Stillwell lectures for pulm Flashcards
common cold `
- usually VIRAL -> rhinovirus, influenza virus
- purulent nasal discharge does NOT mean bacterial infection
- Afrin/Otrivan used SHORT term to prevent RHINITIS MEDICAMENTOSA
pharyngitis
- usually VIRAL -> Adenovirus, rhinovirus, coronavirus
- bacterial -> GAS, Diphtheria (myocarditis, bull neck, nerve palsies; NOT scrape off)
- fungal -> Candida scrapes off
- diagnose w/ throat culture -> NO tests if you are going to treat anyway
conjunctivitis, coryza, cough, diarrhea, ulcerative lesions
suggests VIRAL instead of bacterial infection
Peritonsillar/Parapharyngeal abscesses
- usually polymicrobial
- UVULAR deviation
- hot potato mouth
odontogenic infections
- dental carries caused by STREP MUTANS
- acute ulcerative gingivitis -> caused by Fusobacterium & non-syphilitic spirochetes
- Ludwig angina -> elevation of mouth, gland swelling, trismus
- Actinomyces -> lumpy jaw and sulfur granules
stomatitis
- HSV, Enteroviruses, Angular chelitis from CANDIDA
- stomatitis + ulcers -> symptoms in HIV patients
HPV
subtype 16 -> oropharyngeal SCC and cervical cancer
- squamous cell papilloma -> CAULIFLOWER
- verruca vulgaris -> PARSNIPS
Parotitis/Sialadenitis
- caused by MUMPS virus
- caused by STAPH AUREUS in NOSOCOMIAL setting
Sinusitis
- usually VIRAL -> many
- bacterial -> Strep pneumo, H. influenza, Moraxella
- fungal -> MUCORMYCOSIS in immunodeficient & uncontrolled diabetics
- Pott’s puffy tumor
- cavernous sinus thrombosis w/ septic thrombophlebitis -> CN6 most affected
- NO benefit in treating w/ antibiotics if not improving 7-10 days or less -> follow up in week
- treat w/ amoxicillin-cluvalonic acid
Otitis Media
-bacterial -> strep pneumo, H. influenza, Moraxella
- acute -> BACTERIAL
- serous -> NOT infectious -> do not use antibiotics; use decongestants
- blisters on tympanic membrane -> bullous myringitis
- risk of cholesteatoma and mastoiditis
- treat w/ amoxicillin
Otitis Externa
- caused by staph or GAS
- diabetics -> PSUEDOMONAS aeruginosa -> MALIGANT otitis externa
Facial cellulitis
- GAS in adults
- H. influenza in children
-erysipelas -> bright red, sharp margins
Epiglottis
- caused by strep pneumo and H. influenza
- do NOT inspect back of throat if suspected -> spasm & compress airway
- THUMBPRINT sign
Croup (laryngotracheobronchitis)
-caused by PARAINFLUENZA virus
- barking cough
- STEEPLE sign
-treat w/ steroids
Lemierre’s syndrome
-caused by FUSOBACTERIUM necrophorum -> thrombophlebitis of IJV
Infectious Esophagitis
- caused by GERD or Candida
- treat w/ FLUCONAZOLE for Candida
- COBBLESTONE w/ Candida
- if HSV -> multinucleated giant cells
- if CMV -> Owl’s eye
Infected Cervical Lymphadenitis
- usually Staph or Strep - also bartonella, tularensis, myc. TB
- POSTERIOR cervical lymphadenopathy w/ African trypanosomiasis if from Africa -> WINTERBOTTOM sign
Infectious Conjunctivitis “pinkeye”
- usually VIRAL -> Adenovirus
- Pre-auricular adenopathy
- chlamydia trachomatis in mom -> blindness in newborns
Infectious Keratitis (cornea)
- bacteria (most common) -> Staph aureus and Pseudomonas
- viral -> Adenovirus (SUBCORNEAL infiltrate) or HSV (DENDRITIC ulcers)
- amoebic -> Acanthamoeba in contacts
- parasite -> Onchocerca volvulus
Atelectasis
- usually UNILATERAL
- caused by obstruction (resorption), contraction, extra/intrapulmonary compression
Bronchiectasis
- caused by pneumonia, smoking, CF, kartagener
- bacteria -> H. influenza and Pseudomonas***
- SIGNET RING sign & TREE IN BUD
Kartagener Syndrome aka Primary Ciliary Dyskinesia
-defects in DYNEIN arms
- Bronchiectasis
- Chronic Rhinos-sinusitis
- Situs inversus w/ dextrocardia
also infertility
Cor Pulmonale
-COPD/chronic bronchitis -> vasoconstriction of pulmonary artery due to low O2 -> dilation/hypertrophy of RV
most common causes of community acquired pneumonia (CAP)?
strep pneumonia and H. influenza
does the immune response or the pathogen kill you in pneumonia?
