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USMLE > Respiratory Pathology > Flashcards

Respiratory Pathology Flashcards

1
Q

What does a ‘barrel chest’ indicate?

A

Hyperinflation, as in COPD. In particular, it may be seen in emphysema

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2
Q

What do unilateral diminished breath sounds indicate?

A

Pneumothorax

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3
Q

What do acute bilateral diminished breath sounds indicate?

A

Asthma (attack)

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4
Q

What do chronic bilateral diminished breath sounds indicate?

A

Emphysema (due to reduced lung tissue)

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5
Q

What may chronic wheeze suggest?

A

Obstructive disease, e.g. asthma or COPD

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6
Q

What may acute wheeze suggest?

A

FB aspiration

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7
Q

What does stridor represent?

A

Tracheal or laryngeal obstruction

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8
Q

What does dullness to percussion indicate?

A

Lung consolidation, e.g. pneumonia

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9
Q

What does increased tactile remits indicate?

A

Lung consolidation, e.g. pneumonia

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10
Q

What are the 3 obstructive lung diseases?

A
  1. COPD (emphysema + bronchitis)
  2. Asthma
  3. Bronchiectasis
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11
Q

What is the hallmark finding of obstructive lung disease?

A

A reduced FEV1/FVC ratio

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12
Q

What 2 diseases does COPD include?

A
  1. Emphysema

2. Chronic bronchitis

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13
Q

What is the underlying pathogenesis of emphysema?

A

= underlying loss of elastic recoil + dilatation of terminal air spaces

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14
Q

How may smoking cause emphysema?

A

The enzyme elastase digests elastin. Cigarette smoke both inactivates alpha-1-antitrypsin (which prevents elastase becoming active) and attracts inflammatory cells (which produce elastase)

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15
Q

How may hereditary alpha-1-antitrypsin deficiency cause emphysema?

A

There is a lack of alpha-1-antitrypsin and it is alpha-1-antitrypsin that prevent elastase from being constitutively active

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16
Q

What proportion of emphysema does hereditary alpha-1-antitrypsin deficiency constitute?

A

1%

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17
Q

Where does emphysema shift the compliance curve of the lungs?

A

Up + left

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18
Q

How might a typical emphysema patient be described?

A

Pink puffer (not cyanotic, although both ventilation and perfusion are both reduced, the V/Q mismatch is not severe)

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19
Q

What are the signs of emphysema O/E?

A
  1. Cachexic
  2. Tri-poding
  3. Accessory muscle use
  4. Signs of hyperinflation
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20
Q

What are the 2 main pathological types of emphysema?

A
  1. Panacinar

2. Centriacinar

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21
Q

What is panacinar emphysema?

A

Primarily affects the lower lobes. Dilatation of the entire acinus. Associated with alpha-1-antitrypsin deficiency

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22
Q

What is centriacinar emphysema?

A

Pattern of involvement is irregular, or localised to the upper lobes. Dilatation of the just the proximal part of the acinus, i.e. the respiratory bronchioles. Associated with smoking

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23
Q

What is the clinical definition of chronic bronchitis?

A

A productive cough for at least 3/12 per year over 2 consecutive years

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24
Q

What is the underlying pathogenesis of chronic bronchitis?

A
  1. Smoking = proliferation and hypertrophy of bronchial mucous glands. = excessive mucus production, which is also more viscous than normal.
  2. The cilia lining of the bronchial lumen us also damaged, impeding mucus clearance.
  3. Inflammatory cell influx = airway inflammation.
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25
Q

How might a typical chronic bronchitis patient be described?

A

Blue bloater (cyanotic - there is significant V/Q mismatch due to the reduced ventilation as a result of damaged airways, but the preservation of perfusion)

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26
Q

What are the signs of chronic bronchitis O/E?

A
  1. Obese
  2. Peripheral oedema (due to associated right ventricular failure)
  3. Cyanosis of peripheries
  4. Clubbing - as a result of the hypoxaemia
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27
Q

What condition might arise as a result of chronic bronchitis?

