1
Q
how many types of influenzae are there?
A
3 - A, B, C
2
Q
what is influenzae A responsible for?
A
- Influenza A- responsible for pandemics (antigenic variability, zoonotic – has more reservoirs). Aquatic birds act as natural reservoirs, several other animals can be infected
3
Q
what is influenzae B responsible for?
A
- Influenza B responsible for more local, less severe outbreaks – most humans act as reservoirs, little antigenic diversity
4
Q
what symptoms would present with influenzae?
A
Symptoms: initially fever, muscle aches, rigors
- May develop later – headache, sore throat, dry cough, conjunctivitis – usually occurs for weeks but can take months
5
Q
what are complications of influenzae?
A
Complications: bronchitis, viral pneumonia or secondary bacterial pneumonia, sinusitis, otitis media (middle ear infection – causing inflammation – build up of fluid behind eardrum), encephalitis – serious brain inflammation. Pericarditis
6
Q
what treatment is used for influenzae?
A
Treatment: bed rest, paracetamol, NSAID.
- In severe cases requiring hospital admission antibiotics be given to prevent side effects (bacterial pneumonia)
7
Q
what is the flu jab and who is eligible for NHS jab?
A
- Oseltamivir (Tamiflu) and zanamivir (Relenza) – active against influenza A and B. recommended in UK for those over 65yrs and anything at risk (immunosuppressed, chronic resp disease). It will reduce length of illness.
Prevention – WHO tries to predict strain of influenza which will cause most suffering/ cause biggest endemics - Vaccine formed depending on these strains (3-4 strains popped in). available free on NHS to over 65+, pregnancy, chronic lung diseases, CKD, diabetes, heart disease, immunopressive states, very overweight, living in long term residential care home, carers, front line health care and social care worker
8
Q
what is the common cold (coryza) usually caused by?
A
rhinovirus
9
Q
what are complications of common cold?
A
otitis media, pneumonia
10
Q
what type of treatment is required for cold?
A
supportive
11
Q
what virus mainly causes pharyngitis?
A
adenovirus
12
Q
what are symptoms of pharyngitis
A
inflamed back of throat
red
13
Q
what is the feverPAIN criteria?
A
FeverPAIN: easier to do if remote: get 1 point for each
- Fever >38
- Purulence (pharyngeal/ tonsillar exudate (white spots)
- Attend rapidly (3 days or less from first symptoms)
- Severe inflamed tonsils
- No cough or coryza
14
Q
what is the feverPAIN scoring system?
A
Score of 1> - small chance of isolating strep. 2-3 – higher chance of isolating strep. 4-5 62% chance of strep
15
Q
can antibiotics be used with pharyngitis?
A
- Delayed Antibiotics treatments (phenoxymethylpenicillin or clarithromycin)
- AB if: marked systemic upset, risk of serious complications, valvular heart disease, region of higher prevalence of rheumatic heart disease or high feverPAIN score, immunosuppressed
16
Q
what are symptoms of laryngitis?
A
inflammation of larynx
- Sore throat, fever, cough
- Pain on swallowing, pain when speaking and hoarse voice
17
Q
what is a common cause of laryngitis?
A
Common cause – rhinovirus, can be influenza, parainfluenza, RSV.
- Bacterial causes: group A strep, streptococcus pneumoniae
18
Q
what treatment is used in laryngitis?
A
supportive
19
Q
what are the causes of tonsillitis?
A
usually viral
bacterial makes up 30%
20
Q
what treatment is available for tonsillitis?
A
supportive
- Antibiotics: penicillin V (5 day course)
- Corticosteroids – reduce inflammation
- Tonsillectomy
21
Q
when would a tonsillectomy be used?
A
– indicated if recurrent >5 days a year for at least 2yrs or recurrent quinsy ( pus and abscess)
22
Q
what is peri-tonsilla abscess?
A
Peri-tonsilla abscess – along with tonsillitis symptoms may have trismus (pain when closing mouth)
23
Q
what is infective mononucleosis?
A
glandular fever
24
Q
what caused mono?
A
- Most common in adolescents and young people – uni halls
- Caused by Epstein barr virus (EBV) - DNA virus part of herpes group of viruses
25
what are the symptom of infective mono?
- Fever, headache, malaise, sore throat
- Inflamed tonsils with white patches
- Palatal petechiae – bruising on roof of mouth
- Transient macular skin rash – 90% who receive ampicillin will develop rash (not an allergy its just wrong meds)
- Cervical lymphadenopathy
- Splenomegaly and heptamegaly
26
what are complications of infective mono?
meningitis, encephalitis, myocarditis, neuropathy, chronic fatigue syndrome (5x more likely than other causes of URTI), haemolytic anaemia, thrombocytopenia
27
how do you diagnose mono?
