Respiratory IV (Pneumonia; Sarcoidosis) Flashcards
Which atypical pneumonia is most likely to cause erythema multiforme?
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia
Which atypical pneumonia is most likely to cause erythema multiforme?
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia
Which atypical pneumonia is most likely to cause hyponatraemia?
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia
Which atypical pneumonia is most likely to cause hyponatraemia?
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia - causes SIADH
Chlamydia psittaci
Q fever pneumonia
Which atypical pneumonia is most likely to caused by hanging out with a parrot?
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia
Which atypical pneumonia is most likely to caused by hanging out with a parrot?
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia
Which atypical pneumonia is most likely to caused by farm animals?
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia
Which atypical pneumonia is most likely to caused by farm animals?
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia
Which atypical pneumonia is can cause haemolytic anaemia if left untreated?
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia
Which atypical pneumonia is can cause haemolytic anaemia if left untreated?
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia
What CURB-65 scores would indicate:
Treatment at home [1]
Admission [1]
Intensive care [1]
Score 0/1: Consider treatment at home
Score ≥ 2: Consider hospital admission
Score ≥ 3: Consider intensive care
Which type of organisms are most likely to cause HAP? [1]
Which infective organisms are most likely to cause HAP? [4]
Gram negative organisms:
PEKA:
Pseudomonas aeruginosa,
Escherichia coli
Klebsiella pneumoniae
Acinetobacter species.
What are the features that would make pneumonia atypical? [4]
- symptoms may be subacute or less severe hence the term ‘walking pneumonia’
- absence of lobar consolidation on chest x-ray
- not detectable on Gram stain
- lack of response to penicillin antibiotics
Which organisms are most likely to cause atypical pneumonias? [5]
TOM TIP: You can remember the 5 causes of atypical pneumonia with the mnemonic: “Legions of psittaci MCQs”:
Legions: Legionella pneumophila
Psittaci: Chlamydia psittaci
M – Mycoplasma pneumoniae
C – Chlamydophila pneumoniae
Qs – Q fever (coxiella burnetii)
Atypical pneumonias:
Which type of pneumonia occurs from inhaling infected water from infected water systems, such as air conditioning units? [1]
Legionella pneumophila (Legionnaires’ disease)
The typical exam patient has recently had a cheap hotel holiday and presents with pneumonia symptoms and hyponatraemia
Describe the pathological consequences of Legionella pneumophila [2]
Causes SIADH: results in hyponatraemia
Comparison of Legionella and Mycoplasma pneumonia
Name three distinguishing features of Leginella pneumonia that would differentiate from Mycoplasma pneumonia
Hyponatramia (from SIADH)
Lymphopenia
Diagnosis via urinary antigen
Which drug do you use to tx Legionellas? [1]
With erythromycin/clarithromycin
Describe the clinical features of Mycoplasma pneumonia [3]
- prolonged and gradual onset
- Erythema multiforme RASH: effects 1/3rd of patients on trunks and limbs
- flu-like symptoms ( classically PRECEED a dry, persistent cough
- bilateral consolidation on x-ray
- cold autoimmune haemolytic anaemia
Describe ascultation findings of Mycoplasma pneumonia [1]
Coarse crackles will CHANGE to fine crackles at a late phase (3-5 days after initial onset).
If an atypical pathogen such as Mycoplasma pneumoniae is suspected, it is best to confirm the diagnosis using a [] ?
