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Respiratory Medicine Exam I > Respiratory Infections & Tumors > Flashcards

Respiratory Infections & Tumors Flashcards

1
Q

How can pulmonary infections be classified by anatomic distribution?

A

Bronchopneumonia — patchy infiltrate

Lobar pneumonia — diffusely affecting one specific lung lobe

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2
Q

4 Stages of lobar pneumonia and associated pathologic changes

A
  1. Congestion: vascular engorgement
  2. Red hepatization: red cells and inflammation
  3. Grey hepatization: inflammation and debris
  4. Resolution: fibrosis, macrophage clean-up
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3
Q

3 primary complications of lobar pneumonia

A

Abscess
Empyema
Bacteremia

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4
Q

What is the difference between an abscess and an empyema?

A

Abscess destroys surrounding area and fills with inflammatory fluid

Empyema is when inflammatory fluid builds up in pre-existing anatomic space

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5
Q

Bacterial causes of community-acquired pneumonia

A 
S.pneumoniae
H.influenzae
S.aureus
K.pneumoniae
P.aeruginosa
L.pneumophila
M.pneumoniae
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6
Q

Most common cause of community acquired pneumonia

A

Streptococcus pneumoniae (aka “pneumococcus”)

[although incidence is decreasing due to vaccination in older adults, children, and smokers]

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7
Q

Characteristic histology of streptococcus pneumoniae

A

Lancet-shaped gram positive diplococci in pairs and chains

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8
Q

______ _____ is a virulent pneumonia in children, and vaccination is recommended for type B (most virulent strain) in kids <5 y/o

A

Haemophilus influenzae

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9
Q

Bacteria causing pneumonia that is associated with abscess formation and IV drug use

A

Staphylococcus aureus (usually MRSA)

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10
Q

Bacteria causing pneumonia, often associated with currant jelly sputum and alcoholism

A

Klebsiella pneumoniae

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11
Q

What type of organism is typically implicated in pts who have community-acquired pneumonia in the setting of cystic fibrosis?

A

Pseudomonas aeruginosa

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12
Q

Gram-negative bacillus that grows in warm freshwater with airborne transmission, causes community acquired bacterial pneumonia

A

Legionella pneumophila

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13
Q

Viral causes of community-acquired pneumonia

A

Influenza (H1N1)
SARS
RSV

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14
Q

Influenza virus is classified by what 2 proteins?

A

Hemagglutinin — attachment to cells

Neuraminidase — release of replicated virus from cells

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15
Q

Signs/symptoms of influenza

A 
Abrupt symptom onset
Fever (lasts 3-4 days)
Severe aches
Chills
Fatigue, weakness
Headache also common

[contrast with common cold which has gradual onset, fever and chills rare, milder aches, hadache is rare]

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16
Q

Differentiate antigenic drift from antigenic shift

A

Antigenic drift:
Associated with epidemics; MINOR changes to proteins (Ags) on the virus, allowsing increased spread. Similar enough to original virus to allow for some immunity in many individuals

Antigenic shift:
Associated with pandemics; genomic changes with MAJOR resulting changes to protein structure. Naive immunity for almost all people

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17
Q

What type of virus causes severe acute respiratory syndrome (SARS)?

A

Coronavirus

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18
Q

Neonatal bacterial causes of pneumonia

A

Group B strep, gram-negative bacilli, listeria

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19
Q

Viral causes of pneumonia in children >1 month

A 
Respiratory syncytial virus
Parainfluenza virus
Influenza A and B
Adenovirus
Rhinovirus
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20
Q

Bacterial causes of pneumonia in children >1 month

A

S.pneumoniae
H.influenzae
M.catarralis
S.aureus

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21
Q

Causes of pneumonia in older children/adolescents are similar to those in younger children, with less likelihood of ________ virus.

Additional bacterial considerations in older children include ______ and _______

A

respiratory syncytial

M.pneumoniae
C.pneumoniae

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22
Q

What type of virus is RSV and what are some clinical features?

