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General Thoracic Surgery > Thoracic Infections and Hemoptysis > Flashcards

Thoracic Infections and Hemoptysis Flashcards

1
Q

Indications for surgery for M. tuberculosis infection

A
  • Massive hemoptysis
  • BPF
  • Broncial stenosis
  • Entrapped lung
  • Failure of medical therapy
  • Persistent cavitary diease
  • Destroyed lung of lobe
  • Rule out malignancy
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2
Q

Prior to sugery for M. tuberculosis, patients should have what profile

A
  • Combination drug therapy for 3 months
  • Sputum cultures ideally should be negative
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3
Q

First line medical therapy for M. tuberculosis

A
  • INH and Rifampin (6 total months)
    • INH+Rifampin+Pyrazinamide+Ethambutol (first 2 months)
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4
Q

Increases need for surgery for those with M. tuberculosis

A

Multi-drug resistant TB (MDR-TB)

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5
Q

Pericardial compication of TB

A

Pericardial effusion or constrictive pericarditis

(pericardial bx diagnostic, high level of ADA in pericardial fluid suggestive)

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6
Q

Tx of TB related pericardial effusion

A

Antibiotics

Pericardial drainage

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7
Q

Tx of TB related constrictive pericarditis

A

Antibiotics

Pericardectomy

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8
Q

Pleural TB associated with _

A

Lymphocyte-rich pleural effusion

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9
Q

Dx of pleural TB

A

Pleural biopsy (fluid culture may result in no growth)

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10
Q

Tx of pleural TB

A
  • Tube thoracostomy (large effusion)
  • Decortication (trapped lung or empyema)
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11
Q

May form in cavitary lung lesions after TB infection

A

Aspergillomas

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12
Q

Uncommon endobronchial compication that may result from TB infecton

A

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)

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13
Q

MCC (organisms) of Non-tuberculous mycobacterial infection (NTM)

A

Mycobacterium avium and intracellulare (M avium complex)

Other organisms:

M. chelonae

M. abscessus

M. fortuitum

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14
Q

NTM infections most common in what patient populations

A

Disease lungs

Women

Caucasians

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15
Q

T/F

NTM infections more resistentant to drug therpy than MTB infecitons

A

True

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16
Q

Surgical treatment approach to NTM infections

A
  • 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
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17
Q

Complications associated with surgical resections for mycobacterial infections

A

High rate of BPF

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18
Q

Overall classification scheme of lung abscesses

A

Primary vs. secondary lung abscess

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19
Q

MC overall etiology of lung abscesses

A

Aspiration

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20
Q

Atypical bacterium that classically causes multiple abscesses throughout the body, including the lungs

A

Actinomyces

(PCN sensitive)

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21
Q

Most accurate diagnostic modality for lung abscesses

A

High resolution CT

(cavity with air-fluid level)

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22
Q

First line treatment for lung abscesses

A

Prolonged antibiotic therapy (directed by cultures)

Lack of response to antibiotic therapy is bronchoscopy (r/o obstructive process)

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23
Q

Sampling of lung abscess most accurately performed by what technique

A

CT-guided or bronchoscopic FNA

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24
Q

Indications for external drainage of lung abscesses (as an adjunct to Abx)

A
  • Failure of medical managment
  • Giant abscess (>8 cm in diameter)
  • Contralateral contamination
  • Rupture
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25
Q

Indications for surgery for lung abscesses

A
  • Empyema
  • BPF
  • Major hemoptysis
  • Suspicion of cancer
  • Failure of non-operative therapy
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26
Q

7 major mycotic lung infections

A
  • Histoplasmosis
  • Coccidiomycosis
  • Blastomycosis
  • Cryptococcus
  • Mucormycosis
  • Aspergillosis
  • Pneumocystis
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27
Q

Mycotic infection associated with bat and/or bird feces** and **Mississippi Valley

A

Histoplasmosis

28
Q

Presentation of Histoplasmosis

A
  • 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
29
Q

Rare complication of histoplasmosis resulting in progressive compression of mediastinal structures (SVC, esophagus, etc)

A

Fibrosing mediastinitis

30
Q

Can mimic TB

A

Chronic cavitary histoplasmosis

(Dx: isolation of organisms in culture)

31
Q

Mycotic infection associated wtih dimorphic fungus found in soil in the Southwest US, Mexico, Central America

A

Coccidiomycosis (“Valley fever”)

32
Q

Characteristics of Coccidiomycosis

A
  • 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
33
Q

Surgical indications for coccidiomycosis

A
  • Treatment of complications
    • Effusion
    • Ptx
    • BPF
    • Empyema
  • Differentiate Coccidioides nodules from cancer
34
Q

Mycotic infection found in Southeastern and Central US

A

Blastomycosis

  • Types:
    • Pulmonary blastomycosis
    • Cutaneous blastomycosis
      • Multiple ulcerated skin nodules
    • Disseminated blastomycosis
35
Q

