent
* Pneumonia and empyema share similar symptoms
Pleural empyema
91
Pleural empyema
Other features
* Swinging fever, night sweats
* Weight loss
* Chest pain
92
Pleural empyema
Investigation
* Pleural aspiration
* Blood and sputum culture
® HIV test
93
Pleural empyema
Management
® Chest drain, if:
- pH of the pleural aspirate is <7.2
- Effusion is causing respiratory compromise
94
Pneumothorax
Risk factors
Smoking
95
Types
Pneumothorax
1. Primary spontaneous
- Occurs without apparent cause
- Most commonly in tall, athletic, thin men aged 20-40 years
- 90% unilateral (commonly at right side)
- Usually caused by rupture of a small subpleural blebs (collection of air < 2cm)
- Presented with dyspnea, chest pain, cough & tachypnea
- lpsilateral decreased chest wall movement, hyper-resonant hemithorax to percussion
2. Secondary spontaneous
- Occurs in presence of existing lung pathology (e.g. Asthma, COPD)
3. Simple pneumothorax
- Non-expanding collection of air around the lung
4, Tension pneumothorax [one-way valve]
- Expanding collection of air around the lung
Investigation
96
Pneumothorax
Investigation
» Chest X-ray — Diagnostic
- Visible lung edge and absent lung markings peripherally
» ABG — if patient is dyspneic, cyanosed or there's an underlying condition
97
NO distended neck veins
NO tracheal deviation
Usually caused by stabbing injuries
Hemothorax
98
Management of 2ry spontaneous pneumothorax
>2cm (50%) OR Hypoxic — Chest drain
<2cm (50%) — Cannula insertion
99
* Acute respiratory distress * NO tracheal deviation
* Hypotension * Usually caused by stabbing injuries
* Raised JVP Management of 2ry spontaneous pneumothorax
* Tracheal deviation away from the pneumothorax side
* Reduced air entry on affected side
Tension pneumothorax
100
Non Tension Pneumothorax
101
Management of Tension Pneumothorax
1. Initial = High flow 02
2. Insert large-bore cannula into 2" intercostal space in midclavicular line (just above 3™ rib) on side of pneumothorax — hiss sound is from the air escaping and confirms the diagnosis
3. Do NOT wait for chest X-ray if the patient is seriously compromised or cardiac arrest has occurred or if the
diagnosis is clinically certain
4. Air should be aspirated until the patient is less distressed, then insert a chest drain in mid-axillary line
leaving the cannula in place until you've finished and the underwater seal is bubbling satisfactorily
5. Always perform a chest X-ray post chest drain insertion to ensure the drain is appropriately placed
102
Seen in both tension pneumothorax and
cardiac tamponade
Engorged neck veins indicate high pressure in the right ventricle
103
Beck's triad for cardiac tamponade
1. Engorged neck veins
2. Hypotension
3. Muffled heart sounds (Vs. reduced air entry and tracheal deviation in tension pneumothorax)
103
Non Tension Pneumothorax
104
Causes of post-operative breathlessness
Infection/atelectasis
- Occurs early (within hours)
- Common in smokers
Pulmonary embolism
- Occurs early (within hours/days)
Left ventricular failure (LVF) (fluid overload)
Exacerbation of underlying disease such as COPD
Tension pneumothorax
105
» The collapse or closure of a lung resulting in reduced or absent gas exchange (Reduced air entry)
» History of smoking
Atelectasis
106
Alveoli either deflated or filled with alveolar fluid
* Atelectasis
107
may happen in about 3 days if atelectasis is not resolved. If this happens, fever will persist and X-ray will show infiltrates.
Pneumonia
108
Management of Atelectasis
Analgesia — To encourage expectoration
Nebulized saline
Chest physiotherapy
Deep breathing and coughing
Postural drainage
Incentive spirometry
If lung doesn’t re-inflate = Bronchoscopy to suction out secretions
109
Non Tension Pneumothorax
109
Irreversible dilatation of small and medium sized bronchi, with chronic airway inflammation destroying their elastic and muscular structure
It's associated with chronic sputum production, chronic cough, recurrent acute chest infections and airflow
obstruction
Bronchiectasis
110
Etiology
Bronchiectasis
Infection — Most common
- Childhood respiratory viral infections (e.g. measles, pertussis, influenza, respiratory syncytial virus)
- TB
- Bacterial pneumonia — Look out for history of recurrent pneumonia
* Immunodeficiency
- HIV — Serious, persistent or recurrent infections
+ Connective tissue diseases
- RA
- Sjogren's $
- Systemic sclerosis
= SLE PR
- Ehlers-Danlos $
- Marfan's §
* Toxic insults
- Gastric aspiration
- Inhalation of toxic gases
* Congenital defects
- Cystic fibrosis = Most important to exclude
111
Bronchiectasis
112
» Malignant mesothelioma is a tumor of mesothelial cells that usually occurs in the pleura, rarely in peritoneum
» Associated with occupational exposures to asbestos (history of being a builder)
» Latent period between exposure and development of the tumor may be up to 45 years
» Deaths are reported to the coroner as it's an industrial disease
Mesothelioma
113
Mesothelioma
Features
* SOB, chest pain, weight loss = Most common symptoms
* Finger clubbing
* Recurrent pleural effusion admission
114
Signs of metastasis
Mesothelioma
* Lymphadenopathy
*Hepatomegaly
* Bone pain and tenderness
* Abdominal pain or obstruction (peritoneal malignant mesothelioma
115