If an atypical pathogen such as Mycoplasma pneumoniae is suspected, it is best to confirm the diagnosis using a NAAT: e.g., polymerase chain reaction [PCR] on nose and throat swabs
Mycoplasma pneumonia may cause what haematological consequence? [1]
haemolytic anaemia
Name and describe the rash exhibited by Mycoplasma pneumoniae [2]
erythema multiforme:
- Target lesions: pink rings and pale centres
State 4 clinical consequences of untreated Mycoplasma pneumonia [4]
Haemolytic anaemia
Erythema multiforme
Encephalitis
Peri / myocarditis
How do you treat Mycoplasma pneumonia? [2]
1st line:Erythromycin OR Clarithromycin
2nd line: Doxycycline or a macrolide (e.g. )
Because generally there is no diagnosis of the pathogen at the time of treatment, initiation of the treatment is usually empirical
BMJ BP
State and describe this complication of Mycoplasma pneuomia [2]
bullous myringitis: painful vesicles on the tympanic membrane
Which infective organsim causing atypical pneumonia is linked to exposure by bodily fluids of animals? [1]
Coxiella burnetii, or Q fever, is linked to exposure to the bodily fluids of animals. The typical exam patient is a farmer with a flu-like illness.
Atypical pneuomonia
[] is typically contracted from contact with infected birds. The typical exam patient is a parrot owner.
Chlamydia psittaci is typically contracted from contact with infected birds. The typical exam patient is a parrot owner.
How does PCP usually present? [5]
Pneumocystis jirovecii pneumonia (PCP)
dyspnoea
night sweats
dry cough
fever
very few chest signs
Pneumothorax is a common complication of PCP.
What clinical presentation may indicate COVID caused pneuomonia? [1]
Silent hypoxia: Patients may not feel particularly short of breath despite having low oxygen saturations
what is HAP definition with regards to timings? [2]
HAP = Inpatient > 48hrs or less than ten days post discharge
Elderly patients are less likely to suffer pneumonia from which two pathogens? [2]
Mycoplasma pneumoniae
Legionella
Alongside CURB65, describe which test is sometimes used to determine Abx therapy in the primary care setting [3]
NICE also mention point-of-care CRP test. This is currently not widely available but they make the following recommendation with reference to the use of antibiotic therapy:
CRP < 20 mg/L - do NOT routinely offer antibiotic therapy
CRP 20 - 100 mg/L - consider a DELAYED antibiotic prescription
CRP > 100 mg/L - OFFER antibiotic therapy
Describe the treatment algorithm for mild / low severity CAP? [2]
First line: 5 day course
- Amoxicillin
- If if penicillin allergic: clarithromycin (macrolide) OR doxycycline (tetracycline)
Second line:
- No respond to amoxicillin monotherapy, consider adding, or switching to, a macrolide (e.g., clarithromycin).
How quickly should you try and prescribe treatment for moderate severity pneumonia after hospital admission? [1]
This should be within 4 hours of presentation to hospital
Describe the treatment algorithm for confirmed CAP on chest x-ray: presenting in hospital | moderate-severity (CURB-65 = 2)?
7-10 day course is recommended
1st line:
- ORAL amoxicillin plus a macrolide: clarithomycin
- For patients who are allergic to penicillin in whom oral antibiotics are contraindicated: second-generation cephalosporin (e.g., cefuroxime) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone)
PLUS
clarithromycin, or intravenous levofloxacin monotherapy
2nd line:
- Change to doxycycline or a fluoroquinolone: ciprofloxacin AND pneumococcal cover: levofloxacin or moxifloxacin
d
What are NICE guidelines about route of administration about Abx? [1]
NICE guidelines on antimicrobial prescribing in adults recommend reviewing intravenous antibiotics by 48 hours, and considering switching to oral treatment if possible
Describe the treatment algorithm for confirmed CAP on chest x-ray: presenting in hospital | high-severity (CURB-65 = 3-5)?