A

Cor pulmonale, as a result of the pulmonary HTN secondary to hypoxaemia and pulmonary vasoconstriction

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28
Q

What lung condition may occur in CF patients? + why?

A

Bronchiectasis. Because the thick mucus secretions produced are difficult to clear + harbour bacteria, resulting in chronic infection

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29
Q

What bacteria, although rare, almost exclusively colonises the lungs of patients with CF?

A

Burkholderia cepacia

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30
Q

What bacteria more commonly colonise the lungs of CF patients?

A
  1. Pseudomonas aeruginosa
  2. S.aureus
  3. H.influenzae
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31
Q

What drug may be given to CF patients to break down the thick mucus secretions?

A

DNase

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32
Q

What is bronchiectasis?

A

Irreversible dilatation of the airways

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33
Q

What are the causes of bronchiectasis?

A
  1. CF (due to the thick mucus causing chronic infection)
  2. Infection
  3. Obstruction (often tumour)
  4. Airway clearance defect (e.g. Kartagener syndrome)
    (all lead to the inflammatory destruction of airways)
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34
Q

What may be seen on a bronchiectasis XR?

A

Ring shadows

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35
Q

What is the preferred method of bronchiectasis diagnosis?

A

CT

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36
Q

What are the patterns of airway dilatation seen in bronchiectasis?

A
  1. Cylindrical
  2. Varicose
  3. Saccular
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37
Q

What is the difference between asthma and COPD?

A

Asthma = a REVERSIBLE obstructive disease (whereas COPD is IRREVERSIBLE)

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38
Q

What are the 2 sub-types of asthma?

A
  1. Extrinsic

2. Intrinsic

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39
Q

What type of hypersensitivity reaction is extrinsic asthma?

A

Type I

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40
Q

What are the features of extrinsic asthma?

A

Type I hypersensitivity, involving IgE and mast cells.
Begins in childhood/in those with a FHx of atopy.
Allergens = animal dander (esp. cats); pollen; mold; dust mites

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41
Q

What are the features of intrinsic asthma?

A

Allergens = cold; exercise; cigarette smoke; medication (esp. aspirin); stress

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42
Q

Which mediators are associated with inflammation in asthma?

A

Eosinophils; lymphocytes; histamine; leukotrines; IgE

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43
Q

Which growth factors cause fibrosis in asthma?

A

EGF; IGF-1; PDGF

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44
Q

With epithelial-derived mediator causes bronchoconstriction in asthma?

A

Endothelin-1

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45
Q

With epithelial-derived mediators cause vasodilation in asthma?

A

NO; PGE2; 15-HETE

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46
Q

With epithelial-derived mediators (all cytokines) cause inflammation in asthma?

A

GM-CSF; IL-8; RANTES; Eotaxin

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47
Q

What are the ‘relievers’ used in asthma?

A
  1. Short-acting beta-2-agonists
  2. Ipratropium
  3. IV steroids
  4. Magnesium sulfate
  5. Epinephrine
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48
Q

What are the ‘controllers’ used in asthma?

A
  1. PO steroids
  2. Inhaled steroids
  3. Long-acting beta-2-agonists
  4. Xanthines
  5. Mast cell stabilisers
  6. Leukotrine blockers
  7. Omalizumab
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49
Q

What is the name of a severe asthma attach refractory to therapy?

A

Status asthmaticus

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50
Q

What actions of steroids are useful in their relief of asthma?

A

Reduce inflammation by:

  1. Decrease cytokine formation
  2. Inactivation of a nuclear factor of activated B cells
  3. Inhibition of generation of vasodilators
  4. Decreasing microvascular permeability
  5. Reducing mediator release from eosinophils
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51
Q

What is the action of Xanthines?

A

Increase cAMP in smooth muscle cells though inhibition of phosphodiesterase isoenzymes, leading to airway dilatation

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52
Q

What is the action of mast cell stabilisers?

