Sarcoid, TB, & Pneumothorax Flashcards
Patient presents with Lofgren syndrome, what were their findings?
- fever
- erythema nodosum
- LAD
- periarthritis of ankle & knee
- hilar LAD on CXR
what does Lofgren syndrome indicate?
acute sarcoid arthritis
What are clinical & imaging findings of sarcoidosis?
- bilateral hilar LAD
- pulmonary infiltrate
- skin lesions
- b/l LAD on CXR
A patient comes in with fever, fatigue, anorexia, weight loss, & arthralgias. If suspecting a pulmonary cause what would be higher on your differential?
sarcoidosis
What is heerfordt syndrome?
- uveitis
- parotid enlargement
- facial palsy
- fever
What are diagnostic criteria for sarcoidosis?
- Clinical & radiographic findings
- noncaseating granulomas
- rule-out: TB, fungal, malignancy
What are the CXR findings in sarcoidosis staging?
- Hilar LAD, 60-80%
- Hilar LAD & reticulonodular opacity
- Reticulonodular opacities
- Fibrotic
reticulonodular pattern is like peripheral interstitial effect
What is the differential if a patient has bilateral hilar LAD on CXR?
- Sarcoidosis
- TB
- Malignancy
TB would have apex involvment!
What are the % spontaneous remission according to sarcoid stagin?
- 60-80%
- 50-60%
- <30%
What is the differential if considering Sarcoid?
- Infection (TB, fungus, tularemia, brucella, toxoplasma)
- Berylliosis (pulmonary symptoms)
- Cancer
- hypersensitivity pneumonitis
- Granulomatosis with polyangiitis
- Eosinophilic granulomatosis with polyangiitis
In a lab workup for sarcoid what may be shown?
- WBC < 4k
- elevated ESR
- Hypercalcemia or hypercalciuria
- elevated ACE (active)
- restrictive PFT…
- heart block or dysrhythmia on ECG
- negative eye exam
PFTs may be normal or obstructive
What would be treatment for symptomatic sarcoidosis?
oral corticosteroids
to reduce inflammation & prevent fibrosis
Indications for treating pulmonary sarcoidosis are:
worsening symptoms, PFTs, & imaging
Indications for treating extrapulmonary sarcoids are:
disabling symptoms, hypercalcemia, or eye, neuro, cardiac, or renal involvment
What are risk factors for M. tuberculosis infection?
- household exposure
- incarceration
- drug use
- travel or residence in endemic area
What are risks of reactivation TB?
- infection traveling/immigration within 2 y
- immune compromised (TNFi, heme-cancer)
- DM
- tobacco use
- malnutrition
- gastrectomy
- silicosis
What is latent TB?
- can NOT transmit
- no symptoms unless reactivated
What is active TB?
symptomatic & transmissable
what is cause of progressive primary TB?
random ractivation from inadequate immune response in infants, elderly, & immune suppressed
may or may not be reactivated latent infection
What are the clinical findings in 1º TB?
asymptomatic & no imaging findings
infants, elderly, IMM-suppressed
what are the findings in LTB?
- + skin test
- bacillin in granuloma forming T cells & macrophage
what are the findings in active TB?
chronic cough, ill & malnourished
What are clinical signs of pulmonary TB?
- dry -> productive cough
- malaise
- fever
- sweat
- weight loss
- adverse lung sounds possible
+/- hemoptysis
What are initial steps for diagnosing TB?
- AFB smear x 3 morning specimens
- NAAT
- Drug susceptibility testing
how to treat lofgrens?
NSAIDS & colcichine
who are at increased risk of sarcoidosis?
- young & middle aged adults
- higher in AA population
lymphatic involvement in sarcoidosis can present as?
parotid enlargment, hepatosplenomegaly, & LAD
If a patient presents with below, what would their condition be called?
Lupus pernio in sarcoidosis
what findings would be present in a patient with cardiac sarcoid?
heart block (AV), arrythmia, CHF, reduced LVEF <10%
from granuloma invasion of myocardia
how would you diagnose cardiac sarcoid?