Dx:

wide-based budding yeast with double refractile walls

A

Blastomycosis

36
Q

Treatment of Blastomycosis

A
  • Antifungals
  • Surgery: rule out malignancy
37
Q

Mycotic infection characterized by encapsulated yeast round in soil

A

Cryptococcus

38
Q

Mycotic infection with tendency to invade meninges (especially in immunocomprimised)

A

Cryptococcus

39
Q

Microscopic appearance:

capsule with narrow budding

A

Cryptococcus

40
Q

Next step in diagnosis and treatment after pathology demonstrates Cryptococcus in lung mass

A

CSF analysis (r/o meningitis)

Amphotericin

41
Q

Omnipresent yeast found in soil that thrives in acidic, hyperglycemic enviornments

A

Mucormycosis

(DKA patients susceptible)

42
Q

Risk factors for Mucormycosis

A
  • Diabetic ketoacidosis (uncontrolled hyperglycemia)
  • Corticosteroid use (immunosuppressed)
  • Neutropenia
43
Q

Mycotic infection that causes infarction of tissue and is associated with PA rupture and hemoptysis, and invasion of chest wall and mediastinal structures

A

Mucormycosis

44
Q

Typical presentation of Mucormycosis

A

PNA refractory to antibacterial therapy

45
Q

Microscopic appearance:

broad aseptate hyphae with right-angled, finger-like projections)

A

Mucormycosis

46
Q

Treatment principles of Mucormycosis

A
  • Correction of DKA
  • Reversal of immunosuppression
  • GM-CSF (if neutropenia)
  • Amphotericin
  • Rapid and aggressive surgical resection
47
Q

Mycotic infection that typically affects immunocompromised patients or those with structural lung disease

A

Aspergillosis

48
Q

Types of aspergillus infection

A
  • Aspergilloma
  • Invasive pulmonary aspergillosis
  • Allergic bronchopulmonary aspergillosis (asthma, cystic fibrosis)
    • Esosinophilia and IgE elevation
49
Q

Cross-sectional imaging charactistics of aspergillosis

A

Fungus ball within thick-walled cavity sometimes surrounded by a crescent of air (Monod’s sign)

50
Q

Monod’s sign

A

Fungus ball within thick-walled cavity surrounded by a crescent of air (Aspergillosis)

51
Q

Diagnostic stains used to visualize Aspergillosis

A

Gomori methenamine silver stain

Calcofluor

52
Q

Can be visualized in sputum with polarizing light microscopy to diagnose Aspergillosis

A

Birefringent calcium oxalate crystals

53
Q

Component of Aspergillosis cell wall that can be measured in serum or BAL fluid

A

Galactomannan

54
Q

MC symptoms of aspergillosis

A

Hemoptysis

Tx: bronchial artery embolization (recurrence of bleeding 50%)

Rebleeding = surgical resection

55
Q

T/F

Antifungal therapy is helpful for treatment of aspergilloma

A

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
56
Q

Complication of invasive pulmonary aspergilosis

A

Necrotizing bronchopneumonia refractory to antibacterial therapy

(Immunocompromised patients)

57
Q

Treatment of invasive pulmonary aspergilosis

A

Antifungal therapy (high mortality rate)

Surgery reserved when diagnosis questionable or for patient with resectable disease

58
Q

Opportunistic mycotic infection limited to immunocompromised patients (commonly found in lungs of healthy individuals)

A

Pneumocystis

(i.e. Pneumocystis PNA [PCP])

59
Q

TOC for PCP

A

Bactrim

60
Q

MCC of massive hemoptysis

MCC of death d/t massive hemoptysis

A
  • MCC
    • bronchiectasis
    • cancer
    • TB
    • Mycetoma
  • MCC death: asphyxiation
61
Q

Initial treatment priorities for massive hemoptysis

A
  • 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
62
Q

Bronchoscopic measures to control bleeding with massive hemoptysis

A
  • Ice-cold saline lavage
  • Epinepherine lavage
  • Directed cautery
  • Application of pro-coagulants (fibrin, thrombin)
  • Balloon tamponade
63
Q

MC source of hemoptysis

A

Bronchial arteries (~ 95%)

Justification for bronchial artery embolizaiton (BAE)

64
Q

Embolizaiton techniques utilized for hemoptysis

A
  • Bronchial Artery Embolization (BAE)
    • ~ 95% of hemoptysis due to broncial artery bleeding
  • PA angiographe with vaso-occlsion or endovascular stenting
    • if PA bleeding
65
Q

Risk of early re-bleeding after BAE

A

~30%

Thus, semi-elective surgical resection usually desired after BAE

66
Q

TOC for massive hemoptysis if BAE fails or patient too unstable

A

Emergent surgical resection (lobectomy)

General Thoracic Surgery (36 decks)

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