DOUBLE CHECK
1st line:
- A broad-spectrum beta-lactamase-resistant penicillin: amoxicillin/clavulanate plus a macrolide: clarithromycin
- If allergic to penicillin: second-generation cephalosporin (e.g., cefuroxime) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone) PLUS a macrolide (e.g., clarithromycin)
2nd line:
- Doxycycline OR
- Cefalexin OR
- Trimethoprim
3rd Line:
- levofloxacin
BMJ BP
In patients with suspected or confirmed Staphylococcus aureus MRSA infection, what are the two treatments? [2]
IV Vancomycin
OR
IV teicoplanin
with or without
Rifampicin (orally or intravenously)
State the treatments for these atypical pneumonias [5]
A: Clarithromycin (orally or intravenously)
B: Fluoroquinolone (ciprofloxacin) (orally or intravenously)
C: Amoxicillin (orally) or
D: benzylpenicillin
(intravenously)
E: Doxycycline (orally)
In patients with suspected or confirmed Staphylococcus aureus non-MRSA infection, what are the two treatments? [2]
Flucloxacillin (intravenously)
with or without
Rifampicin (orally or intravenously)
What is the treatment algorithm for mild to moderate symptoms/signs and not at higher risk of resistance for HAP? [2]
How long for? [1]
5 day prescription
ORAL:
- amoxicillin/clavulanate (aka Co-amoxiclax)
- If allergic: Doxycycline
Cefalexin (use caution in penicillin allergy)
Trimethoprim/sulfamethoxazole
NICE
What is the treatment algorithm for severe symptoms/signs and not at higher risk of resistance for HAP? [2]
How long for? [1]
1st line:
- piperacillin/tazobactam OR
- ceftazidime OR
- cefuroxime OR
- meropenem
2nd line:
- levofloxacin
In severe pneumonia, strong suspicion of what needs to be suspected? [1]
How do you manage this? [1]
Pneumonia is one of the main sources of sepsis
State 4 potential extra -pulmonary complications of pneumonia [5]
Bacteremia and sepsis
Acute kidney injury (AKI): esult from sepsis, hypovolemia, or drug-induced nephrotoxicity
Pericarditis: direct extension of pneumonia or hematogenous spread
Label the progress expected post-pneumonia from 1 week - 6 months
1 week:
- Fever should have resolved
4 weeks:
- Chest pain and sputum production should have substantially reduced
6 weeks:
- Cough and breathlessness should have substantially reduced
3 months
- Most symptoms should have resolved but fatigue may still be present
6 months:
- Most people will feel back to normal.
All patients with moderate-severe pneumonia should have what investigations? [3]
(NICE & BTS)
All in patients:
- CXR
- FBC (WCC raised; CRP raised)
- U&E
- LFTS
- Oxygen sats
Moderate-Severe:
- Blood and sputum culture
- Pneumococcal urinary antigen
- Legionella urinary antigen + sputum
All patients with severe + outbreaks of pneumonia should have what investigations? [3]
(NICE & BTS)
All in patients:
- CXR
- FBC (WCC raised; CRP raised)
- U&E
- LFTS
- Oxygen sats
Moderate-Severe:
- Blood and sputum culture
- Pneumococcal urinary antigen
- Legionella urinary antigen + sputum
Severe+:
- Mycoplasma PCR
- Chlamydophilia PCR
- Viral PCR
Urine dipstick tests are only currently available for which two pathogens? [2]
Pneumococcal
Legionella
BUT - don’t give data on sensitivity
BTS Guidelines:
Gram negative enteric bacilli are rec. to be treated with which drugs? [3]
Cefuorxime 1.5g TDS
Cefotaxime 1-2g TDS
Ceftriaxone 1-2g BD IV
BTS guidelines:
What are the treatments for
S. aureus non-MRSA? [1]
S. aureus MRSA? [2]
S. aureus non-MRSA: flucloxacillin
S. aureus MRSA: vancomycin OR linezolid OR teicoplanin +/- rifampicin
How long after the pneumonia do you check up on patients? [1]
6 weeks
Which groups are given a seasonal influenza vaccine? [5]
- All 65+ & 2-4
- Healthcare workers
> 6months in the following groups:
- Asthma
- COPD
- Chronic resp, heart, kidney, liver or neurological disease
- Diabetes
- IS
- Pregnant women
A 69-year-old male is investigated by the respiratory team for worsening shortness of breath and cough over the past nine months. He has never smoked and is usually fit and well. The only significant history of note is that he has taken up pigeon racing since retiring. Following investigation, the patient is diagnosed with interstitial pneumonia.
Which of the following organisms is most commonly associated with interstitial pneumonia?
