Thoracic Infections and Hemoptysis Flashcards
Indications for surgery for M. tuberculosis infection
- Massive hemoptysis
- BPF
- Broncial stenosis
- Entrapped lung
- Failure of medical therapy
- Persistent cavitary diease
- Destroyed lung of lobe
- Rule out malignancy
Prior to sugery for M. tuberculosis, patients should have what profile
- Combination drug therapy for 3 months
- Sputum cultures ideally should be negative
First line medical therapy for M. tuberculosis
- INH and Rifampin (6 total months)
- INH+Rifampin+Pyrazinamide+Ethambutol (first 2 months)
Increases need for surgery for those with M. tuberculosis
Multi-drug resistant TB (MDR-TB)
Pericardial compication of TB
Pericardial effusion or constrictive pericarditis
(pericardial bx diagnostic, high level of ADA in pericardial fluid suggestive)
Tx of TB related pericardial effusion
Antibiotics
Pericardial drainage
Tx of TB related constrictive pericarditis
Antibiotics
Pericardectomy
Pleural TB associated with _
Lymphocyte-rich pleural effusion
Dx of pleural TB
Pleural biopsy (fluid culture may result in no growth)
Tx of pleural TB
- Tube thoracostomy (large effusion)
- Decortication (trapped lung or empyema)
May form in cavitary lung lesions after TB infection
Aspergillomas
Uncommon endobronchial compication that may result from TB infecton
Endobroncial stenosis (scarring) or obstruction (extrinsic compression from lymph nodes)
Tx (endobronchial stenosis): inhaled corticosteroids (I&D of lymph nodes if steroids unsuccessful, not lymph node excision)
MCC (organisms) of Non-tuberculous mycobacterial infection (NTM)
Mycobacterium avium and intracellulare (M avium complex)
Other organisms:
M. chelonae
M. abscessus
M. fortuitum
NTM infections most common in what patient populations
Disease lungs
Women
Caucasians
T/F
NTM infections more resistentant to drug therpy than MTB infecitons
True
Surgical treatment approach to NTM infections
- Pts with localized disease more amenable to surgical therapy
- Consider surgery in course of treatment
- Extrapleural dissection preferential
- d/t dense adhesions between parietal and visceral pleura
- All grossly infected tissue should be removed
- Tissue flaps used to reduce bronchial stump complications
- Continue anti-tubercular medications x 12-24 hrs postoperatively
Complications associated with surgical resections for mycobacterial infections
High rate of BPF
Overall classification scheme of lung abscesses
Primary vs. secondary lung abscess
MC overall etiology of lung abscesses
Aspiration
Atypical bacterium that classically causes multiple abscesses throughout the body, including the lungs
Actinomyces
(PCN sensitive)
Most accurate diagnostic modality for lung abscesses
High resolution CT
(cavity with air-fluid level)
First line treatment for lung abscesses
Prolonged antibiotic therapy (directed by cultures)
Lack of response to antibiotic therapy is bronchoscopy (r/o obstructive process)
Sampling of lung abscess most accurately performed by what technique
CT-guided or bronchoscopic FNA
Indications for external drainage of lung abscesses (as an adjunct to Abx)
- Failure of medical managment
- Giant abscess (>8 cm in diameter)
- Contralateral contamination
- Rupture
Indications for surgery for lung abscesses
- Empyema
- BPF
- Major hemoptysis
- Suspicion of cancer
- Failure of non-operative therapy
7 major mycotic lung infections
- Histoplasmosis
- Coccidiomycosis
- Blastomycosis
- Cryptococcus
- Mucormycosis
- Aspergillosis
- Pneumocystis
Mycotic infection associated with bat and/or bird feces** and **Mississippi Valley
Histoplasmosis
Presentation of Histoplasmosis
- Self-limited, flu-like illness (often do not require treatment)
- Disseminated histoplasmosis (immunocompromised)
- Tx: amphotericin
- Granulomas (non-caseating, sometimes calcified)
- can compress or erode into trachobronchial tree
- Obstruction or hemoptysis
- can compress or erode into trachobronchial tree
Rare complication of histoplasmosis resulting in progressive compression of mediastinal structures (SVC, esophagus, etc)
Fibrosing mediastinitis
Can mimic TB
Chronic cavitary histoplasmosis
(Dx: isolation of organisms in culture)
Mycotic infection associated wtih dimorphic fungus found in soil in the Southwest US, Mexico, Central America
Coccidiomycosis (“Valley fever”)
Characteristics of Coccidiomycosis
- Self resolved infecton in immunocompetent patient
- Erythema nodosum (positive prognostic sign of cell-mediated immunity)
- Chronic infection = cavitary lesion
- Cavitations located peripherally, may rupture into pleural space
- Effusion
- Ptx
- BPF
- Empyema
Surgical indications for coccidiomycosis
- Treatment of complications
- Effusion
- Ptx
- BPF
- Empyema
- Differentiate Coccidioides nodules from cancer
Mycotic infection found in Southeastern and Central US
Blastomycosis
- Types:
- Pulmonary blastomycosis
- Cutaneous blastomycosis
- Multiple ulcerated skin nodules
- Disseminated blastomycosis
Dx:
wide-based budding yeast with double refractile walls
Blastomycosis
Treatment of Blastomycosis
-
Antifungals
- Although spontaneous remission can occur, it is recommended that all patients with mild or moderate disease be treated to avoid dissemination and recurrence.