A

Paramyxovirus

Symptoms of rhinorrhea, cough, wheezing, dyspnea, tachypnea, cyanosis

[generation of mucus in airways is what leads to difficulty breathing]

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23
Q

Other than RSV, what are some paramyxoviridae with effects on respiratory system?

A

Human metapneumovirus (hMPV)

Parainfluenza

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24
Q

What is the major difference between bacterial vs. viral pneumonia on histology?

A

Bacterial pneumonia shows infiltrate in alveolar spaces

Viral pneumonia shows infiltrate in interstitium

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25
Q

Describe bacterial pneumonia in terms of onset, association with epidemics and/or sepsis, fever, lung exam findings, CXR findings, pleural involvement, and treatment

A

Abrupt onset

Not associated with epidemics (exceptions: legionella, pertussis)

May have associated bacteremia

High grade fever

Crackles on lung exam

Lobar or consolidated appearance

May involve pleura

Responds quickly to appropriate antibiotics

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26
Q

Describe viral pneumonia in terms of onset, association with epidemics and/or sepsis, fever, lung exam findings, CXR findings, pleural involvement, and treatment

A

Gradual onset

Epidemics are common

Not typically associated with viremia

No fever or low grade fevers

Wheezes on lung exam

Diffuse infiltrates on CXR

Will not typically involve pleura

Will not respond to antibiotics but tend to be self-limiting

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27
Q

Lung abscess is a complication of pneumonia often associated with what 2 bacterial causes?

A

S.aureus

K.pneumoniae

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28
Q

Aspiration leading to lung abscess is often associated with what patient population?

A

Chronic alcoholics

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29
Q

How does the course of TB infection change in immunocompetent vs. immunocompromised hosts?

A

In immunocompetent patients, the primary infection usually resolves into latent/dormant pulmonary lesion that may reactivate to become the more aggressive secondary/miliary TB in the setting of changes in the immune system later (like if pt contracts HIV, develops RA, etc.)

In a patient that is already immunocompromised, the primary infection is more likely to progress to miliary TB directly after primary infection

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30
Q

Characteristic histologic and gross findings of TB

A

Histology: caseating granulomas (infiltrate consisting of histiocytes, multinucleated giant cells, neutrophils)

Gross: Ghon complex

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31
Q

Fungus endemic in midwest and Caribbean (Ohio and Mississippi river valleys), typically causing subclinical infection with granulomatous response (calcifications or coin lesions on CXR) with characteristic yeast forms showing “pumpkin seed” morphology; can run aggressive course, especially in immunocompromised patients

A

Histoplasma capsulatum

32
Q

Fungus endemic in central and SE US (ohio and mississippi river valleys) that causes granulomatous response in the lungs with characteristic yeast forms that show broad-based budding; can also infect skin and rarely disseminated infection

A

Blastomyces dermatitides

33
Q

Fungus endemic in SW US and Mexico, causing granulomatous response with eosinophils in the lungs; often subclinical and self-limited disease but can produce disseminated infection especially in immunocompromised pts

A

Coccidioides immitis

34
Q

Causes of pneumonia with diffuse infiltrates in immunocompromised pts

A

Common:
CMV
Pneumocystis jiroveci
Drug reaction

Uncommon:
Bacterial pneumonia
Aspergillus
Cryptococcus
Malignancy
35
Q

Causes of pneumonia with focal infiltrates in immunocompromised pts

A 
Common:
Gram-negative bacterial infections
Staphylococcus aureus
Aspergillus
Candida
Malignancy
Uncommon:
Cryptococcus
Mucor
Pneumocystis jiroveci
Legionella pneumophila
36
Q

Opportunistic fungal infection and AIDS-defining illness with characteristic cup-shaped yeast forms on histology, and that can present in many ways radiographically

A

Pneumocystis jiroveci (carinii)

37
Q

Infection in immunocompromised or elderly patients characterized as AIDS-defining illness and displays as thin mycobacteria seen as slender red forms on acid-fast staining

A

Mycobacterium avium complex (MAC)

38
Q

After a lung transplant, what test is required to differentiate lung infection from rejection, which both cause infiltrates and fever? Why is it important to distinguish between the two in terms of management?