Haemophilus
Klebsiella
Streptococcus
Staphylococcus
Mycoplasma
Mycoplasma
Define what is meant by sarcoidosis [1]
A chronic granulomatous disorder of unknown aetiology, commonly affecting the lungs, skin, and eyes.
It is characterised by accumulation of lymphocytes and macrophages and the formation of non-caseating granulomas in the lungs and other organs.
Although lungs and lymph nodes are involved in more than 90% of patients, virtually any organ can be involved.
TOM TIP: The typical MCQ exam patient for a presentation of sarcoidisis consistents of what presentation? [4]
20-40 y/o black women
Dry cough
SOB
Nodules on shin (erythema nodosum)
Describe the pathophysiology of sarcoidosis
Sarcoidosis is characterized by an exaggerated immune response, leading to the formation of non-caseating granulomas.:
Antigen presentation
- In genetically susceptible individuals, exposure to a yet unidentified antigenic stimulus triggers the activation of antigen-presenting cells (APCs), such as dendritic cells and macrophages, which present the antigen to CD4+ T-helper cells.
T cell activation:
- APCS & CD4+ Thelpers interacting causes differentation of T helpers into Th1 and Th17s
- Th1 cells: secrete IFN-y & IL-2
- Th17 cells secrete IL-17; IL2-21 & IL-22
Granuloma formation:
- All the cytokines recruit macrophages
- Macrophages transfrom into multinucleated giant cells and create non-causeating granulomas
- The granulomas isolate the antigenic stimulus; limiting tissue damage
Fibrosis:
- In severe cases, sarcoid granulomas lead to fibrosis and therefore organ failure and dysfunction
State what is meant by Lofgren’s syndrome [1]
How does Lofgren’s syndrome usually present? [4]
Lofgren’s syndrome is an acute form of the disease characterised by:
- bilateral hilar lymphadenopathy (BHL)
- erythema nodosum
- fever
- polyarthralgia.
It usually carries an excellent prognosis
Explain what is meant by Heerford’ts syndrome [1]
What is the classical presentation? [3]
Heerfordt’s syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis
Describe the clinical features of sarcoidosis if each of the following are effected:
- Skin [3]
- Lungs [3]
- Systemically [3]
Skin:
- Erythema nodosum - raised, red, tender painful subcut nodules across both shins. Over time they appear as bruises
- Papular sarcoidosis: multiple papules develop, generally on the head and neck or areas of trauma.
- Lupus pernio: specific to sarcoidosis and presents with raised purple skin lesions, often on the cheeks and nose.
What is the name for this symptom of sarcoidosis
Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome
What is the name for this symptom of sarcoidosis
Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome
What is the name for this symptom of sarcoidosis
Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome
What is the name for this symptom of sarcoidosis
Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome
What is the name for this symptom of sarcoidosis
Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome
What is the name for this symptom of sarcoidosis
Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome
Describe the manifestation of sarcoidosis if the effects the following systems:
Pulmonary [3]
Liver [5]
Systemic [3]
Lungs:
* Mediastinal lymphadenopathy
* Pulmonary fibrosis
* Pulmonary nodules
Liver:
* Liver nodules
* Cirrhosis
* Pruritis
* Jaundice
* Cholestasis
Systemic Symptoms:
* Fever
* Fatigue
* Weight loss
Describe the manifestation of sarcoidosis if the effects the following systems:
CNS [3]
Eyes [3]
Heart [3]
Eyes:
* Uveitis
* Conjunctivitis
* Optic neuritis
Heart:
* Bundle branch block
* Heart block
* Myocardial muscle involvement
Central nervous system:
* Nodules
* Pituitary involvement (diabetes insipidus)
* Encephalopathy
Describe the manifestation of sarcoidosis if the effects the following systems:
PNS [2]
Bones [3]
Kindey [3]
Kidneys:
* Kidney stones (due to hypercalcaemia)
* Nephrocalcinosis
* Interstitial nephritis
Peripheral Nervous System:
* Facial nerve palsy
* Mononeuritis multiplex
Bones:
* Arthralgia
* Arthritis
* Myopathy
Which symptoms would indicate that a patient is sufferinf from uveitis? [3]
Photophobia
Red painful eye
Blurred vision
Describe the CXR that would suggest sarcoidosis [5]
- bilateral hilar lymphadenopathy
- right paratracheal adenopathy
- bilateral pulmonary infiltrates, predominantly in the upper lobes
- pleural effusions (rare)
- egg shell calcifications (very rare)
Chest x-ray demonstrates upper zone reticulonodular opacities with extensive mediastinal and hilar nodal enlargement. Stage II sarcoidosis with both nodal and parenchymal disease.