- Paul bunnel test/ monospot test/ heterophil AB test. rapid test. Detects heterophile AB (IgM) that agglutinate in sheep erythrocytes – false positives in viral hepatitis, hodgkins lymphoma, acute leukaemias, malaria
- FBC/ blood tests – lymphocytosis – atypical mononuclear cells
- Specific mononuclear cells
- Specific IgM AB
- EBV PCR
28
what treatment is used for mono?
- Supportive , self limiting
- Steroids may be needed if neurological complications or marked haemolysis or thrombocytopenia
29
what causes acute sinusitis?
usually viral
30
what are symptoms of sinusitis?
frontal headache, rhinorrhoea (thin, clear runny nose), facial pain, tenderness, fever
31
what are treatments of sinusitis?
nasal decongestants
- AB if persistent/ fever response
- Nasal corticosteroids, steam inhalation
32
what complications can arise from sinusitis?
(rare): meningitis, orbital cellulitis/ abscess, brain abscess
33
what commonly causes acute brochitis?
rhinovirus
34
what are risk factors of acute bronchitis?
largest RF) smoke, pollution, COPD
- If underlying lung disease or smoker more likely to have bacterial cause
35
how is pneumonia classified?
- Location – lobar( solid) vs bronchopneumonia (patchy)
- Origin – hospital(48hrs after being in hospital) vs community vs aspiration
36
what is bronchopnuemonia?
infection diffuse through lobules and usually in bronchioles and bronchus.
37
how does bronchopneumonia present?
- Differentiated from bronchitis – bronchial breathing, patchy on CXR
- Typically in elderly
- Common if other underlying problems
- Common terminal event
38
what is aspiration pnuemonia?
acute aspiration of gastric content sinto lungs
- Gastric acid can destroy lung lining
- Initial causes: impaired consciousness, reflux oesophagitis, dysphagia, oesophageal stricture
- Persistent pneumonia can lead to anaerobic infection (fluid – no oxygen)
- Can progress to lung abscess or bronchiectasis
39
how long do you need to be in hospital before it can be classed as hospital acquired pneumonia
48hrs
40
what are common bacterial causes of HAP?
- Staph.A, MRSA, pseudomonas, klebsiella
41
describe a CXR of someone with pnuemonia?
consolidation may lag behind symptoms
- May remain on CXR for several weeks after patient is recovered (takes awhile to clear debris)
- Follow up CXR is done 6-8 weeks and persistence of consolidation at this point usually indicates bronchial abnormality – carcinoma and persisting infection
42
what investigations may be done for pneumonia?
- CXR
- Blood tests – FBC, U+E, CRP, LFTS, blood cultures, ABG – mycoplasma
- Urine – legionella and pneumococcal antigen
- Sputum MC+S (microscopy culture + sensitivity)
43
does pneumonia management vary?
yes depending on trust, area CURB65, origin of pneumonia
44
what is the CURB65 test?
CURB65 – 1 point per feature:
- C – confusion
- U – raised urea nitrogen >7mmol/L
- R – raised resp rate >30breaths/ min
- B – low blood pressure (diastolic 60mmHg>, or systolic 90>)
- 65 yrs <
Score: 0-1 is low risk, 2- intermediate risk, 3 – high risk (15% mortality rate)
45
what is most common bacteria causing pneumonia?
streptococcal pneumoniae
46
what would indicate streptococcal pnuemoniae?
- Common in elderly, alcoholics, post-splenectomy , immuno-suppressed
- Usually always following a preceding viral infection
- Followed by a fever, pleuritic chest pain, cough usually with rusty sputum
47
what type of bacteria is streptococcal pneumoniae?
gram +ve bacterial diplococci
48
who is more likely to have strepA as cause of pneumonia?
- Risk if elderly, IV drug users (on skin and hence entry point), long term IV catheters, immunosuppression
49
what follows strep.A caused pnuemonia?
cavities which can later form abscesses and empyema can develop
50
who is likely to get klebsiella caused pneumonia?
alcoholics. elderly, diabetics
51
what occurs from klebsiella pneumonia?
– bronchopneumonia and affects upper lobes
- Can cause cavitating pneumonia which leads to abscesses
52
who is most likely to have chlamydia pneumonia outbreaks?
areas of close proximity - boarding schools
53
what can chlamydia pneumonia cause?
