1
Q
typically central
associated with PTHrP secretion → hypercalcaemia
strongly associated with finger clubbing
cavitating lesions are more common than other types
hypertrophic pulmonary osteoarthropathy (HPOA)
Which is the type of lung cancer?
A
Non small cell
Squamous cell cancer
Central, Ca, Clubbing, Cavitation, HPOA = SCC
2
Q
typically peripheral
most common type of lung cancer in non-smokers
What type of lung cancer?
A
Non small cell
Adenocarcinoma
3
Q
- typically peripheral
- anaplastic, poorly differentiated tumours with a poor prognosis
- may secrete β-hCG
What type of lung cancer?
A
Non small cell
Large cell lung carcinoma
4
Q
- central
- arise from APUD* cells
- associated with ectopic ADH, ACTH secretion
- ADH → hyponatraemia
- ACTH → Cushing’s syndrome
- ACTH secretion can cause bilateral adrenal hyperplasia, the high levels of cortisol can lead to hypokalaemic alkalosis
- Lambert-Eaton syndrome: antibodies to voltage gated calcium channels causing myasthenic like syndrome
What type of lung cancer?
A
Small cell lung cancer
5
Q
Management of small cell
A
very early stage disease (T1-2a, N0, M0) are now considered for surgery.
however, most patients with limited disease receive a combination of chemotherapy and radiotherapy
palliative chemotherapy for more extensive disease
6
Q
Management of Non small cell
A
only 20% suitable for surgery
mediastinoscopy performed prior to surgery as CT does not always show mediastinal lymph node involvement
curative or palliative radiotherapy
poor response to chemotherapy
7
Q
Non small cell lung cancer sugery contraindications (7)
A
- assess general health
- stage IIIb or IV (i.e. metastases present)
- FEV1 < 1.5 L
- malignant pleural effusion
- tumour near hilum
- vocal cord paralysis
- SVC obstruction
8
Q
In non small cell lung cancer
1. Lobectomy if FEV1…….
- Pneumonectomy if FEV1 ……
A
- < 1.5 L
- < 2.5 L
9
Q
Lung cancer: 8 risk factors
A
- Smoking - increases risk of lung ca by a factor of 10
- asbestos - increases risk of lung ca by a factor of 5
- arsenic
- aromatic hydrocarbon
- chromate
- cryptogenic fibrosing alveolitis
- radon
- nickel
10
Q
Management of Lung cancer: carcinoid
A
surgical resection
if no metastases then 90% survival at 5 years
11
Q
- typical age = 40-50 years
- smoking not risk factor
- slow growing: e.g. long history of cough, recurrent haemoptysis
- often centrally located and not seen on CXR
- ‘cherry red ball’ often seen on bronchoscopy
- rare associated with liver metastases
Features of ………….
A
Lung carcinoid features
12
Q
Lung cancer: paraneoplastic features of small cell (3)
A
- ADH
- ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc
- Lambert Eaton syndrome
13
Q
Lung cancer: paraneoplastic features of squamous cell (4)
A
- PTHrP secretion causing hypercalcemia
- Hyperthyroidism due to ectopic TSH
- Clubbing
- Hypertrophic pulmonary osteoarthropathy
14
Q
Lung cancer: paraneoplastic features of Adenocarcinoma (2)
A
- gynaecomastia
- hypertrophic pulmonary osteoarthropathy (HPOA)
15
Q
Lung metastases are seen with a wide variety of cancers including:
A
breast cancer
colorectal cancer
renal cell cancer
bladder cancer
prostate cancer
16
Q
Calcification in lung metastases is uncommon except in the case of
A
- chondrosarcoma
- osteosarcoma
17
Q
” cannonball metastases” are most commonly seen with…..
A
- renal cell cancer
may also occur secondary to
- choriocarcinoma
- prostate cancer.