IMMUNE RESPONSE to the pathogen
lobes affected in aspiration pneumonia
SUPERIOR segment of right lower lobe and POSTERIOR segment of right upper lobe
what is the cause of Miliary pneumonia?
TB***
-MILLET SEEDS
what causes lobular (patchy) pneumonia?
Staph aureus
CAP - Strep pneumo
- gram + DIPLOCOCCI
- # 1 cause of CAP
- RUSTY SPUTUM
- LANCET shaped
- strains sensitive to penicillin –> MIC =.06
- intermediate -> MIC .12-1
- resistant -> MIC >/=2
-treat with vancomycin
CAP - H. influenza
- gram neg. COCCOBACILLUS
- beta lactamase producers
CAP - Moraxella
- gram neg DIPLOCOCCI
- looks like N. gonorrhea on gram stain
- beta lactamase producer
CAP - staph aureus
- lobar infiltrates become necrotizing
- see cavity pneumatocoeles and lung abscesses
- PLV toxin
CAP - Klebsiella
- ALCOHOLICS
- reddish JELLY sputum
- BULGING FISSURE SIGN
-gram neg rod w/ CAPSULE -> treat w/ Cefipime
CAP - cystic fibrosis (CF) patients
caused by Staph aureus, Pseudomonas, Burkholderia cepacia
atypical pneumonia - Mycoplasma pneumonia
- CROWDED places
- pathy infiltrates on chest Xray -> looks WORSE than patient
-treat w/ macrolides, tetracyclines, quinolones
atypical pneumonia - Chlamydophila pneumonia
ASTHMATIC syndrome -> bronchospasm, wheezing
-treat same as M. pneumonia
atypical pneumonia - Legionella**
- can live in amoeba
- BCYE agar
- CONTAMINATED water
- Faget sign and hyponatremia (SIADH)
- URINE for legionella antigen
- L. micdadei -> PONTIAC FEVER
-treat w/ quinolone and macrolide
atypical pneumonia - viral pneumonia
- RSV and parinfluenza virus -> infants/children
- influenza -> adults
- metapneumovirus -> SEVERE pneumonia
atypical pneumonia - Tularemia
- hilar lymphadenopathy -> nodular and lobar infiltrate
- sudden outbreak in ER settings
atypical pneumonia - Q fever
- placenta birth products, abatoir workers
- treat w/ doxycycline
causes of post-influenza bacterial pneumonia
Strep pneumo #1
Staph aureus #2
PERTUSSIS**
- “whooping cough” 100 days
- cough SYNCOPE, cough EMESIS
- Bordet Gengou or Regan-Lowe Charcoal Blood agars
-treat with MACROLIDES
PROCALCITONIN***
- acute phase reactant
- higher in bacterial infections, and lower in viral infections
Pneumonia treatment***
- healthy person -> Macrolide
- chronic disease, asplenia, immunosuppressed -> Quinolone
- inpatient, non-ICU -> Quinolone, ceftriaxone/macrolide, ceftriaxone/doxycycline
- inpatient, ICU -> ceftriaxone + quinolone
when do you do follow up chest x ray after pneumonia?
> 1 month after pneumonia treatment to make sure mass was not obscured by infiltrate
what kind of organisms are seen in Nosocomial pneumonias?
-MDR organisms -> mix of aerobes and anaerobes
HAP/Nosocomial pneumonia pathogens
- Gram neg organisms #1 (Pseudomonas, Klebsiella, Enterobacter) -> MacConkey agar
- Staph aureus -> blood agar
- Anaerobes in aspirations & strep, enterococci,haemophilus -> chocolate agar
- Gram neg rods (nonfermenters) -> Pseudomonas > Acinetobacter > Stenotrophomonas
most powerful predictor in parapneumonic effusion (complicated pneumonia)
LOW pH <7.20
-sterile
Nosocomial pneumonia treatment
- beta lactam w/ broad gram neg coverage
- vancomycin or linezolid to cover MRSA, MSSA
Aspiration pneumonia treatment
- Clindamycin for anaerobes ABOVE the diaphragm that are gram +
- Metronidazole for anaerobes BELOW the diaphragm that are gram NEG
why do you want to de-escalate the antibiotics when possible?
-prevent C. difficile colitis
what drug do you NOT use in pulmonary infections
DAPTOMYCIN -> inactivated by surfactant
most common typical mycobacteria?
M. tuberculosis (TB)
what atypical mycobacteria does NOT grow on culture?