- Causes pharyngitis, laryngitis, sinusitis followed by pneumonia
54
who is most likely to get chlamydia psittaci?
those with close contact with birds - parrots
55
what bacterial pneumonia are COPD patients likely to get?
haemophilus influenza
56
anaerobes are most likely to come from which origin on pneumonia?
aspiration - ventilator
57
who is most likely to get legionella pneumonia?
hot water tanks
hotel air con - holidays
58
how would legionella pneumonia present?
- Flu like symptoms – dry cough, generally unwell
- CXR – bi-basal consolidation, lymphopenia
59
what are complications of legionella pneumonia?
: D+V, hepatits, hyponatraemia , haematuria
60
when would mycoplasma pneumonia be most common
usually in teens/ early 20s
- Boarding institutions/ uni halls
61
what are signs of mycoplasma pneumonia?
- General malaise, headache, arthralgia (joint pain) before chest
- CXR: reticulo-nodular shadowing or patchy consolidation
62
what is erythema mutliforme?
target lesions, raised, round rashes, bullseye shape
63
what would cause a lung abscess?
- Causes: aspiration (anaerobes), foreign body ingestion, bronchial carninoma, staph or klebsiella, septic emboli (usually from staph causing multiple metastasis)
- Additional sign may be clubbing
64
what is empyema?
pus in pleural cavity
65
what would calcification in cavities on CXR indicate?
previous TB
66
why would alcoholism put a patient at risk of pneumonias?
defects in innate and adaptive immunity
67
what is most frequent bacteria causing CAP?
streptococcal pneumonia
68
which bacterias can be tested using a uriniary antigen testing?
pneumococcal or legionella
69
which diagnostics are gold standard for CAP?
blood cultures
thoracic CT - can not do routinely - too expensive and do not need to expose patients to the radiation
70
what is the use of a CXR in pneumonia diagnostics?
help define parenchymal lung infection - causing the consolidation
identify complications
71
what are known SE to AB?
- AB can have side effects as they upset natural bacteria balance – potentially resulting in diarrhoea/ thrush – may allow more harmful bacteria to increase. Can cause rashes, stomach pains and reactions to sunlight
72
according to NICE - how long AB treated for low severity bacterial pnemonia?
5 days therapy
73
according to NICE - how long therapy for moderate severity of pneumonia?
7 days
74
who requires annual flu and pneumococcal vaccinations?
those ages 65+, anyone with high risk conditions, those in long term health care facilities, front line health care workers, carers
75
how does the body control its temperature?
- Typical body temp is balance of heat production and heat loss
- The hypothalamus monitors balance
76
how does body respond to infection in terms of own body temp?
- When immune system responds to infection – hypothalamus can set body temp to be higher – prompts complex process
77
why does a fever cause an increase in body temp?
- Fevers are caused by pryogens flowing in bloodstream and when they get to hypothalamus they bind and up body temperature
- Common pyrogen is IL-1 and this is produced by WBC which come into contact with certain bacteria and viruses
- One purpose of fever – raise body temp to kill off temp sensitive bacteria/ viruses
78
how is paracetamol believed to lower body temp in a fever?
- Believed to act on central pathway that the chemicals react with hypothalamus
- Lead to peripheral blood vessel dilation to dissipate heat
79
what do basophils and eosinophils treat?
parasitic infection, allergies
80
what do neutrophils fight?
phagocytosis
81
what do mast cells defend against?
parasites - release antohistamine - allergies
82
what do monocytes develop into and what is their function once mature?
develop into macrophages - phagocytosis
83
what do monocytes and neutrophils do together around an injury site?
– surround local tissue injury to create a tight wound seal
84
what is the function of NK cells?
both innate and adaptive
- Recognise and kill virus infected cells or tumour cells
- Cause apoptosis – no danger release signals, less damage and debris
85
what is the role of B cells?
B cells: present antigens to T cells and produce AB to neutralise infectious microbes
- AB coat surface of pathogen and neutralise, opsonize and complement activation
- Neutralization: pathogen covered by AB – prevents further binding
- Opsonisation: AB- bound pathogen serves as a red flag to alert other immune cells
- Complement: process for directly destroying/ lysing bacteria
86
what do CD8+ cytotoxic cells do?
recognise and remove virus infected and cancer cells
87
what do CD4+ T helper cells do?
T helper cells which coordinate immune response. They produce and secrete molecules that alert and activate other immune cells
88
what is the role of reg T cells?