18
Q
Chest x-ray: cavitating lung lesion (9)
A
- abscess (Staph aureus, Klebsiella andPseudomonas)
- squamous cell lung cancer
- TB
- Wegener’s granulomatosis
- PE
- rheumatoid arthritis
- aspergillosis,
- histoplasmosis,
- coccidioidomycosis
19
Q
Causes of Respiratory acidosis (5)
A
- COPD
- Decompensation in other respiratory conditions: BA , pulmonary oedema
- OHS
- Neuromuscular disease
- sedative drugs:benzodiazepines,opiate overdose
20
Q
Causes of Respiratory alkalosis (6)
A
- Hyperventilation
- PE
- Pregnancy
- CNS disorders: stroke, subarachnoid hemorrhage, encephalitis
- Altitude
- Salicylate poisoning: Early stimulation of the respiratory centre leads to a respiratory alkalosiswhilst later the direct acid effects of salicylates (combined with AKI) may lead to an acidosis
21
Q
Recommended initial settings for BIPAP in COPD
- IPAP:
- EPAP:
- Back up rate :
- I:E ratio :
A
- IPAP: RCP advocate 10 cm H20 whilst BTS suggest 12-15 cm H2O
- EPAP: 4-5 cm H2O
- back up rate: 15 breaths/min
- I:E ratio: 1:3
22
Q
Non-invasive ventilation - key indications (4)
A
- COPD with respiratory acidosis pH 7.25-7.35
- T2 RF secondary to chest wall deformity, neuromuscular disease or OSA
- cardiogenic pulmonary oedema unresponsive to CPAP
- weaning from tracheal intubation
23
Q
Acute mountain sickness is
A
a self-limiting condition.
start to occur above 2,500 - 3,000m,
developing gradually over 6-12 hours
headache
nausea
fatigue
24
Q
Prevention and treatment of Acute mountain sickness
A
- gain altitude at no more than 500 m per day
- acetazolamide (a carbonic anhydrase inhibitor)is widely used to prevent AMS
- it causes a primary metabolic acidosis and compensatory respiratory alkalosis which increases respiratory rate and improves oxygenation - treatment: descent
25
Management of high altitude cerebral oedema HACE
descent
dexamethasone
26
Management of high altitude pulmonary oedema HAPE
1. descent
2. nifedipine, dexamethasone, acetazolamide, phosphodiesterase type V inhibitors*
3. oxygen if available
27
Causes of decreased lung compliance (4)
3PK
1. Pulmonary oedema
2. Pulmonary fibrosis
3. Pneumonectomy
4. Kyphosis
28
Causes of increased lung compliance (2)
1. Age
2. Emphysema - this is due to loss alveolar walls and associated elastic tissue
29
Oxygen dissociation curve
Shifts to Right = Raised oxygen delivery
(5)
1. Raised [H+] (acidic)
2. Raised pCO2
3. Raised 2,3-DPG*
4. Raised temperature
5. Exercise
30
Oxygen dissociation curve
Shifts to Left = Lower oxygen delivery
(5)
1. Low [H+] (alkali)
2. Low pCO2
3. Low 2,3-DPG
4. Low temperature
5. HbF, methaemoglobin, carboxyhaemoglobin
31
the most suitable way of assessing compression of the upper airway
Flow volume loops
32
FEV1 - significantly reduced
FVC - reduced or normal
FEV1% (FEV1/FVC) - reduced
Obstructive lung disease
33
FEV1 - reduced
FVC - significantly reduced
FEV1% (FEV1/FVC) - normal or increased
Restrictive lung disease
34
7 Causes of a raised TLCO
1. asthma
2. pulmonary haemorrhage (e.g. granulomatosis with polyangiitis, Goodpasture's)
3. left-to-right cardiac shunts
4. polycythaemia
5. hyperkinetic states
6. male gender,
7. exercise
“A Happy Life Promotes Healthy Men’s Exercise”
35
7 Causes of a lower TLCO
4P ACE
1. pulmonary fibrosis
2. pneumonia
3. pulmonary emboli
4. pulmonary oedema
5. anaemia
6. low cardiac output
7. emphysema
36
4 Causes of increased KCO with normal or reduced TLCO
1. pneumonectomy/lobectomy
2. scoliosis/kyphosis
3. neuromuscular weakness
4. ankylosis of costovertebral joints e.g. ankylosing spondylitis
37
Hypoxia leads to