Investigation
Mesothelioma
* Chest X-ray — Pleural thickening or effusion
* Thoracoscopy under local anesthetic:
- Pleural fluid aspiration and cytological analysis — very sensitive
- Pleural biopsy = Most definitive
- lt also enables drainage of pleural fluid, and pleurodesi
* The diagnosis is often made post-mortem
116
Management
Mesothelioma
* Usually symptomatic
* Cure is only possible with surgery for localized (stage I)
117
* When cancer-fighting antibodies (WBCs) mistakenly attack normal cells in the nervous system
* Often associated with SCLC
® SCLC — Lambert-Eaton 5 (proximal muscle weakness, depressed tendon reflexes & autonomic changes) +
Hyponatremia due to SIADH + Hypokalemia (increased mineralocorticoid activity)
* Sq. cell = Hypercalcemia due to PTH like action
Paraneoplastic syndromes
118
Extrinsic allergic alveolitis/Hypersensitivity pneumonitis
* Due to repeated inhalation of organic antigens in dusts (e.g. from dairy or grain products, animal dander and
protein and water reservoir vaporizers)
* Occupational risk: farmers, vets, bakers and people dealing with chemicals
119
* Chest X-ray —
Extrinsic allergic alveolitis/Hypersensitivity pneumonitis
Diffuse micronodular interstitial shadowing
120
There are 3 forms of extrinsic allergic alveolitis
1. Acute
- Symptoms start 4-8h after exposure to the sensitizing antigen and resolve quickly, within days
- Flu-like illness with fever, chest tightness, dry cough, dyspnea
- Associated symptoms: malaise, chills, headache, generalized aches and pains. Sometimes wheezes
- Signs: fever, tachypnea and bi-basal fine respiratory crackles
2.Subacute
3.Chronic
121
A systemic disease of unknown cause
Characterized histologically by the presence of non-specific non-caseating granulomas in the lungs and other
Sarcoidosis
122
Sarcoidosis
Presentation
* Up to 50% are asymptomatic (discovered accidently by chest X-ray — Hilar adenopathy)
+ Involves almost any organ system but pulmonary is the most common
+ Fever, Fatigue
* Skin: erythema nodosum
* Eyes: Uveitis
+ Kidneys: Stones
* Lymphadenopathy
123
Heerfordt-Waldenstrom
124
Lofgren
125
Lung + kidney
Goodpasture
126
Lung + GIT
Cystic Fibrosis
127
Lung + eye
Pancoast Tumor
128
Investigations of Sarcoidosis
129
Treatment of Sarcoidosis
Steroids
130
A tumor of the pulmonary apex
Defined primarily by its location situated on top of end of
either right or left lung
Pancoast Tumor
131
Presentation of
Pancoast Tumor
* Ipsilateral invasion of cervical sympathetic plexus — Horner's $
(ptosis, myosis, anhidrosis + enophthalmos)
* Brachial plexus invasion — Muscle wasting of the intrinsic
hand muscles and paresthesia in the medial side of the arm
along with shoulder and arm pain
* RLN compression — HOV
132
Patient works as a farmer or a baker
Extrinsic allergic alveolitis/hypersensitivity pneumonitis
133
Pt works at a pet shop —
[Ch]lamydiophilia pisittaci — Rx with [Cl]arithromycin
134
Pt was in anything starts with [H] like Hospital, hostel, hotel, hot tub — Legionella
Legionella
135
Bilateral cavitation in the lung (for any reason) + pneumatoceles
Staph
136
Upper lobe cavitation on CXR —
Klebsiella — Rx with Cephalosporin (Keflex)
137
Bilateral Patchy consolidation, Myalgia + peri-hilar shadowing on CXR, dry cough, target lesions on back of the
hands (erythema multiform)
Mycoplasma
138
* lobar consolidation on CXR —
Most common cause of community-acquired
pneumonia
Strept (G +ve cocci)
139
* lobar consolidation on CXR —
Most common cause of community-acquired
pneumonia
Strept (G +ve cocci)
140
Bi-basal consolidation —
Legionella
141
Peri-hilar interstitial shadowing —
Carinii
142
Diffuse micronodular interstitial shadowing
Extrinsic allergic alveolitis
143
Rusty-colored sputum
Strept
144
Currant jelly
Klebsiella
145
Green
Pseudomonas
146
Purulent
Staph
147
Pneumonia + neurological signs
Legionella
148
Fever + murmur + pneumonia
Coxiella burentti
149
Pneumonia + herpes labialis
Strept or Carinii
150
Reticular infiltrations + ground-glass appearance
Viral/Atypical pneumonia [mycoplasma/legionella)
151
Pneumatoceles
Staph
152
Ashestoses
Mesothelioma
153
Coal mining — Coal worker's pneumoconiosis (CWP)
Progressive massive fibrosis
154
Central lung cancers
Sq. cell + Small cell
155
Peripheral lung cancers
Adenocarcinoma + Large cell
156
Keratin pearls + intercellular bridges
Sq. cell
157
Oat cell + neuroendocrine involvement
Small cell
158
Glandular + mucin producing
Adenocarcinoma
159
Anaplastic + undifferentiated sheets/nests of polygonal/multinuclear cells
Large cell
160
Most common lung cancer in non-smokers
Adenocarcinoma
161
A lung cancer with a strong smoking history
Sq. cell
162
One side of the chest
Hemithorax
163
Erythema nodosum
Sarcoidosis
164
Erythema multiforme (target lesions at the back of the hand)
Mycoplasma pneumonia
165
Post-flu illness
Staph
166
Hyponatremia
Legionella
167
Terminal case with noisy breathing — Terminal respiratory secretions (death rattle]
Hyoscine SC
168
a procedure that uses medicine to adhere lungs to the chest wall
Pleurodesis
169
Corticosteroid inhalers can lead to oral thrush =
Spacers help steroids to get straight to the lungs as opposed
to the oral cavity
170
Non-caseating granulomas
Sarcoidosis, Caseating granulomas -> TB