- _Itraconazole i_s the treatment of choice for all forms of the disease, except in severe, life-threatening cases.
- Amphotericin B is used in severe and life-threatening diseases at a high dose of 0.7 to 1 mg/kg/day to a total dose of 1.5 to 2 grams. Liposomal amphotericin B at a dose of 3 to 5 mg/kg per day can alternatively be used for severe infection and is preferred for CNS blastomycosis and treatment in pregnant women.
- Surgery: rule out malignancy
Mycotic infection characterized by encapsulated yeast round in soil
Cryptococcus
Mycotic infection with tendency to invade meninges (especially in immunocomprimised)
Cryptococcus
Microscopic appearance:
capsule with narrow budding
Cryptococcus
Next step in diagnosis and treatment after pathology demonstrates Cryptococcus in lung mass
CSF analysis (r/o meningitis)
Amphotericin
Omnipresent yeast found in soil that thrives in acidic, hyperglycemic enviornments
Mucormycosis
(DKA patients susceptible)
Risk factors for Mucormycosis
- Diabetic ketoacidosis (uncontrolled hyperglycemia)
- Corticosteroid use (immunosuppressed)
- Neutropenia
Mycotic infection that causes infarction of tissue and is associated with PA rupture and hemoptysis, and invasion of chest wall and mediastinal structures
Mucormycosis
Typical presentation of Mucormycosis
PNA refractory to antibacterial therapy
Microscopic appearance:
broad aseptate hyphae with right-angled, finger-like projections)
Mucormycosis
Treatment principles of Mucormycosis
- Correction of DKA
- Reversal of immunosuppression
- GM-CSF (if neutropenia)
- Amphotericin
- Rapid and aggressive surgical resection
Mycotic infection that typically affects immunocompromised patients or those with structural lung disease
Aspergillosis
Types of aspergillus infection
- Aspergilloma
- Invasive pulmonary aspergillosis
- Allergic bronchopulmonary aspergillosis (asthma, cystic fibrosis)
- Esosinophilia and IgE elevation
Cross-sectional imaging charactistics of aspergillosis
Fungus ball within thick-walled cavity sometimes surrounded by a crescent of air (Monod’s sign)
Monod’s sign
Fungus ball within thick-walled cavity surrounded by a crescent of air (Aspergillosis)
Diagnostic stains used to visualize Aspergillosis
Gomori methenamine silver stain
Calcofluor
Can be visualized in sputum with polarizing light microscopy to diagnose Aspergillosis
Birefringent calcium oxalate crystals
Component of Aspergillosis cell wall that can be measured in serum or BAL fluid
Galactomannan
MC symptoms of aspergillosis
Hemoptysis
Tx: bronchial artery embolization (recurrence of bleeding 50%)
Rebleeding = surgical resection
T/F
Antifungal therapy is helpful for treatment of aspergilloma
False:
Antifungal therpy is not helpful for treatment of aspergilloma
- Asymptomatic aspergilloma: should not be treated (most resolve)
- Symptomatic aspergilloma (i.e. hemoptysis): bronchial artery embolization/resection
Complication of invasive pulmonary aspergilosis
Necrotizing bronchopneumonia refractory to antibacterial therapy
(Immunocompromised patients)
Treatment of invasive pulmonary aspergilosis
Antifungal therapy (high mortality rate)
Surgery reserved when diagnosis questionable or for patient with resectable disease
Opportunistic mycotic infection limited to immunocompromised patients (commonly found in lungs of healthy individuals)
Pneumocystis
(i.e. Pneumocystis PNA [PCP])
TOC for PCP
Bactrim
MCC of massive hemoptysis
MCC of death d/t massive hemoptysis
- MCC
- bronchiectasis
- cancer
- TB
- Mycetoma
- MCC death: asphyxiation
Initial treatment priorities for massive hemoptysis
- Stabilization of airway (mainstem intubate non-bleeding side)
- Resuscitation
- Position in lateral decubitus position (bleeding side down)
- Anti-tussive
- Avoid bronchodilators
- Bronchoscopy (evacuate blood, selective intubation)
- Balloon occlusion if possible
Bronchoscopic measures to control bleeding with massive hemoptysis
- Ice-cold saline lavage
- Epinepherine lavage
- Directed cautery
- Application of pro-coagulants (fibrin, thrombin)
- Balloon tamponade
MC source of hemoptysis
Bronchial arteries (~ 95%)
Justification for bronchial artery embolizaiton (BAE)
Embolizaiton techniques utilized for hemoptysis
- Bronchial Artery Embolization (BAE)
- ~ 95% of hemoptysis due to broncial artery bleeding
- PA angiographe with vaso-occlsion or endovascular stenting
- if PA bleeding
Risk of early re-bleeding after BAE
~30%
Thus, semi-elective surgical resection usually desired after BAE
TOC for massive hemoptysis if BAE fails or patient too unstable
Emergent surgical resection (lobectomy)