vasoconstriction of the pulmonary arteries. This allows blood to be diverted to better aerated areas of the lung and improves the efficiency of gaseous exchange
38
Control of respiration
1. central regulatory centres
2. central and peripheral chemoreceptors
3. pulmonary receptors
39
Central regulatory centres
1. medullary respiratory centre
2. apneustic centre (lower pons)
3. pneumotaxic centre (upper pons)
* MAP = central regulatory centers
* (p)neuroma is = u(pp)er
40
Central and peripheral chemoreceptors
1. central: raised [H+] in ECF stimulates respiration
2. peripheral: carotid + aortic bodies, respond to raised pCO2 & [H+], lesser extent low pO2
*low PH
*high pCo2
*low O2
41
Pulmonary receptors
1. stretch receptors, lung distension causes slowing of respiratory rate (Hering-Bruer reflex)
2. irritant receptor, leading to bronchoconstriction
3. juxtacapillary receptors, stimulated by stretching of the microvasculature
42
Haldane effect
increase pO2 means CO2 binds less well to Hb
43
Bohr effect
increasing acidity (or pCO2) means O2 binds less well to Hb
44
Chloride shift
- CO2 diffuses into RBCs
- CO2 + H20 ---- carbonic anhydrase -→
- HCO3- + H+
- H+ combines with Hb
- HCO3- diffuses out of cell,- Cl- replaces it
45
Mechanism of action
Methylxanthines (e.g. theophylline)
Non-specific inhibitor of phosphodiesterase resulting in an increase in cAMP
46
FeNO: is considered positive
- in adults level of >= 40
- in children a level of >= 35
47
Reversibility testing considers a positive test if
in adults
- improvement in FEV1 of > 12% and increase in volume of > 200 ml
in children
- improvement in FEV1 of > 12%
48
chemicals is associated with occupational asthma:
1. isocyanates
2. glutaraldehyde
3. platinum salts
4. proteolytic enzymes
5. soldering flux resin
6. epoxy resins
7. flour
*I G 2p SEF
49
Adverse effects of Omalizumab
abdominal pain
headache
fever
Churg-Strauss syndrome
50
Drugs associated with the development of Churg-Strauss syndrome
1. Leukotriene receptor antagonists
2. Omalizumab
51
Life-threatening of acute asthma
1. PEFR < 33 %
2. SPO2 < 92 %
3. Bradycardia, dysrthmia
4. Hypotension
5. Silent chest, cyanosis or feeble respiratory effort
6. Exhaustion, confusion or coma
52
Severe acute asthma
1. PEFR 33-50%
2. RR > 25
3. HR > 110
4. Can't complete sentences
53
Moderate acute asthma
1. PEFR 50 - 75 %
2. RR < 25
3. HR < 110
4. normal speech
54
In acute asthma, chest x-ray is not routinely recommended, unless
1. life-threatening asthma
2. suspected pneumothorax
3. failure to respond to treatment
55
Criteria for discharge, patient with acute asthma
1. been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
2. inhaler technique checked and recorded
3. PEF >75%
56
COPD: causes
- Smoking!
- Alpha-1 antitrypsin deficiency
- Other causes
1. cadmium (used in smelting)
2. coal
4. cotton
5. cement
6. grain
COPD = 4C G
57
The severity of COPD is categorised using the FEV1
4 stages
- mild FEV1 > 80 %
- moderat FEV1 50 - 79 %
- severe FEV1 30 - 49 %
- very severe FEV1 < 30 %
58
LTOT INDICATED IN
1. very severe airflow obstruction (FEV1 < 30%
2. cyanosis
3. polycythaemia
4. peripheral oedema
5. raised jugular venous pressure
6. SPO2 < 92 %
7. PO2 < 7.3 kpa
59
criteria NICE suggest to determine whether a patient has asthmatic/steroid responsive features:
1. any previous, secure diagnosis of asthma or of atopy
2. a higher blood eosinophil count - note that NICE recommend a CBC for all patients as part of the work-up
3. substantial variation in FEV1 over time (at least 400 ml)
4. substantial diurnal variation in peak expiratory flow (at least 20%)