What are the red circles outlining in this CXR of a ptx with sarcoidosis? [1]
Egg shell calcifications
Figure. PA and lateral chest x-rays demonstrate bilateral egg shell calcification of the hilar lymph nodes. See red circles.
State the 5 different CXR stages of sarcoidosis [5]
A chest x-ray may show the following changes:
- stage 0 = normal
- stage 1 = bilateral hilar lymphadenopathy (BHL)
- stage 2 = BHL + interstitial infiltrates (granulomas in the lungs)
- stage 3 = diffuse interstitial infiltrates only
- stage 4 = diffuse fibrosis
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
- stage 0 = normal
- stage 1 = bilateral hilar lymphadenopathy (BHL)
- stage 2 = BHL + interstitial infiltrates
- stage 3 = diffuse interstitial infiltrates only
- stage 4 = diffuse fibrosis
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
stage 1: bilateral hilar lymphadenopathy
Bilateral hilar lymphadenopathy. No lung infiltrations are shown. No fibrosis.
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
There is diffuse reticulonodular
pattern, the lung parenchyma is distorted by fibrosis, and
the right hilum is retracted due to right upper lobe fibrosis
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Stage 2 sarcoidosis with bilateral hilar and right
paratracheal adenopathy and diffuse reticulonodular disease
pattern in the lungs. The appearance is of fine lines and tiny
nodules.
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
What is the name for this symptom of sarcoidosis
Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome
What is the name for this symptom of sarcoidosis
Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome
Describe why sarcoidosis may lead to hypercalcaemia [1]
Hypercalcaemia is seen in around 15% of cases.:
* This occurs due to the uncontrolled synthesis of 1,25-dihydroxyvitamin D3 by macrophages in causing 1-α hydroxylation of 25-hydroxyvitamin D and so increases levels of activated vitamin D
* This leads to increased levels of calcium.
Describe the treatment plan for sarcoidosis for symptomatic patients / moderate & severe disease [4]
First line: Prednisolone:
- High-dose induction: typically 20 - 40mg each day for 4 - 6 weeks
- Dose tapering: the initial dose is gradually reduced (e.g. 5mg every two weeks)
- Maintenance dose: typically 5 - 10mg each day
Second-line agents: classical immunosuppressants
- Methotrexate (first line)
- Azathioprine
- Mycophenolate mofetil.
Third line / refractory disease: biologic therapies
- infliximab
- adalimumab
Lung transplantation
Severe sarcoidosis can lead to which two lung pathologies? [2]
What would indicate lung transplantation for sarcoidosis ptx? [2]
Advanced pulmonary fibrosis
Pulmonary hypertension
What would you prescribe alongside long-term corticosteroids to avoid unwanted side effects of the steroids? [1]
Bisphosphonates protect against osteoporosis whilst on long-term steroids.
Describe a GUM implication of sarcoidosis [1]
Polyuria and polydipsia: increased macrophages caused increaesd Ca2+
Describe the diagnosis pathway for sarcoidosis
Which investigational modality is increasingly used for sarcoidosis? [1]
PET scanning
What treatment might be given to for treating skin sarcoid? [1]
Hydroxychloroquine
Raised serum ACE is indicative of sarcoidosis. Name 4 other pathological states where you might see a raised serum ACE [4]
Raised serum ACE may also be moderate in human immunodeficiency virus (HIV), histoplasmosis, diabetes mellitus, hyperthyroidism, tuberculosis and leprosy.