M. leprae
-have to biopsy
the most common atypical mycobacteria
M. Avium complex (MAC)
Mycobacterial Stain
-ACID FAST bacilli (ZN, Kinyoun, Fite, Fluorochrome)
Mycobacterial cultures
-Lowenstein-Jensen media (3-8 weeks to grow)
Latent TB
dormant, not active, asymptomatic, ready to activate, NOT passed to others
-ISONIAZID is drug of choice
symptoms of TB
- chronic cough
- night sweats
- weight loss (anorexia)
- hemoptysis
- amphoric breath sounds
Host response to M. TB
CELL MEDIATED immunity -> CASEATING granulomas
pulmonary infection from M. TB
- apical and posterior segments of UPPER lobes
- hemoptysis from Rasmussen’s aneurysm or aspergilloma
- miliary TB disseminates -> MILLET seeds on chest xray
pathology of TB
- Gohn lesion/complex
- Ranke complex
- Simon’s foci
- apical scarring
- upper lobe infiltrates and cavitations
TB skin test
-given 0.1 ml intradermally -> measure INDURATION 2-3 days after
to have POS test:
>/= 15mm -> healthy people
> /= 10mm -> high risk (DM, children <4 y/o
> /= 5mm -> recent contact w/ TB or X-ray of past TB, HIV+, transplants
what can you get a false POS TB skin test with?
M. BOVIS
-BCG vaccine does NOT give false +
Mycobacterium avium complex (MAC)
Lady Windermere Syndrome in white women -> pectus excavatum, hour glass chest on imaging, scoliosis, MV prolapse
what do you do if you suspect UPPER lobe infiltrative or cavitary lung process?
think TB until proven otherwise
-isolation with special N95 masks and ventilated room w/ outdoor air
Actinomycosis
- spread through fascial planes -> “wooden texture”
- extend through chest wall -> SINUS TRACTS
- SULFUR granules -> lumpy jaw
- 45 degree branching, CONTINUOUS strands
-treat w/ Penicillin
Nocardia
- N. Brasiliensis (skin/soft tissue) and N. Asteroides (non-cutaneous invasive)
- AFB +
- travel to the BRAIN -> brain abscess
- 90 degree branching, BEADS
-treat with TMP-SMX
Histoplasmosis
- bird and bat quano
- disrupt soil -> aerosolized
- mycelial -> yeast in body
- caseating or non-caseating granulomas
- BUCKSHOT calcifications
- yeasts w/I MACROPHAGES
- acute -> erythema nodosum, Histoplasmoma -> itraconazole (6-12 weeks)
- chronic -> itraconazole (12-24 months)
- disseminated -> AIDS patients -> oropharyngeal and GI ulcers -> amphotericin B and itraconazole
Bastomycosis
- dogs can get
- mycelia -> yeast in body
- BROAD based, single budding
- Pneumonia is common presentation
- ulcerative lesions
- like to go to BONE
-treat with itraconazole or amp.B
Actinomyces vs. Nocardia
- both show up on gram or silver stain
- only Nocardia on AFT stain
- both are gram neg rods
what organism can colonize the oral cavity with Actinomyces?
Aggregatibacter actinomycetemcomitans (aka Actinobacillus)
-Ag grows on culture, Actino does NOT
2 organisms that have erythema nodosum
- Histomplasmosis
2. TB
Coccidioidomycosis
- mycelia -> yeast in body
- SPHERULES
- THIN walled CAVITATIONS
- skin lesions
- can go to brain (meningitis) -> FLUCONAZOLE
Cryptococcus
- C. Neoformans, C. Gattii
- latent in granulomas
- polysaccharide CAPSULE with NARROW based budding
- MUCICARMINE stain
- Cryptocomma
- meningitis and skin lesions
-treat with LIPOSOMAL amphotericin B > Fluconazole
Penicilliosis/Talaromycosis
- Immunocompromised (AIDS) patients from SE Asia
- looks like Histo in Macs
- SAUSAGE and SEPTATE
-treat with Liposomal Amphotericin B -> itraconazole
Paracoccidioidomycosis
- MULBERRY lesions
- MULTIPLE budding yeasts
Aspergillosis
- Gang sign
- Aspergilloma (fungus ball)
- HALO sign
- Galactomannan on blood test
- Silver stain -> 45 branching and are SEPTATE
- Bronchopulmonary Aspergillosis -> bronchiectasis
treat with VORICONAZOLE
Mycomycosis (Zygomycosis)
- black, dead tissue/eschars
- Silver stain -> broad, NON-SEPTATE 90 degree branching
- fatal hemoptysis
Pneumocystis pneumonia (PJP/PCP)
- most common in HIV +
- sputum on GMS stain
- TEA CUPS and PING PONG balls
- SPONTANEOUS pneumothorax
-treat/prophylaxis with TMP-SMX
Candida Pneumonia
- chemotherapy induced NEUTROPENIA
- treat with amph. B +/- Flucytosine
- C. krusei -> fluconazole RESISTANT, voriconazole sensitive
- C. AURIS -> treat with ECHINOCANDINS**
Paragonimiasis
- lung fluke
- cause HEMOPTYSIS
Nematodes (roundoworms)
- Ascaris Lumbricoides
- Ancyclostoma duodenal and Necator Americanus (hookworm)
- Toxocara canis and cati (larva migrans)
- Strongyloides stercoralis
- EOSINOPHILIA -> Charcot-Leyden crystals
- Loeffler syndrome
Strongyloidiasis
- HYPERINFECTION syndrome
- treat with Ivermectin
