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CRRAB II > Respiratory Pathology Lecture 2 > Flashcards

Respiratory Pathology Lecture 2 Flashcards

1
Q

What is required for infection of the lungs?

A
  1. Defect in host defenses and/or pre-existing acute or chronic lung disease
  2. Markedly virulent organism
  3. Overwhelming infections
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2
Q

Predisposing factors to pneumonia (11)

A
  1. Extremes of age
  2. Altered consciousness: poor cough/expectoration and increased aspiration risk
  3. Cigarette smoking
  4. COPD
  5. Pulmonary Edema
  6. Malnutrition
  7. Immunosuppression
  8. Cystic fibrosis
  9. Immotile cilia
  10. Bronchial obstruction
  11. Viral URI w/secondary bacterial pneumonia
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3
Q

Clinical classification of pneumonia (4)

A
  1. Community acquired
  2. Hospital/healthcare facility acquired
  3. Immunocompromised
  4. Immunocompromised w/chronic pneumonia
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4
Q

Is “atypical” pneumonia milder or more severe than common bacterial pneumonia? How do you differentiate?

A

Atypical milder. Can’t differentiate clinically due to symptom overlap

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5
Q

What % of patients w/pneumonia may be afebrile?

A

20% esp. elderly

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6
Q

When and in who does leukopenia w/pneumonia usually occur?

A

Overwhelming infection. Esp. in infants and elderly.

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7
Q

How often is pneumonia etiology discovered w/max. lab effort?

A

Only 50-60% of patients

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8
Q

How often is causative bug of pneumonia identified in everyday clinical practice?

A

10-20%

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9
Q

How are most hospitalized pneumonia patients treated?

A

Empirically w/o bug I.D

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10
Q

How effective are empiric antibiotics in community acquired pneumonia?

A

> 95% of patients.

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11
Q

Microbiological means of dx of pneumonia (7)

A
  1. SPUTUM (stains, culture, PCR)
  2. Culture of aspirated pleural/empyema fluid or lung abscess
  3. Urinary antigen testing (pneumococcus, legionellaa)
  4. Lung biopsy (for culture and histology)
  5. Serology.
  6. Blood culture
  7. Procalcitonin (emerging test)
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12
Q

Is the organism identified from sputum or other respiratory secretions always causative of the patients pneumonia?

A

Not always. May just be a respiratory tract colonizer.

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13
Q

Which bugs if identified in lungs are always regarded as causative? Why is it important to identify these?

A
  1. Legionella
  2. Influenza
  3. M. tuberculosis
  4. C. psittasi
  5. Agents of bioterrorism
  6. Hanta virus, francisella tularensis, coxiella burnetii
  7. Fungal organisms (histoplasma, blastomyces, coccidioides)

These require different Rx than usual empiric antibiotics!

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14
Q

Most common bugs in community acquired pneumonia?

A

S. pneumoniae, mycoplasma pneumoniae, chlamydophilia pneumoniae, legionella, respiratory viruses

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15
Q

Most common overall causes of pneumonia?

A

Bacteria. Pneumococcus most common overall.

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16
Q

Patients w/prior flu, antibiotic rx, chronic pulmonary disease are at greater risk for pneumonia from what bugs?

A

S. aureus, enterobacteriaceae, pseudomonas

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17
Q

Most common bugs in ind. w/severe pneumonia w/ICU admit

A

S. pneumoniae, enteric gram - bacilli, S. aureus, legionella, H. influenzae, respiratory viruses, pneumocysitis jirovecii, mixed infections (immunosuppressed)

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18
Q

What is the most common cause of viral pneumonia in adults?

A

Influenza (A, B, avian)

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19
Q

How is viral pneumonia best diagnosed?

A

PCR

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20
Q

What are additional types of community-acquired pneumonias depending on endemic risk?

A

TB (esp. immigrant pop.