Define what is meant by sarcoidosis [1]
A chronic granulomatous disorder of unknown aetiology, commonly affecting the lungs, skin, and eyes.
It is characterised by accumulation of lymphocytes and macrophages and the formation of non-caseating granulomas in the lungs and other organs.
Although lungs and lymph nodes are involved in more than 90% of patients, virtually any organ can be involved.
TOM TIP: The typical MCQ exam patient for a presentation of sarcoidisis consistents of what presentation? [4]
20-40 y/o black women
Dry cough
SOB
Nodules on shin (erythema nodosum)
Describe the pathophysiology of sarcoidosis
Sarcoidosis is characterized by an exaggerated immune response, leading to the formation of non-caseating granulomas.:
Antigen presentation
- In genetically susceptible individuals, exposure to a yet unidentified antigenic stimulus triggers the activation of antigen-presenting cells (APCs), such as dendritic cells and macrophages, which present the antigen to CD4+ T-helper cells.
T cell activation:
- APCS & CD4+ Thelpers interacting causes differentation of T helpers into Th1 and Th17s
- Th1 cells: secrete IFN-y & IL-2
- Th17 cells secrete IL-17; IL2-21 & IL-22
Granuloma formation:
- All the cytokines recruit macrophages
- Macrophages transfrom into multinucleated giant cells and create non-causeating granulomas
- The granulomas isolate the antigenic stimulus; limiting tissue damage
Fibrosis:
- In severe cases, sarcoid granulomas lead to fibrosis and therefore organ failure and dysfunction
State what is meant by Lofgren’s syndrome [1]
How does Lofgren’s syndrome usually present? [4]
Lofgren’s syndrome is an acute form of the disease characterised by:
- bilateral hilar lymphadenopathy (BHL)
- erythema nodosum
- fever
- polyarthralgia.
It usually carries an excellent prognosis
Explain what is meant by Heerford’ts syndrome [1]
What is the classical presentation? [3]
Heerfordt’s syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis
Describe the clinical features of sarcoidosis if each of the following are effected:
- Skin [3]
- Lungs [3]
- Systemically [3]
Skin:
- Erythema nodosum - raised, red, tender painful subcut nodules across both shins. Over time they appear as bruises
- Papular sarcoidosis: multiple papules develop, generally on the head and neck or areas of trauma.
- Lupus pernio: specific to sarcoidosis and presents with raised purple skin lesions, often on the cheeks and nose.
What is the name for this symptom of sarcoidosis
Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome
What is the name for this symptom of sarcoidosis
Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome
What is the name for this symptom of sarcoidosis
Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome
What is the name for this symptom of sarcoidosis
Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome
What is the name for this symptom of sarcoidosis
Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome
What is the name for this symptom of sarcoidosis
Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome
Describe the manifestation of sarcoidosis if the effects the following systems:
Pulmonary [3]
Liver [5]
Systemic [3]
Lungs:
* Mediastinal lymphadenopathy
* Pulmonary fibrosis
* Pulmonary nodules
Liver:
* Liver nodules
* Cirrhosis
* Pruritis
* Jaundice
* Cholestasis
Systemic Symptoms:
* Fever
* Fatigue
* Weight loss
Describe the manifestation of sarcoidosis if the effects the following systems:
CNS [3]
Eyes [3]
Heart [3]
Eyes:
* Uveitis
* Conjunctivitis
* Optic neuritis
Heart:
* Bundle branch block
* Heart block
* Myocardial muscle involvement
Central nervous system:
* Nodules
* Pituitary involvement (diabetes insipidus)
* Encephalopathy
Describe the manifestation of sarcoidosis if the effects the following systems:
PNS [2]
Bones [3]
Kindey [3]
Kidneys:
* Kidney stones (due to hypercalcaemia)
* Nephrocalcinosis
* Interstitial nephritis
Peripheral Nervous System:
* Facial nerve palsy
* Mononeuritis multiplex
Bones:
* Arthralgia
* Arthritis
* Myopathy
Which symptoms would indicate that a patient is sufferinf from uveitis? [3]
Photophobia
Red painful eye
Blurred vision
Describe the CXR that would suggest sarcoidosis [5]
- bilateral hilar lymphadenopathy
- right paratracheal adenopathy
- bilateral pulmonary infiltrates, predominantly in the upper lobes
- pleural effusions (rare)
- egg shell calcifications (very rare)
Chest x-ray demonstrates upper zone reticulonodular opacities with extensive mediastinal and hilar nodal enlargement. Stage II sarcoidosis with both nodal and parenchymal disease.