60
Phosphodiesterase-4 (PDE-4) inhibitors
oral as roflumilast reduce the risk of COPD exacerbations
Recommend if
1. FEV1 < 50
2. Had > 1 exacerbation in the previous 12 months despite triple therapy LAMA, LA A and ICS.
61
Bronchiectasis: causes
1. post-infective: TB, measles, pertussis, pneumonia
2. cystic fibrosis
3. bronchial obstruction e.g. lung cancer/foreign body
3. immune deficiency: selective IgA, hypogammaglobulinaemia
4. allergic bronchopulmonary aspergillosis (ABPA)
5. ciliary dyskinetic syndromes: Kartagener's syndrome, Young's syndrome
6. yellow nail syndrome
62
Most common organisms isolated from patients with bronchiectasis:
Haemophilus influenzae (most common)
Pseudomonas aeruginosa
Klebsiella spp.
Streptococcus pneumoniae
63
dynein arm defect results in immotile cilia
Kartagener's syndrome
64
Predisposing factors of Obstructive sleep apnoea/hypopnoea syndrome
1. obesity
2. macroglossia: acromegaly, hypothyroidism, amyloidosis
3. large tonsils
4. Marfan's syndrome
65
Cystic fibrosis, due to a defect in ....
cystic fibrosis transmembrane conductance regulator gene (CFTR), which codes a cAMP-regulated chloride channel
66
In the UK 80% of Cystic fibrosis cases are due to delta ..... on the long arm of chromosome .........
due to (delta F508) on the long arm of chromosome (7)
67
Organisms which may colonise CF patients
Staphylococcus aureus
Pseudomonas aeruginosa
Burkholderia cepacia*
Aspergillus
68
features of cystic fibrosis
1. short stature
2. DM
3. delayed puberty
4. rectal prolapse (due to bulky stools)
5. nasal polyps
6. male infertility, female subfertility
7. recurrent chest infections
8. malabsorption
9. liver disease
69
Cystic fibrosis: management
1. regular (at least twice daily) chest physiotherapy and postural drainage
2. high calorie diet, including high fat intake
3. vitamin supplementation
4. pancreatic enzyme supplements taken with meals
5. lung transplantion
chronic infection with Burkholderia cepacia is an important CF-specific contraindication to lung transplantation
6. Lumacaftor/Ivacaftor (Orkambi)
is used to treat cystic fibrosis patients who are homozygous for the delta F508 mutation
70
Criteria of ARDS (American-European Consensus Conference)
1. acute onset (within 1 week of a known risk factor)
2. pulmonary oedema: bilateral infiltrates on chest x-ray ('not fully explained by effusions, lobar/lung collapse or nodules)
3. non-cardiogenic (pulmonary artery wedge pressure needed if doubt)
4. pO2/FiO2 < 40kPa (300 mmHg)
71
Allergic bronchopulmonary aspergillosis results from an allergy to
Aspergillus spores
72
Allergic bronchopulmonary aspergillosis
Investigations
eosinophilia
flitting CXR changes
positive radioallergosorbent (RAST) test to Aspergillus
positive IgG precipitins (not as positive as in aspergilloma)
raised IgE
73
Management of Allergic bronchopulmonary aspergillosis
1. oral glucocorticoids
2. itraconazole is sometimes introduced as a second-line agent
74
Alpha-1 antitrypsin deficiency is caused by a lack of ...1.... normally produced by .....2.....