MRI or PET
how to treat cardiac sarcoid with arrythmia?
implanted defibrillator or immune modulators
when would latent TB reactivate?
impaired or reduced immune response
if a patient comes in with a TST >5mm, how would you define if they are positive?
risk factors:
* HIV positive
* recent contact
* fibrosis on CXR
* Organ transplant or immune suppressed
where do most individuals at low risk of TB fall for a TST to be positive?
greater than 10mm
at what age is interferone gamma release assay indicated?
older 5yo
what is benefit of IGRA over TST?
higher specificity
what are cons to both TST & IGRA?
poor at differentiating progression, latent/active, reinfection, immune compromised
what are general principles in treating TB?
- multiple meds
- ensure adherence
- add 2 new antiTB if failure suspected
- report to public health and infectious disease
what drugs are used in treatment of TB?
- isoniazid
- rifampin
- rifapentine
- pyrazinamide
- ethambutol
what are the side-effects of isoniazid?
peripheral neuropathy, CNS hepatitis, rash
what are the side-effects of rifampin?
kidney failure, rash, hepatitis, GI upset, flu-like, bleeding
what are the side-effects of rifapentine?
marrow suppression, hematuria/pyuria, hepatitis, GI upset, flu-like
what are the side-effects of pyrazinamide?
hyperuricemia, joint aches, rash, hepatotoxic, GI upset
what are the side-effects of ethambutol?
optic neuritis
What lab tests are indicated for addressing s/e of anti-TB drugs?
- AST/ALT
- CBC
- Platelets
- Uric acid (pyrazinamide)
- Red-green color discrimination (ethambutol)
what drug interactions are likely with isoniazid?
phnytoin & disulfiram
what drug interaction is likely on rifapentine?
CYP450 (inducer)
what is difference between 1º, 2º, & traumatic pneumothorax?
1º - no pulmonary disease
2º - underlying pulm disease
traumatic - iatrogenic or accident
Marfans, ehlers danlos, smoking increase risk of what type of pneumothorax?
Primary
a patient with 1º pneumothorax is typically
Young tall thin male
a patient with 2º pneumothorax will have what underlying cystic lung conditions?
- lymphangioleimyomatosis
- tuberous sclerosis
- langerhans cell histiocytosis
2º pneumothorax is poorly tolerated because underlying disease causes
decreased respiratory reserver
large pneumothorax will have what PE findings?
reduced chest wall movement, breath sounds, fremitus, & hyperresonance
pressure in pleural space is greater than alveolar/venous pressure leading to what?
compression & decreased venous return
this is tension pneumothorax
a patient with tachycardia, hypotension, & mediastinal/tracheal shift away from lesion likely has what?
tension pneumothorax
a patient is tachycardic with a CXR shown below. What would a potential cause be of this patients condition?
- Penetrating trauma
- lung infection
- CPR
- positive pressure ventilation
tension pneumothorax
what findings on CXR show a tension pneumo?
- vasculature to chest wall
- look for “rim” of lung
A patient comes in with pneumothorax, what would you look for to determine if they are stable?
- RR <24
- HR <120 & >60
- normal BP
- Room air (RA) >90%
- speak whole sentences
If a patient has RR 26, HR 121, SpO2 85%, and has to stop speaking between sentences. How would you define their condition?
Unstable (likely) 2º pneumothorax
In a patient deemed unstable with 2º pneumo, what would be the appropriate next steps?
Chest tube thoracostomy or needle decompression
In a stable patient with 2º pneumo that is asymptomatic and CXR shows a 1cm pneumo. What would be your next steps?
Observe, O2, monitor for aspiration
In a stable patient with 2º pneumo with significant symptoms & 1cm pneumo on CXR, what would next steps be?
catheter or tube thoracostomy + admitted
In a stable patient with 2º pneumo measuring 2cm, what would be next steps?
immediate drainage tube or catheter throacostomy + admission
In a patient with 1º pneumothorax what are treatment steps?
* observe (first or small)
* catheter or needle (large/severe)
* chest tube (if large)
* pleurodesis (chemical)
