respiratory_week_4_20190518190116 Flashcards
what does TB look like on chest x-ray
dense consolidation in right upper lobe with cavity formationheals with calcification
what are the main pathogens of TB
m. tuberculosis and m. bovis
how is TB spread
airborne
what is military TB
massive seeding of mycobacteria through bloodstream
what is general symptoms of TB
weight loss, malaise and night sweats
what is respiratory symptoms of TB
cough, haemoptysis, breathlessness and upper zone crackles
what are meningeal symptoms of TB
headache, drowsy, fits
what are GI symptoms of TB
pain, bowel, obstruction
what is spinal symptoms of TB
pain, deformity, paraplegia
what is other symptoms of TB
lymphadenopathy, cold access, pericardial tamponade, renal failure, septic arthritis and hypoadrenalism
what are infections with opportunistic pathogens
virus (cytomegalovirus), bacterium (mycobacterium avian intracellulare), fungi (aspergillus, candida, pneumocystis) and protozoa (cryptosporidia, toxoplasma)
how is TB diagnosed
Zn stain, AAFB, auramine stain, PCR
what is the histology of TB
multinucleate giant cell granulomas, caseating necrosis and sometimes visible mycobacteria
what drugs are used in the treatment of TB
two months of: rifampicin, isoniazid, pyrazinamide, ethambutol four months of: rifampicin, isoniazid
what is side effect if rifampicin
colours urine and all body fluids orange, also potent inducer of cytochrome enzymes (breaks down steroid molecules)
what is side effects of ethambutol
causes optic neuritis
what is latent TB
symptom free and culture negative - history of TB prior to 1960, calcification on X ray and exposure to high prevalence area
what is secondary TB
the reactivation of latent TB (due to age, coincident disease e.g. HIV, immunosuppressives)
how is previous exposure of TB tested for
interferon gamma release assay (blood test)mantoux test (skin test) - also tests for BCG - can cause type 4 hypersensitivity reason
what is treatment of latent TB
either treat or leave alonedrugs: 6 months of isoniazid or 3 month of rifampicin and isoniazid (both cause liver disturbance)
what is BCG immunisation
attenuated strain of mycobacterium bovis, most effective in neonates of high risk families
why should all TB cases be offering HIV test and vice versa
they go hand in hand
when should you consider pleural infection
when patient not settling with 2-3 days antibiotics
what can pleural infections rapidly coagulate and organise to form
fibrous peels even with antibiotics
what is risk factors for pleural infections
diabetes mellitus, immunosupression, gastro-oesophagel reflux, alcohol misuse, IV drug abuse
what is a complicated parapneumonic effusion
+ve stain, pH <7.2, low glucose, septations and loculations
what is pleural empyema
pus in pleural cavity
what is management of pleural infection
antibiotics and drainnutrition, VTE prophylaxis, fibrinolytic and reassess patients who do not improve
what are some gram positive upper respiratory tract colonisers
a-haemolytic streptococci: strep pneumoniaeb-haemolytic streptococci: strep pyogenes staphlyoccus aureus
what are some gram negative upper respiratory tract colonisers
haemophilus influenza moraxella catarrhalis
what bacteria could be responsible for acute exacerbation of COPD
haemophilus influenza, moraxella catarrhalis, streptococcus pneumoniae and others
which bacteria causes whooping cough
bordetella pertussis: gram negative coccobacillus
how is bordetella pertussis diagnosed
bacterial culture, PCR or serology
how is whooping cough treated in children under one month
clarythromycin
how is whooping cough treated in children over one month
clarythromycin / azithromycin
how is whooping cough treated in pregnancy
erthryromycin
what is cystic fibrosis
inherited disease which leads to abnormally viscous mucous - blockage of many tubular structures inc airways and lungs (repeated chest infection and chronic colonisation)
what bacteria most prominent in cystic fibrosis
pseudomonas aeruginosa and burkholderia cepacia
how is pneumonia caused
fluid (oedema) in alveolar airspaces causes swelling, leads to consolidation, thickened alveolar walls and congested capillaries
what is lobar pneumonia
only in specific lobe(s)
what is broncho pneumonia
infection starts in airway and spreads to lung (usually pre existing disease)
what is the most common bacteria in community acquired
streptococcus pneumoniae
what is used to assess severity of pneumonia
CURB65confusion urea >7resp rate >30/minblood pressure (<90/<60)65 or older add 10% if COPDscore 3 or greater severe
when is mycoplasma pneumoniae common and what is symptoms
older children and young adultsdry cough, autoimmune anaemia and erythema multiforme, atypical chest signs
what is used to treat mycoplasma pneumoniae
erythromycin / doxycycline resistant to beta lactams (penicillin etc)
what causes aspiration pneumonia
inhalation of foreign material into lungs