A

Biopsy is needed to discriminate between the two

Rejection shows mononuclear infiltrates around vessels, and management requires an increase in immunosuppression therapy

With acute infection, you do NOT increase immunosuppression because their condition will worsen

39
Q

Leading cause of cancer deaths in males vs. females

A

Leading cause is lung and bronchus cancer in both males and females

[second leading in estimated new cases for both males and females as well]

40
Q

Epidemiology and risk factors for lung and bronchial cancer in terms of smoking

A

Tobacco use in terms of duration AND intensity (note pack years)

Carcinogen exposure may be mitigated by genetic variation in patients (P450 polymorphisms and genes responsible for DNA repair)

41
Q

3 basic classifications of lung tumors

A

Adenocarcinoma (38%)
Squamous cell carcinoma (20%)
Small cell carcinoma (14%)

42
Q

How would you characterize dysplastic pneumocytes present along alveoli with some interstitial fibrosis and is <5 mm?

A

Atypical adenomatous hyperplasia (AAH)

43
Q

How would you characterize dysplastic pneumocytes confluently growing along alveoli and is <3 cm?

A

Adenocarcinoma in situ (AIS)

[formerly bronchioloalveolar carcinoma (BAC)]

44
Q

Most common lung malignancy in smokers and non-smokers

A

Pulmonary adenocarcinoma

45
Q

T/F: pulmonary adenocarcinoma can arise from precursors or develop de novo. There are many variants so it is important to distinguish between them for tx purposes

A

True

46
Q

The most important histologic feature of pulmonary adenocarcinoma is malignant ____ invading the lung tissue

A

Glands

47
Q

What is unique about mucinous adenocarcinoma in terms of spread?

A

Spreads via respiration/air movement throughout the lungs — so it can mimic pneumonia on CXR

48
Q

Progression of squamous carcinoma

A

Normal bronchial epithelium
Squamous metaplasia
Squamous carcinoma in situ
Invasive squamous carcinoma

49
Q

Squamous carcinoma is more common in _____, has a strong association with _____, and often occurs in _____ location

A

Men; smoking; central

50
Q

Squamous carcinoma may be recognized on histology by presence of ______ _____ and/or ______ _____

On cytology, _____ may show up as orange cytoplasm

A

Keratin pearls; intercellular bridges

Keratin

51
Q

Small cell neuroendocrine carcinoma is almost always associated with _____ and has a _____ rate of metastasis

A

Smoking; high

52
Q

Histologic features of small cell neuroendocrine carcinoma

A

Small cells with fine blue nuclear chromatin, scant cytoplasm, and characteristic pattern of necrosis

53
Q

Why is it important to identify small cell neuroendocrine carcinoma for tx purposes?

A

Surgical excision is not recommended if metastasized to LNs

Specific chemotherapy available for different types

Chemo/radiation is effective in most cases but there is a high rate of recurrence

54
Q

Paraneoplastic syndrome associated with squamous carcinoma

A

Hypercalcemia (PTH-related peptide)

55
Q

Paraneoplastic syndromes associated with small cell carcinoma

A

SIADH

Cushing’s syndrome (secretion of ACTH)

56
Q

Paraneoplastic syndrome characterized by enophthalmos, ptosis, miosis, and anhidrosis

A

Horner’s syndrome

57
Q

“Precursor lesion” of neuroendocrine tumors

A

Diffuse interstitial pulmonary neuroendocrine cell hyperplasia (DIPNECH)

58
Q

DIPNECH nodules may be detected by high-resolution CT scan. What are the size restrictions to be characterized as DIPNECH?

A

Very small, less than 5mm (still considered hyperplasia!)