Fungal disease

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21
Q

S. pneumoniae info

A
  • -colonizes up to 20% of adults
  • -Most common cause of bacterial pneumonia
  • -More definitive dx if bug grown in blood, pleural fluid culture or if + urine antigen test
  • -Usually produce lobar pneumonia
  • -Vaccine available against common serotypes for high risk ind.
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22
Q

H. influenzae info

A
  • -Frequent pharyngeal colonizer
  • -Pneumonia in adults and children
  • -S/P type B vaccine (for encapsulated)
  • -Most common type of bacterial pneumonia in COPD patients
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23
Q

Mycoplasma pneumoniae info

A
  • -No cell wall
  • -Up to 15% of community acquired pneumonia
  • -Can have URI sx
  • -Only serology to diagnose
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24
Q

Chlamydophilia pneumoniae info

A
  • -Intracellular bacterium
  • -5-10% community acquired pneumonia
  • -Can have URI sx
  • -Only serological dx
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25
Q

Legionella pneumophilia

A
  • -2-9% community acquired pneumonia
  • -Can have URI sx
  • -Infection from aerosolized water droplets from water reservoirs
  • -Often epidemic outbreaks
  • -Favors patients w/predisposing chronic disease
  • -Fatality up to 50%
  • -Urinary antigen test/growth on diagnostic media
  • -Associated with HYPONATREMIA
26
Q

Gram - bacilli info

A
  • -Common cause of hospital-acquired pneumonia
  • -Typically severe and often require ICU care
  • -Highest risk: mechanically ventilated patients
  • -Klebsiella, pseudomonas aeruginosa, moraxella catarrhalis, other. misc. bugs (E. coli, enterobacter, acinetobacter)
27
Q

Patients at highest risk for Klebsiella infection

A

COPD, diabetes, EtOH abuse, homeless

28
Q

Patients at highest risk for psudomonas aeruginosa infection

A

CF, COPD, IPF, immunocompromised patients

29
Q

Patients at highest risk for moraxella catarrhalis infection?

A

COPD, immunocompromised

30
Q

Group A streptococcus info

A

–Can cause pneumonia w/early empyema formation in young/immunocompetent patients

31
Q

Anaerobic bacteria info

A

–Typically associated w/aspiration of gastric contents

32
Q

Aspiration pneumonia

A

Usually mixed anaerobic/aerobic infection combined w/chemical injury (frequent abscess formation)

33
Q

Influenza info regarding pneumonia

A
  • -Typically outbreaks of disease
  • -Predominantly cause URI w/secondary risk of complicating bacterial pneumonia (esp. staph aureus).
  • -Rapid PCR dx. can be important for guiding dx and rx
34
Q

Varicella pneumonia

A

–Most common complication of varicella infection in healthy adults (10-30% mortality)

35
Q

Hanta virus

A

Infected mice in SW USA

Flu-like sx, non-cardiogenic pulmonary edema

36
Q

Fungal pneumonia in immunocompetent hosts (names of 3)

A

Histoplasmosis, blastomycosis, coccidiodomycosis

37
Q

How does fungal pneumonia occur?

A

Inhalation of spores –> pulmonary infection +/- systemic spread

38
Q

When is fungal pneumonia usually diagnosed?

A

–After failure of empiric antibacterial Rx for dx of common community acquired pneumonia

39
Q

What does CT/CXR usually show w/fungal pneumonia?

A

May show ordinary pulmonary infiltrate or resemble a mass/tumor

40
Q

Pathology of fungal pneumonia?

A

Necrotizing granulomas that can mimic TB and Wegener’s granulomatosis

41
Q

Histoplasmosis info

A
  • -OH/MS river valley regions
  • -Bat/bird droppings
  • -Cave explorers high risk
  • -Flu-like sx w/pulmonary complaints
42
Q

Histoplasmosis CXR and dx

A
  • -CXR: can mimic sarcoidosis, TB, malignancy, associated w/mediastinal/hilar adenopathy
  • -Respiratory secretions and tissue biopsy (culture, fungal stains, urine antigen testing, serology)
43
Q

North American Blastomycosis info

A
  • -Central/SE USA and Great Lakes region
  • -Moist soil w/decaying vegetation
  • -Direct or indirect spore inhalation
  • -Nonspecific pulmonary sx (Cough, fever, sputum production)
  • -Bloodstream dissemination (esp. to skin, bones/joints, GU)
44
Q