A

Inhibits the release of inflammatory mediators from mast cells

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53
Q

What is the action of leukotrine blockers?

A

Inhibit 5-lipoxygenase, reducing the conversion of arachidonic acid to leukotrienes

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54
Q

What is the action of Omalizumab?

A

= monoclonal Ab. Binds to circulating IgE

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55
Q

What are the 2 categories of restrictive lung diseases?

A
  1. Extrapulmonary disorders

2. Interstitial lung diseases

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56
Q

What characterises sarcoidosis?

A

Non-caseating granulomas, often involving multiple organ systems

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57
Q

How does hypersensitivity pneumonitis differ from asthma and allergy?

A

= not a type I hypersensitivity reaction.

It is an alveolar disease, whereas asthma is a disease of the bronchi.

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58
Q

How is hypersensitivity pneumonitis definitively diagnosed?

A

Biopsy - loosely organised granulomas - + consistent Hx

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59
Q

What is the usual cause of a spontaneous pneumothorax?

A

Rupture of an air-filled lung bleb

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60
Q

In what direction will the mediastinum/trachea deviate in a tension pneumothorax?

A

AWAY from the side of the pneumothorax

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61
Q

What does the term ‘allergy’ refer to?

A

Type I hypersensitivity —- mediated by IgE —- results in mast cell degranulation and histamine-mediated vascular permeability

62
Q

How may we test for allergies?

63
Q

What is the action of first-generation anti-histamines?

A

Reversible antagonists of H1 histamine receptors, therefore reversing the vascular permeability caused by mast cell degranulation

64
Q

Can first-generation anti-histamines cross the BBB?

A

Yes, this is responsible for the S/E of drowsiness

65
Q

What is the difference between first-generation and second-generation anti-histamines?

A

Second-generation does not cross the BBB

66
Q

How do nasal decongestants work?

A

Reduce congestion and oedema by increasing alpha-1-adrenergic signalling

67
Q

What organism is responsible for ‘strep throat’?

A

Streptococcus pyogenes

68
Q

What may treatment of streptococcus pyogenes, with penicillin V, prevent?

A

Rheumatic fever

69
Q

What is epiglottitis most commonly caused by?

A

H.influenzae

70
Q

What may croup be caused by?

A
  1. Parainfluenza virus
  2. Influenza virus
  3. RSV
71
Q

What is the classic train of croup in a child?

A
  1. Barking cough
  2. Stridor
  3. Hoarseness
72
Q

What stain is used for TB?

A

Ziehl-Neelsen acid-fast stain

73
Q

What type of bacterium is mycoplasma tuberculosis?

A

Aerobic, rod-shaped acid-fast bacterium

74
Q

How does Miliary TB become disseminated?

A

Haematogenous spread

75
Q

Where is secondary TB most likely to be found in the lungs?

76
Q

What characterises primary TB?

A

Ghon complex development, developing into a granuloma, developing into Ranke complex

77
Q

What is a Ghon complex?

A

= a peripheral parenchymal lesion called a Ghon focus and granulomas in involved hillier lymph nodes

78
Q

What is the type of hypersensitivity reaction of the Mantoux test?

A

Type IV hypersensitivity reaction

79
Q

What is the treatment for TB? (RIPE)

A

Rifampicin
Isoniazid
Pyrazinamide
Ethambutol

All taken for the first 2 months, rifampicin and isoniazid continued for a further 4 months

80
Q

What are the 4 R’s of rifampicin?

A 
R = ramps up cP450 metabolism
R = red or orange urine
R = resistance when used alone
R = RNA polymerase inhibition is it's mechanism of action
81
Q

How may pneumonia be classified?

A

Community-acquired vs. hospital acquired

Typical vs. atypical

82
Q

What does typical pneumonia tend to cause?

A

Lobar pneumonia and broncho-pneumonia

83
Q

What does atypical pneumonia tend to cause?