What are the red circles outlining in this CXR of a ptx with sarcoidosis? [1]
Egg shell calcifications
Figure. PA and lateral chest x-rays demonstrate bilateral egg shell calcification of the hilar lymph nodes. See red circles.
State the 5 different CXR stages of sarcoidosis [5]
A chest x-ray may show the following changes:
- stage 0 = normal
- stage 1 = bilateral hilar lymphadenopathy (BHL)
- stage 2 = BHL + interstitial infiltrates (granulomas in the lungs)
- stage 3 = diffuse interstitial infiltrates only
- stage 4 = diffuse fibrosis
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
- stage 0 = normal
- stage 1 = bilateral hilar lymphadenopathy (BHL)
- stage 2 = BHL + interstitial infiltrates
- stage 3 = diffuse interstitial infiltrates only
- stage 4 = diffuse fibrosis
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
stage 1: bilateral hilar lymphadenopathy
Bilateral hilar lymphadenopathy. No lung infiltrations are shown. No fibrosis.
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
There is diffuse reticulonodular
pattern, the lung parenchyma is distorted by fibrosis, and
the right hilum is retracted due to right upper lobe fibrosis
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Stage 2 sarcoidosis with bilateral hilar and right
paratracheal adenopathy and diffuse reticulonodular disease
pattern in the lungs. The appearance is of fine lines and tiny
nodules.
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Which stage of sarcoidosis is depicted in this CXR?
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
What is the name for this symptom of sarcoidosis
Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome
What is the name for this symptom of sarcoidosis
Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome
Describe why sarcoidosis may lead to hypercalcaemia [1]
Hypercalcaemia is seen in around 15% of cases.:
* This occurs due to the uncontrolled synthesis of 1,25-dihydroxyvitamin D3 by macrophages in causing 1-α hydroxylation of 25-hydroxyvitamin D and so increases levels of activated vitamin D
* This leads to increased levels of calcium.
Describe the treatment plan for sarcoidosis for symptomatic patients / moderate & severe disease [4]
First line: Prednisolone:
- High-dose induction: typically 20 - 40mg each day for 4 - 6 weeks
- Dose tapering: the initial dose is gradually reduced (e.g. 5mg every two weeks)
- Maintenance dose: typically 5 - 10mg each day
Second-line agents: classical immunosuppressants
- Methotrexate (first line)
- Azathioprine
- Mycophenolate mofetil.
Third line / refractory disease: biologic therapies
- infliximab
- adalimumab
Lung transplantation
Severe sarcoidosis can lead to which two lung pathologies? [2]
What would indicate lung transplantation for sarcoidosis ptx? [2]
Advanced pulmonary fibrosis
Pulmonary hypertension
What would you prescribe alongside long-term corticosteroids to avoid unwanted side effects of the steroids? [1]
Bisphosphonates protect against osteoporosis whilst on long-term steroids.
Describe a GUM implication of sarcoidosis [1]
Polyuria and polydipsia: increased macrophages caused increaesd Ca2+
Describe the diagnosis pathway for sarcoidosis
Which investigational modality is increasingly used for sarcoidosis? [1]
PET scanning
What treatment might be given to for treating skin sarcoid? [1]
Hydroxychloroquine
Raised serum ACE is indicative of sarcoidosis. Name 4 other pathological states where you might see a raised serum ACE [4]
Raised serum ACE may also be moderate in human immunodeficiency virus (HIV), histoplasmosis, diabetes mellitus, hyperthyroidism, tuberculosis and leprosy.
a prolonged PR interval