1. a protease inhibitor (Pi)
2. the liver
75
Alpha-1 antitrypsin deficiency
Genetics
located on chromosome
chromosome 14
76
Features of Alpha-1 antitrypsin deficiency
lungs: panacinar emphysema, most marked in lower lobes
liver: cirrhosis and hepatocellular carcinoma in adults, cholestasis in children
77
Managment of Alpha-1 antitrypsin deficiency
no smoking
supportive: bronchodilators, physiotherapy
Iv alpha1-antitrypsin protein concentrates
surgery: lung volume reduction surgery, lung transplantation
78
PiMM =
PiMS =
PiMZ =
PiSS =
PiSZ =
PiZZ =
PiMM =100 % normal A1AT levels
PiMS = 80% normal A1AT levels
PiMZ = 60% normal A1AT levels
PiSS = 50 % normal A1AT levels
PiSZ = 40% normal A1AT levels
PiZZ = 10 % normal A1AT levels
79
What is the most common pathogen in Bronchiolitis
Respiratory syncytial virus (RSV)
80
Maternal IgG provides protection to newborns against .....
RSV
81
Varenicline is
nicotinic receptor partial agonist
82
the recommended course of Varenicline is ....
12 weeks (but patients should be monitored regularly and treatment only continued if not smoking)
83
Varenicline is contraindicated in
1. pregnancy
2. breast feeding
84
Bupropion is
norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
85
Bupropion should be started .......... before the patients target date to stop
1 to 2 weeks
86
Bupropion is contraindicated in
1. epilepsy,
2. pregnancy
3. breast feeding.
4. Having an eating disorder is a relative contraindication
87
all pregnant women should be tested for smoking using .......
carbon monoxide detectors
All women who smoke, or have stopped smoking within the last 2 weeks, or those with a CO reading of 》7 ppm should be referred to NHS Stop Smoking Services.
88
the first-line interventions of smoking cessation in pregnancy should be ...
1.cognitive behaviour therapy,
2. motivational interviewing
3. structured self-help
4. support from NHS Stop Smoking Services
89
Transudate pleural effusion if protein level ...
What are the causes?
- if protein < 30g/L
1. heart failure (most common transudate cause)
2. hypoalbuminaemia
- liver disease
- nephrotic syndrome
- malabsorption
3. hypothyroidism
4. Meigs' syndrome
90
Exudate pleural effusion if protein level ...
What are the causes?
- exudate Pleural effusion the protein exceed > 30g/L
1. infection
- pneumonia (most common exudate cause),
- tuberculosis
- subphrenic abscess
2. connective tissue disease
- rheumatoid arthritis
- SLE
3. neoplasia
- lung cancer
- mesothelioma
- metastases
4. pancreatitis
5. PE
6. Dressler's syndrome
7. yellow nail syndrome
91
Light's criteria should be used if the protein level is between .....
25-35 g/L,
92
In Light's criteria
exudate is likely if at least one of the following criteria are met:
pleural fluid protein divided by serum protein >0.5
pleural fluid LDH divided by serum LDH >0.6
pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
93
Other characteristic pleural fluid findings:
low glucose:
raised amylase:
heavy blood staining:
low glucose: rheumatoid arthritis, TB
raised amylase: pancreatitis, oesophageal perforation
heavy blood staining: mesothelioma, PE , TB
94
Chest tube indicated in pleural effusion if
1. the fluid is purulent or turbid/cloudy
2. fluid is clear but the pH is < 7.2
95
Management of recurrent pleural effusion
1. recurrent aspiration
2. pleurodesis
3. indwelling pleural catheter
4. drug management to alleviate symptoms e.g. opioids to relieve dyspnoea
96
Management of low-severity community acquired pneumonia
1. amoxicillin is first-line
2. if penicillin allergic then use a macrolide or tetracycline
* For 5 day course of antibiotics
97
Management of moderate and high-severity community acquired pneumonia
1. dual antibiotic therapy is recommended with amoxicillin and a macrolide
a 7-10 day course is recommended
NICE recommend considering a beta-lactamase stable penicillin such as co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide in high-severity CAP
98
Features of Klebsiella pneumonia (6)
1. more common in alcoholic and diabetics
2. may occur following aspiration
3. 'red-currant jelly' sputum
4. often affects upper lobes
5. commonly causes lung abscess formation and empyema
6. mortality is 30-50%
99
Management of Lung abscess
1. intravenous antibiotics
2. percutaneous drainage if not resolving
3. surgical resection in very rare cases surgical resection
100
monomicrobial causes of lung abscess include:
1. Staphylococcus aureus
2. Klebsiella pneumonia
3. Pseudomonas aeruginosa
101
What is the cause of 3-6% of spontaneous pneumothoraces occurring in menstruating women ?