- Reg t cells: monitor and inhibit activity of other T cells – prevent adverse immune activation and maintain tolerance or the prevention of immune response against body own cells and antigens
89
what are the types of cytokines?
interferons, interleukins, chemokines, TNF
90
what do interferons do?
- Interferons- type 1 mediate antiviral responses. Type II – antibacterial
91
what do interleukins do?
- Interleukins – provide contact specific instructions – activation or inhib
92
what do chemokines do?
attract immune cells
93
what is TNF function?
immune cell proliferation and activation
94
what is the complement pathway?
Complement: unique process to clear away pathogens or dying cells and also activate immune cells
- Series of proteins found in the blood to for a MAC
- Prolific pathway to recruit other complement proteins and punches small holes into pathogen to create leaks to cause death
95
describe phagocytosis?
1. Recognition of target particle
2. Signal to activate internalisation machinery
3. Phagosome formation
4. Phagolysome maturation
- Ingest microbial pathogens and apoptotic cells to contribute to clearance – microbial and tissue homeostasis
96
what is inflammation?
Inflammation: complex local response by tissue cells to an insult eg infection, tumour growth, wound, burn, UV exposure. Characterised by redness (rubor), heat (calor), swelling (tumour), pain (dolor) and dysfunction of inflamed organs.
97
why do you get sensation of heat within inflammation?
increased blood movement in dilated vessels into environmentally cooled peripheries
98
why do you get redness in inflammation?
increased erythrocytes passing through area
99
why do you get swelling within inflammation?
due to increase in permeability and dilation of blood vessels
100
why do you get pain in inflammation?
increase in pain mediators - direct damage or as result of inflam response
- protective feature - tend to protect 'hurt' area more
101
why can you get loss of function in inflammation?
simple loss of mobility due to odema, pain or replacement of cells with scar tissue
102
what is septic shock?
response in acute inflammation
103
where are mast cells found?
connective tissue
104
when is scar tissue produced?
- Scar tissue develops as a result of disease process that determines the ability of the tissue or organ to be functioning – helps provide a bridge between normal tissue edges
- Tissues natural response to injury or disease is associated with fibroblast deposition or scar formation – often formed at expense or normal tissue regeneration
105
how is a wound contracted?
myofibroblasts establish a grip on wound
- Wound healing response is essential for tissue regeneration and provides the wound bed with additional matrix and cells enhances normal tissue formation
106
what is tissue remodelling?
normal process
tightly controlled ECM remodelling - production and degradation
107
how might an abscess occur?
- Formation of an abscess is another possible outcome – localised collection of pus surrounded by granulation tissue containing necrotic tissue with suspended dead and viable neutrophils and dead pathogens – acute inflammation will resolve if drained but If not it will be replaced by scar tissue
- Abscesses can be source for systemic dissemination of a pathogen acting as harbour for infection – causing rising pressures within tissue, causing pain and destruction of local structures
108
describe the shape of strep. pnuemococcal
lancet shape , gram positive, anaerobic bacteria
109
describe staph A
- Gram positive, non spore forming, spherical bacterium
110
describe group A strep
- Commonly found on skin or in throat
- Gram positive cocci
- Can cause acute pharyngitis, impetigo
111
describe klebsiella pneumonia
- Gram negative encapsulated non motile bacterim
- CAP linked to alcoholics and DM
- Typically colonises human surface mucosal surfaces and oropharynx and GI
112
describe haemophillus influenzas
- CAP
- Gram negative coccobacillus that appears red under microscope
- Can invade fluid surrounding spinal cord – meningitis
- Encapsulated type is more resistant to antibiotics
- Type b is most common – mainly affects children, >65 and those immunocompromised (sickle cell disease, AB deficiency syndromes), HIV, those undergoing chemo
113
describe mycoplasma pneumonia
- CAP
- Most common atypical pneumonia
- Short rod cell with no cell wall (not visible on gram stain)
- Incubation of 2-3 weeks
114
how does aspiration pneumonia occur?
aspiration pneumonia: acute aspiration of gastric contents into lungs
- HCL destroys lung lining
- Caused by impaired consciousness, reflux oesphageal stricture.
115
what is a typical presentation of pneumonia?
sudden high fever and chills and then coughing with phlegm
116
how does atypical pneumonia present?
- Have fever or slightly different symptoms
- Starts off slowly with a mild fever/ headache/ aching limbs
- Then progresses to a dry/ tickly cough
117
what is focal pneumonia?
several multi-lobe focal inflammation in the lungs, if it started in the bronchi then it is bronchopneumonia
118
what is lobar pneumonia?