59
Q

How is DIPNECH distinguished from a carcinoid tumor?

A

Based on size and ability to metastasize

DIPNECH are less than 5mm and do not have potential to metastasize at this point

Carcinoid tumors are 5mm or larger and have potential to metastasize (although indolent course) — considered neuroendocrine carcinoma grade 1

60
Q

Atypical carcinoid tumors are considered neuroendocrine tumor grade 2. What are some differences between this type and grade 1?

A

Grade 2 have increased mitotic activity, necrosis, and disordered growth

Increased rate of metastasis and lower survival as well (although still better prognosis than small cell carcinoma)

61
Q

Features of carcinoid syndrome

A

Flushing, diarrhea, cyanosis (presents similarly to GI carcinoid syndromes)

62
Q

Disordered growth of tissues normally found in the organ that it is growing in; lung example histology shows firm “marble” with smooth edges, fibrous tissue with benign glandular epithelium around hyaline cartilage

A

Hamartoma

63
Q

Respiratory pathology typically affecting young women, characterized by proliferation of modified smooth muscle cells, positive for melanoma markers like HMB-45, in addition to perivascular epithilioid cells creating cystic spaces, and may present with penumothorax

A

Lymphangioleiomyomatosis (LAM)

64
Q

Genetic association with lymphangioleiomyomatosis

A

Loss of function of tumor suppressor TSC2

65
Q

Major causes of pleural effusion — if it is transudate

A

Heart failure (increased hydrostatic pressure; “overflow” of liquid from the lung interstitium)

Nephrotic syndrome (decreased plasma oncotic pressure)

Cirrhosis (movement of transudative ascitic fluid through the diaphragm)

66
Q

Major causes of pleural effusion — if it is exudate

A

Inflammatory conditions — infection, PE, CT disease (lupus, RA), adjacent to subdiaphragmatic disease (pancreatitis, subphrenic, subphrenic abscess)

Malignancy

67
Q

How might pleural effusion present grossly in pt with malignancy vs. lymphatic obstruction vs. heart failure?

A

Malignancy - bloody effusion

Lymphatic obstruction - milky chylous effusion

Heart failure - serous transudative effusion

68
Q

Inflammatory exudate with accumulation of pus in the pleural space typically d/t bacterial infection, notorious for creating loculations (web-like traps for fluid); fluid will be thick, yellow with smears of fluid showing neutrophils and often bacteria

A

Empyema

69
Q

Primary (lung) causes of pneumothorax

A

Rupture of subpleural blebs (usually young patients)

70
Q

Secondary causes of pneumothorax

A 
Cystic infections (PCP)
Cystic tumors
Rupture of subpleural blebs
Positive-pressure ventilation
Trauma
71
Q

What causes tension pneumothorax?

A

Injury to the chest wall, resulting in one-way valve allowing air into the pleural space, but not out

[it is the expansion of the chest wall that is responsible for inspiration, and air will be pulled in from wherever it is easiest. In a closed system, air is a space-occupying lesion

72
Q

Compare primary vs. tension pneumothorax in terms of pressure in the pleural cavity

A

Primary: pleural cavity pressure is less than atmospheric pressure

Tension: pleural cavity pressure is greater than the atmospheric pressure

73
Q

Malignancy associated with asbestos exposure, and may occur decades after the exposure (lifetime exposure risk is as high as 10%)

A

Mesothelioma

74
Q

Ferruginous bodies on histological exam are manifestations of _______, which in worst case scenarios may progress to mesothelioma

A

Asbestosis

75
Q

Variants of mesothelioma

A

Epithelioid
Sarcomatoid
Mixed

76
Q

Special stains like ______ help distinguish mesothelioma from adenocarcinoma

A

Calretinin

77
Q

Prognosis for mesothelioma

A

Difficult to treat — cannot be easily excised, limited responsiveness to chemotherapy and radiation

Most patients will not live 2 years after diagnosis, even in early stage disease

Respiratory Medicine Exam I (9 decks)

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