who is most likely to get PCP (pneumocystis carinii pneumonia/pneumocystis jirovecii) and what is signs
immunosuppressed patients (HIV, cancer, steroids) dry cough, no atypical chest signs
how is PCP treated
trimethoprim / sulfamethoxazole / co-trimoxazole
what is legionella pneumonia and what is signs
inhalation of bacteria in contaminated water GI symptoms, renal failure - low sodium and lymphocytes in returning traveller - gram negative bacteria
how is legionella pneumonia treated
clarithromycin, erythromycin and quinolones (levofloxacin)
what is chlamydia trachomitis
STI that causes infantile pneumonia
what is chlamydia pneumoniae
transferred person to person, causes mild respiratory tract infection
what is staphylococcus aureus
recent influenza infection, IV drug user
what is gram negative enterobacteria
alcoholic, usually from achalasia - vomiting
what is fungal (aspergillus) pneumonia and how is it treated
fungal infection that result in pneumonia, breathlessness - treat with surgery, voriconazole, amphorericin B
what is the treatment for severe hospital acquired pneumonia
IV amoxicillin + metronidazole + gentamicin allergic: co-trimoxazole + metronidazole + gentamicin
what is haemophilus influenzae (hospital acquired)
bacteria, “atypical pneumonia”, nursery workers, people with COPD
what is coxiella burnetti (hospital acquired)
Q fever - sheep, goats, cattle, farms culture negative endocarditis responds to tetracylline, macrolides
what is chlamydophilia psittaci (hospital acquired)
caught from pet birds, presents as pneumonia
what is klebsiella pneumoniae (hospital acquired)
gram negative anaerobe, caviating, alcoholism, diabetes, chronic lung diseasetreat with crabapenems (resistant to b lactams)
general symptoms of pneumonia
malaise, anorexia, sweats, rigor, myalgia, arthralgia, headache, confusion, cough, pleurisy, haemoptysis, dyspnoea, preceding URTI, abdominal pain, diarrhoea
general signs of pneumonia
dull to percuss, bronchial breathing (differentiated from PE), crackles, rub heard, cyanosis, hypotension, can reactivate mouth herpes, tachypnoea (rapid breathing)
what are severity markers of pneumonia
temperature less than 35 or greater than 40 cyanosis PaO2 < 8kPawhite blood count <4 or >30multi-lobar involvement
what investigations take place in diagnosis of pneumonia
blood culture (WCC and CRP), serology, PCR, arterial gases, full blood count, urea, liver function, CXR (consolidation)
what are the complications of pneumonia
organisation (scarring), abscess/cavitation, metastatic lung infection, bronchiectasis, respiratory/ARDS/multi-organ failure, pleural / paraneumonic effusion, empyema, death
what increases the risks of pneumonia
smoking, heart failure, diabetes, COPD/asthma, flu, steroids, proton pump inhibitors
what is clinical features of phagocyte deficiencies
recurrent infection
what organisms cause phagocyte deficiencies
common bacteria (staphylococcus aureus) unusual bacteria (burkholderia cepacia) mycobacteria (both TB and atypical) and fungi (candida, aspergillus)
what does failure of neutrophil differentiation cause
severe congenital neutropenia and cyclic neutropenia = shortage of neutrophils - recurrent infection
what does failure to express leukocyte adhesion markers cause
leukocyte adhesion deficiencies = recurrent infection
what does any antibody or complement deficiency cause
failure of opsonisation
what does failure of oxidative killing cause
chronic granulomatous disease
what does failure of cytokine production cause
IFNy and IL-12 deficiency
what is the life cycle of a T lymphocyte
arise from haematopoetic stem cells in bone marrow, exported as immature cells to thymus where undergo selection (10% survive), mature T lymphocyte enter circulation and reside in lymph nodes
what is a defect of haemopoetic stem cells
recticular dysgensis - failure of production of neutrophils, lymphocytes, monocyte/macropages and platelets
what does failure of lymphocyte precursors cause (T cell maturation)
severe combined immune deficiency
what does failure of thymic development cause (T cell maturation)
DiGeorge syndrome
what does failure of expression of HLA molecules cause (T cell maturation)
bare lymphocyte syndromes
what does failure of signalling, cytokine production and effector functions cause (T cell maturation)
IFNy deficiency, IL-12 deficiency
what does failure of normal apoptosis cause (T cell maturation)
autoimmune lymphopoliferative sundromes
what does failure of B cell maturation cause
X-linked agammaglobulinaemia = few B cells
what does failure of lymphocyte precursor cause (B cell maturation)
severe combined immune deficiency
what does failure of production of IgG antibodies cause (B cell maturation)
common variable immune deficiency and selective antibody deficiency
what does failure of IgA production cause (B cell maturation)
selective IgA deficiency
what is causes of stridor in children
