Respiratory: Pleural Infection; Mesothelioma Flashcards
Describe the clinical presentation of pleural infection [4]
Fever
sputum,
chest pain
breathlessness
Which groups should you consider pleural infections in? [4]
- Slow to respond pneumonias
- Pleural effusion with fever
- Malaise/weight loss
- High risk groups
Name some high risk patient groups for pleural infusion [5]
o Diabetes
o Excess alcohol intake
o Gastro-oesophageal reflux (GORD)
o IVDU
o Aspiration and poor dental hygiene
Which investigations would you perform for pleuritc infection? [4]
Diagnostic pleural tap
* Blood culture
* Chest ultrasound
* Chest CT chest
State the difference in investigational findings for:
- simple parapneumonic effusion [4]
- complicated parapneuomic effusion [3]
- Empyema [3]
simple parapneumonic effusion:
- Clear, sterile fluid
- Normal pH
- Normal glucose
- Normal LDH
complicated parapneuomic effusion:
- Fluid infected, but not purulent
- pH < 7.2
- Glucose < 2.2
- LDH > 1000
- Gram stain may be positive
Empyema:
- Pus in pleural space
- Multi-loculated
- Gram stain may be positive
How would you treat the following? [3]
- simple parapneumonic effusion
- complicated parapneuomic effusion
- Empyema
- simple parapneumonic effusion: Abx
- complicated parapneuomic effusion: chest drain
- Empyema: chest drain
What does empyema have a risk of causing? [1]
Fibroblastic changes may occur and cause thick pleura
Which are the most common cause of community acquired infections? [4]
o Streptococcus spp. (~ 52%)
S milleri, S pneumoniae, S intermedius
o Staphylococcus aureus (11%)
o Gram-negative aerobes (9%)
Enterobacteriaceae, E coli
o Anaerobes (20%)
Fusobacterium spp., Bacteroides spp., Peptostreptococcus spp., Mixed
Which are the most common cause of hospital acquired infections? [3]
o Staphylococci
MRSA (25%), S. aureus (10%)
o Gram-negative aerobes (17%)
E coli, Pseudomonas aeruginosa, Klebsiella spp.
o Anaerobes (8%)
Exposure to which substance is identified in 90% of mesothelioma patients? [1]
Asbestos
How long after asbestos exposure does mesothelioma occur? [1]
> 40 yrs exposure
Describe the clinical presentation of mesothelioma patients [5]
Dyspnoea,
weight loss
chest wall pain
Clubbing
30% present as painless pleural effusion
fatigue, profuse sweating, weight loss, anorexia and difficulty in swallowing become common as the disease progresses
presentation and diagnosis often occur at an advanced stage and the prognosis for most patients is extremely poor
How do you investigate for mesothelioma? [4]
-
CXR:
either a pleural effusion or pleural thickening - next step is normally a CT thorax
- if a pleural effusion is present fluid should be sent for MC&S, biochemistry and cytology (but cytology is only helpful in 20-30% of cases)
-
local anaesthetic thoracoscopy is increasingly used to investigate cytology negative exudative effusions as it has a high diagnostic yield (around 95%)
if an area of pleural nodularity is seen on CT then an image-guided pleural biopsy may be used
Which is the most common histological type of mesothelioma? [1]
Name two other types
Epitheloid (50%)
Mixed
Sarcomatoid
Describe the management of mesothelioma [5]
Pleural effusions
- Drainage & pleurodesis (medical or surgical)
Radiotherapy
- To reduce chest wall invasion risk & pain relief
Chemotherapy
- Cisplatin with Pemetrexed or Gemcitibine
Surgery
- selected cases only (high mortality)
- Pain relief
- Palliative Care
Describe chemotherapy that can be used for mesothelioma [3]
- Chemotherapy
- Cisplatin with Pemetrexed or Gemcitibine
Describe the treatment algorithm for a patient with mesothelioma with operable disease [3]
BMJ BP
1ST LINE: surgery
- extra-pleural pneumonectomy [EPP]: removes parietal and visceral pleura
- pleurectomy with decortication pleurectomy removes the lining around the lung (the pleura). Decortication removes tumors or fibrous tissue from the surface of the lung.
PLUS – pre- and/or postoperative chemotherapy:
- cisplatin
AND
- pemetrexed
CONSIDER – radiotherapy
- Post-extrapleural pneumonectomy (EPP) radiotherapy (RT)
Describe the treatment algorithm for a patient with mesothelioma with inoperable disease [3]
1ST LINE – chemotherapy and/or immunotherapy
CONSIDER – radiotherapy
CONSIDER – palliative procedures + supportive care
- Therapeutic thoracentesis and pleurodesis may provide symptomatic relief.
In patients with inoperable or recurrent mesothelioma, chemotherapy and/or immunotherapy is often given in an attempt to improve quality of life and survival.
What is meant by asbestosis? [1]
Asbestosis refers to chronic, diffuse, interstitial fibrosis of the lung related to asbestos exposure.
Asbestos is fibrogenic, meaning it causes lung fibrosis. It is also oncogenic, meaning it causes cancer.
The effects of asbestos usually take several decades to develop. Asbestos inhalation causes several problems. What are they? [4]
Lung fibrosis
Pleural thickening and pleural plaques
Adenocarcinoma
Mesothelioma
What is the difference between length of asbestos exposure between abestos and mesothelioma? [1]
The severity of asbestosis IS related to the length of exposure. This is in contrast
Mesothelioma: even very limited exposure can cause disease.
The latent period is typically 15-30 years.
Asbestosis typically causes fibrosis in which lobes? [1]
Asbestosis typically causes lower lobe fibrosis.