: entire lung lobe is affected and visibly inflamed
119
what is the function of phagocytosis?
ingest microbial pathogens and apoptotic cells to contribute to clearance - microbial and tissue homeostasis
120
what is acute inflammation?
immediate, adaptive and transient response with limited specificity caused by noxious stimuli
121
what hormones are involved in acute inflammation?
bradykinin and histamine - involved within the pain sensation
122
what tissue can not return to normal following injury?
cardiac muscle tissue
lung tissue in ILD
most neurones
liver tissue in cirrhosis
123
what do B lactams do?
inhibit bacteria cell wall biosynthesis
124
what are examples of B lactams?
amoxicillin, flucloxacillin, cafalexin
125
what is the function of aminolycosides?
inhibit synthesis of proteins by bacteria
126
name 4 examples of aminoglycosides
streptomyocin
neomycin
kanamycin
paromycin
127
what is the role of glycopeptides
inhibit bacterial cell wall biosynthesis
128
name 2 examples of glycopeptides
vancomycin
telcopanin
129
what is the action of quinolones?
interfere with bacteria DNA replication and transcription
130
name some examples of quinolones
ciproflaxoncin
levofloxacin
trovafloxacin
131
what is the role of lipopeptides?
disrupt multiple cell membrane functions
132
name 2 lipoprotein drugs
daptomycin
surfactin
133
what is the role of sulonamides?
prevent bacteria growth and multiplication
134
name some sulfonamides
prontosil
sulfanilamide
sulfadiazine
sulfisaxole
135
what is the action of tetracyclines?
inhibit synthesis of proteins by bacteria
136
name some tetracyclines
tetracycline
doxycycline
lymecycline
oxytetracycline
137
what action do macrolides have?
inhibit protein synthesis by bacteria
138
name 3 macrolides?
erythomyocin
clarithomycin
azithromycin
139
with a CURB65 score of 0-1, what treatment is used for pneuomonia?
Oral Amoxicillin or Oral Clarithromycin or
Doxycycline if allergic to Penicillin.
140
what treatment is given if CURB 65 score of 2 in pneumonia treatment?
Amoxicillin Plus Clarithromycin Orally
Penicillin Allergy:
Doxycycline or Levofloxacin or Moxifloxacin
141
in a CURB65 score of 3-5 what treatment is used?
IV. Co-amoxiclav plus Clarithromycin
IV Fluroquinolone – (Suspected Legionnaire’s disease)
Penicillin Allergy:
IV Cephalosporin plus Clarithromycin
IV Benzylpenicillin plus Fluroquinolone (Levofloxacin or Moxifloxacin)
142
what treatment is used in non severe HAP?
co-amoxiclav or levoflaxacin
143
in HAP with severe symptoms or high risk patients what treatment is best?
IV Piperacillin with tazobactam
Fluroquinolone (Levofloxacin or Moxifloxacin)
Cefuroxime
Meropenem (specialist advice only)
144
if MRSA is suspected/ confirmed from HAP what treatment is best?
Vancomycin if MRSA is suspected or confirmed. Dual Antibiotic therapy with medications listed above (See NICE guideline). Medication is adjusted according to serum-vancomycin concentration.
145
what are the common symptoms of HAP?
Cough with greenish or pus-like sputum
Fever and Malaise
Nausea and vomiting with loss of appetite
Sharp chest pain- worse with deep breathing or coughing.
Shortness of breath
Reduced blood pressure and tachycardia.
146
what are common symptoms of aspiration pneumonia?
Coughing up foul-smelling, greenish or dark sputum. Sputum may contain blood or pus.
Fatigue and Shortness of breath.
Wheezing.
Breath odour
Excessive sweating
147
what is the management of aspiration pneumonia?
Should be directed against positive cultures if possible. (High risk of resistance).
Co-amoxiclav may be used to cover gram negative and anaerobic bacteria.
Treatment may be the same for non-aspiration pneumonia as listed above. (See BMJ best practice / aspiration pneumonia)
Agree on as escalation plan – Resuscitation Status (DNACPR) and Ceiling of care (intubation or ICU admission).
Supportive care (Oxygen Therapy and manage hypotension).
Dysphagia Management
(NBM and SALT assessment)
148
on a CXR, what would a bronchopneumonia present as?
patchy areas, spread out throughout lungs
149
what happens to sodium levels during pneumonia?
hyponatremia common - seen in higher disease severity
150
how common is HAP?
0.5-1% of inpatients
151
how common is ventilator acquired pneumonia?
makes up 80% of HAP
respiratory
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