infections (croup, epiglottis, diphtheria), foreign body, anaphylaxis / angioneurotic oedema
what is causes of stridor in adults
neoplasms of larynx, trachea and major bronchi, anaphylaxis, trauma (strangulation, burns)
what is the management of malignant airway obstruction
tumour removal: laser, photodynamic therapy, cryotherapy, diathermy, surgical resection tumour compression by intraluminal stent radiotherapy, chemotherapy & steroids
what is the treatment for anaphylxis
IM epinephrine (adrenaline)IV antihistamine or corticosteroids high flow O2nebulised bronchodilator endotracheal intubation
what is snoring
relaxation of pharyngeal dilator muscles during sleep - upper airflow narrowing, turbulent airflow and vibration of palate and tongue base
what is sleep apnoea
intermittent upper airway collapse
what are risk factors for sleep apnoea
enlarged tonsils, obesity, retrognathia, hypothyroidism, oropharyngeal deformity, neurological issues, drugs, and post op period
what is the consequences of sleep apnoea
daytime sleepiness, personality, cognitive impairment, increase RTA risk, hypertension, raised CRP, impaired endothelial function and glucose tolerance
how to diagnose sleep apnoea
snoring, raised EDS score (normal <12/24), overnight sleep study and full polysmnography
what is treatment of sleep apnoea
remove underlying cause, CPAP (continuous positive airway pressure)others: mandibular advancement device (snoring) and surgery (UPPP, laser Rx)
what are the abnormal host responses which are risk factors for chronic pulmonary infection
immunodeficiency (IgA most common)immunosuppression (steroids, chemo etc)
what are the abnormal innate host defences which are risk factors for chronic pulmonary infection
damaged bronchial mucosa (smoking, pneumonia, malignant)abnormal cilli (kartenagers or youngs syndrome)abnormal secretion (CF or channelopathies)
what are the repeated insults which are risk factors for chronic pulmonary infection
aspiration (NG feeding, poor swallow)indwelling material (NG tube in wrong place, chest drain, inhaled foreign body)
what is symptoms of pulmonary abscess
weight loss, lethargy, tiredness, weaknesscough, sputum high mortality usually a preceding illness e.g. pneumonic infectionflu-> staph pneumonia -> cavitating pneumonia -> abscess
what pathogens cause pulmonary abscess
streptococcus, staphylococcus (post flu) E-coli, gram negatives and aspergillus
what is a simple parapneumonic effusion
clear fluid, pH>7.2, LDH<1000, glucose>2.2
simple can lead to complicated parapneumonic effusion - what is this?
pH<7.2, LDH>1000, glucose<2.2 - requires drainage
complicated effusion can progress to empyema - what is this?
frank pus, look for D on CXR, aerobic organisms more frequently
what gram positive organisms can cause empyema
Steph milleri or staph aureus (usually post op or nosocomial)
what gram negative organisms can cause empyema
e-coli, pseudomonas, haemophilus influenza, kelbsiellae
what is the treatment of empyema
drain, IV antibiotics (amoxicillin and metronidazole) or oral antibiotics
what is bronchiectasis
localised, irreversible dilation of bronchial tree
what is clinical presentation of bronchiectasis
recurrent chest infections, recurrent antibiotics with no/short lived response, persistent sputum production
what is treatment of brochiectasis
stop smoking, flu vaccine, reactive antibiotics e.g. nebulised gentamicin or colomycin anti-inflammatory: clarithromycin or azithromycin
how to tell difference between bronchiectasis and chronic bronchial sepsis
sepsis has all hallmarks of bronchiectasis but not on HRCTconfirmed positive sputum results often young / involved in childcare or old with COPD
what are complications of cystic fibrosis
bronchiectasis, sputum, biliary obstruction, pancreatic dysfunction, infertility for males, psychological, salty sweat, recurrent lung infection, filled sinuses, gallbladder/liver disease
what are health problems associated with cystic fibrosis
sinus problems, nose polyps, enlarged heart, trouble breathing, gallstones, trouble digesting food, fatty BMs
how is cystic fibrosis formed
chloride channel CFTR (pushes chloride out of cell) is dysfunction - more Na moves into cell and this causes dry sputum
what does the management of cystic fibrosis need to include
treatment for pancreas, bowels and liver
what is given for pancreas
exocrine failure (slugged up ducts) -CREON endocrine (destruction of pancreatic cells) - annual OGTT, CGMS
what is given for bowels
DIOS - mucus blocks intestines - gastrograffin, laxido, fluids
what is given for liver
slugged up hepatic ducts and portal hypertension - TIPSS (reduced anastomoses and bleeding risk)
what is the G55ID gene mutation in cystic fibrosis
type III mutation, normal CFTR, non functional channeltreatment - ivacafactor (improves chlorine flow)
what is given for F508del mutation in cystic fibrosis
lumacftor