A

Interstitial pneumonia

84
Q

Which organisms are neonates particularly susceptible to?

A

Group B strep; E.coli; viral pneumonia

85
Q

Which organisms are the elderly particularly susceptible to?

A

Gram-negative bacilli

86
Q

What is typical pneumonia usually caused by?

A

S.pneumonia; S.aureus; Haemophilus; Klebsiella

87
Q

What is atypical pneumonia usually caused by?

A

Mycoplasma; Coxiella; Legionella; Chlamydophila

88
Q

What are the complications of pneumonia?

A
  1. Abscess

2. Empyema

89
Q

How does lobar pneumonia appear on CT?

A

Tends to spread through an entire lobe. Classically caused by streptococcus pneumoniae

90
Q

How does broncho-pneumonia appear on CT?

A

Patchy, involving more than one lobe. Can be caused by a wide variety of organisms

91
Q

How does interstitial pneumonia appear on CT?

A

Diffuse + patchy. Sometimes very subtle

92
Q

Whom is most susceptible to viral pneumonia?

93
Q

What viral organisms may be responsible for viral pneumonia?

A

Influenza virus
Adenovirus
Rhinovirus
RSV

94
Q

How do you treat pneumonia caused by influenzae A?

A

Amantadine + rimantadine

95
Q

How do we treat pneumonia caused by strep pneumoniae?

A

Penicillins
Cephalosporins
Macrolides
Some quinolones

96
Q

What is the complication associated with strep pneumoniae?

97
Q

How would a pneumonia caused by strep pneumoniae present?

A

Rust-coloured sputum, lobar pneumonia

98
Q

What type of bacteria is strep pneumoniae?

A

Gram +ve diplococci

99
Q

What are the common gram-positive bacteria?

A

Strep pneumoniae

Staph aureus

100
Q

What are the common gram-negative bacteria?

A 
H influenzae
Klebsiella
Pseudomonas aeruginosa
Legionella 
Moraxella
101
Q

What type of bacteria is staph aureus?

A

Gram +ve cocci in clusters

102
Q

What type of pneumonia does staph aureus cause?

A

Bronchopneumonia

103
Q

What are the potential complications of pneumonia caused by staph aureus?

A

Abscess formation/empyema. Bacterial endocarditis + abscesses of the brain etc. are possible from haematogenous spread

104
Q

How may pneumonia caused by staph aureus treated?

A

Oxacillin, nafcillin, vancomycin (for MRSA)

105
Q

How may pneumonia caused by H influenzae by treated?

A

2nd or 3rd generation cephalosporins

106
Q

What are the potential complications of pneumonia caused by H influenzae?

A

Meningitis, epiglottitis in infants/children

107
Q

What type of bacteria is H influenzae?

A

Gram -ve coccobacillus

108
Q

What type of pneumonia is caused by H influenzae?

A

Bronchopneumonia

109
Q

What type of bacteria is Klebsiella?

A

Gram -ev rod

110
Q

In whom does Klebsiella pneumonia tend to occur?

A

Diabetic and alcoholic patients. Has high mortality in the elderly

111
Q

How does a pneumonia caused by Klebsiella present?

A

Red-current jelly sputum bronchopneumonia

112
Q

What are the potential complications of a Klebsiella pneumonia?

A

Necrosis and abscess formation

113
Q

How may a pneumonia caused by Klebsiella be treated?

A

Aminoglycosides or 3rd generation cephalosporins

114
Q

What type of bacteria is pseudomonas aeruginosa?

A

Gram -ve rod

115
Q

In whom is a pseudomonas aeruginosa pneumonia most likely?

A

Immunocompromised patients or CF patients

116
Q

How do you treat a pseudomonas aeruginosa pneumonia?

A

Combination therapy of ticarcillin, piperacillin, ciprofloxacin, cefepime or gentamicin

117
Q

What are the complications of a pseudomonas aeruginosa pneumonia?

A

Focal haemorrhage and necorosis

118
Q

What type of bacteria is legionella?