Blastomycosis dx

A

Respiratory secretions (sputum and bronchial wash) and tissue bx for culture, fungal stains, emerging PCR methods

45
Q

Coccidiomycosis info

A

SW USA/semi-desert to desert climates “Valley fever”

  • -Ordinary community acquired pneumonia or flu-like sx
  • -possible skin, bones/joints, CNS dissemination (like blasto)
46
Q

Coccidiomycosis Dx and Rx

A
  • -Dx: respiratory secretions, tissue bx for culture, fungal stains, serology, emerging PCR
  • -Treat active pulmonary disease with antifungal drugs (usually -azoles, occasionally amphotericin B)
47
Q

Pneumonia in immunocompromised individuals (common bugs)

A
  • -Increased risk for all common causes of pneumonia
  • -Nocardiosis
  • -Pneumoncystis jirovecii
  • -Cytomegalovirus
  • -Herpes virus/varicella zoster
  • -Atypical mycobacteria
  • -Invasive fungal disease
  • -Parasites
48
Q

Key points about pneumonia in immunocompromised patients

A
  • -Multiple different causative organisms possible
  • -High index of suspicion if patient manifesting new pulmonary/febrile symptoms
  • -Early imaging studies
  • -Aggressive specific pathogen diagnosis needed
49
Q

Pulmonary edema

A

Movement of fluid into alveolar spaces

50
Q

Causes of pulmonary edema

A
  1. Hemodynamically increased alveolar capillary pressure (L HF = cardiogenic pulmonary edema)
  2. Alveolar microvascular injury (ARDS = non-cardiogenic pulmonary edema, high alt. or neurogenic pulmonary edema)
  3. Pulmonary edema w/mixed cardiogenic/ARDS features.
51
Q

Cardiogenic pulmonary edema

A
  • -Increased alveolar capillary pressure due to increased pulmonary venous pressure–> causes increased pulmonary interstitial fluid formation and then alveolar flooding
  • -Most cases from LV failure
  • -Some from vol. overload (IV or blood admin exceeding CV capacity)
52
Q

Causes of LV failure

A

–Systolic or diastolic due to coronary disease, chronic HTN, cardiomyopathy, aortic valve disease, new-onset arrhythmias

53
Q

Clinical presentation of cardiogenic pulmonary edema

A
  1. Acute dyspnea w/anxiety, diaphoresis, hypoxia
    OR
  2. More gradual onset of dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea with cough +/- frothy pink sputum
    –If associated w/chest pain, think MI or aortic dissection
54
Q

Cardiogenic pulmonary edema physical exam findings

A

Tachypnea, tachycardia, HTN or hypotension, cool extremities, rales +/- rhonchi/wheezes (1st in lung bases), cardiac murmurs (S3, valve-related), JVD

55
Q

CXR findings w/cardiogenic pulmonary edema

A

Bilateral basilar interstitial/alveolar infiltrates +/- cardiomegaly
–Can be delayed up to 12 hrs in acute cases

56
Q

BNP findings in cardiogenic pulmonary edema

A

> 400 high positive predictive value for CHF. (Less than 100 is a high negative predictive value)

57
Q

Echocardiography

A

Good bedside assessment for evaluating LV systolic/diastolic function, cardiac pressures, valvular disease, pericardial effusion/tamponade

58
Q

ARDS

A

Syndrome of acute respiratory distress

–Characterized by dyspnea, hypoxemia, diffuse pulmonary infiltrates on CXR

59
Q

Pathology of ARDS

A

Diffuse alveolar damage w/alveolar hyaline membranes evolving to granulation tissue/organizing phase: either resolution or pulmonary fibrosis/death will occur

60
Q

What is ARDS secondary to what type of previous insults within previous 2-3 days

A

Sepsis, trauma, pulmonary infection, gastric aspiration, inhaled irritants, transfusion, drug overdose, near drowning

CRRAB II (13 decks)

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