A

Gram -ve coccobacillus

119
Q

What culture is used for legionella?

A

Charcoal yeast agar plus iron and cysteine for culture. It stains poorly

120
Q

How is a pneumonia caused by legionella treated?

A

Macrolides, quinolones

121
Q

How is legionella spread?

A

Inhalation of aerosol from contaminated water

122
Q

What type of bacteria is moraxella?

A

Gram -ve diplococci

123
Q

What type of pneumonia does moraxella cause?

A

Bronchopneumonia

124
Q

How may a pneumonia be caused by moraxella be treated?

A

2nd or 3rd generation cephalosporins, macrolides, quinolones

125
Q

What colour is pseudomonas aeruginosa upon culturing?

A

Blue-green

126
Q

When is a anaerobe most likely to cause a pneumonia?

A

Upon aspiration

127
Q

How may a pneumonia caused by an anaerobe be treated?

A

Penicillin, clindamycin

128
Q

What is a frequent cause of interstitial pneumonia in young adults?

A

Mycoplasma pneumoniae

129
Q

How is pneumonia caused by mycoplasma pneumoniae treated?

A

Macrolides, quinolones, tetracyclines

130
Q

What are the intracellulars that can cause pneumonia?

A

Mycoplasma pneumoniae
Chlamydophila pneumoniae
C psittaci
Coxiella burnetii

131
Q

What is most likely to be responsible fro a pneumonia in a individual who works with cattle or sheep (or those that drink unpasteurised milk from infected animals)?

A

Coxiella burnetii

132
Q

Aside from pneumonia, what else can coxiella brunette cause?

A

Hepatitis or myocarditis

133
Q

How may a coxiella burnetii pneumonia be treated?

A

Doxycycline

134
Q

What causes coccidiodomycosis?

A

Coccidioides immitis

135
Q

What is coccidiodomycosis?

A

Can cause granulomas, in which fungal spherules containing endosporins can be found.
Found in Southwestern USA, Mexico and S. America

136
Q

How is coccidiodomycosis treated?

A

Amphotericin B

137
Q

What causes candidiasis infection of the lungs?

A

Candida albicans (yeast)

138
Q

What is candidiasis infection of the lungs?

A

An uncommon cause of pneumonia but may be seen in immunocompromised patients

139
Q

How is candidiasis infection of the lungs treated?

A

Amphotericin B + fluconazole

140
Q

What causes cryptococcosis infection of the lungs?

A

Cryptococcus neoformans (yeast)

141
Q

What is cryptococcosis infection of the lungs?

A

Associated with pigeon droppings.
May also cause cryptococcal meningitis, seen with India ink stain, but definitively diagnosed with latex agglutination test

142
Q

How is cryptococcosis infection of the lungs treated?

A

Cryptococcal meningitis = amphotericin B + flucytosine

Non-CNS involvement = fluconazole

143
Q

What causes aspergillosis?

A

Aspergillus (mold)

144
Q

How is aspergillosis treated?

A

Amphotericin B or itraconazole

145
Q

What causes blastomycosis?

A

Blastomyces dermatitidis

146
Q

What is blastomycosis?

A

Lung infection, but there may also be skin lesions, bone lesion and GU involvement.
It is inhaled from soil.
Found in the midwestern and south-eastern USA.

147
Q

How is blastomycosis treated?

A

Amphotericin B or itraconazole

148
Q

What causes histoplasmosis?

A

Histoplasma capsulatum

149
Q

What is histoplasmosis?

A

Caseating granulomas from, in its disseminated form this can involve multi-system involvement.
Found in the river valleys of central USA + in soil contaminated with bird or bat droppings.

150
Q

How is histoplasmosis treated?

A

Amphotericin B +/- itraconazole

151
Q

What is coccidiodomycosis?

A

Can cause granulomas, in which fungal spherules containing endosporins can be found.
Found in Southwestern USA, Mexico and S. America.

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