It is thought to be caused by ...........?
- Catamenial pneumothorax
- endometriosis within the thorax
102
Management of 1ry pneumothorax
- chest drain if > 2 cm or SOB
- discharge if < 2 cm & asymptomatic
103
Management of 2ry pneumothorax
- O2 & admission for 24 hrs if < 1 cm
- Aspiration if 1-2 cm
- chest drain if
1. Age >50
2. SoB
3. >2 cm
4. Failed Aspiration with 1- 2 cm
104
Management of Iatrogenic pneumothorax
majority will resolve with observation, if treatment is required then aspiration should be used
ventilated patients need chest drains, as may some patients with COPD
105
Management of Persistentent / recurrent pneumothorax
video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy.
106
Post pneumothorax
1. Fitness to fly
2. Scuba diving
1. 2 weeks after successful drainage if there is no residual air
2. Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.'
107
Psittacosis is infection caused by
Chlamydia psittaci
108
Psittacosis should be suspected in a combination of ...
1. typical fever with a history of bird contact.
or
2. presentation with pneumonia and severe headache or organomegaly and failure to respond to penicillin-based antibiotics.
109
Treatment of Psittacosis
1st-line: tetracyclines e.g. doxycycline
2nd-line: macrolides e.g. erythromycin
110
causes of bilateral hilar lymphadenopathy
1. sarcoidosis
2. tuberculosis.
3. lymphoma/other malignancy
4. pneumoconiosis e.g. berylliosis
5. fungi e.g. histoplasmosis, coccidioidomycosis
111
chest drain is contraindicated in patients with any of the following:
1. INR > 1.3
2. Platelet count < 75
3. Pulmonary bullae
4. Pleural adhesions
112
Causes of pulmonary eosinophilia
1. Churg-Strauss syndrome
2. allergic bronchopulmonary aspergillosis (ABPA)
3. eosinophilic pneumonia
4. hypereosinophilic syndrome
5. tropical pulmonary eosinophilia
6. Loffler's syndrome
7. drugs: nitrofurantoin, sulphonamides
8. less common: Wegener's granulomatosis
113
Loffler's syndrome due to parasites such as
Ascaris lumbricoides
114
Tropical pulmonary eosinophilia associated with
Wuchereria bancrofti infection
115
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
Features (5)
1. asthma
2. blood eosinophilia (e.g. > 10%)
3. paranasal sinusitis
4. mononeuritis multiplex
5. pANCA positive in 60%
116
Churg-Strauss syndrome may precipitated by ...
Leukotriene receptor antagonists
117
Granulomatosis with polyangiitis (Wegener's granulomatosis)
Features
1. upper respiratory tract: epistaxis, sinusitis, nasal crusting
2. lower respiratory tract: dyspnoea, haemoptysis
3. rapidly progressive glomerulonephritis ('pauci-immune', 80% of patients)
4. saddle-shape nose deformity
5. also: vasculitic rash, eye involvement (e.g. proptosis), cranial nerve lesions
118
Granulomatosis with polyangiitis (Wegener's granulomatosis)
Investigations
cANCA positive in > 90%, pANCA positive in 25%
chest x-ray: wide variety of presentations, including cavitating lesions
renal biopsy: epithelial crescents in Bowman's capsule
119
Granulomatosis with polyangiitis (Wegener's granulomatosis)
Treatment
steroids
cyclophosphamide (90% response)
plasma exchange
median survival = 8-9 years
120
Microscopic polyangiitis
Features
renal impairment: raised creatinine, haematuria, proteinuria
fever
other systemic symptoms: lethargy, myalgia, weight loss
rash: palpable purpura
cough, dyspnoea, haemoptysis
mononeuritis multiplex
121
Microscopic polyangiitis
pANCA (against MPO) - positive in 50-75%
cANCA (against PR3) - positive in 40%
122
mushroom workers' lung
thermophilic actinomycetes
123
malt workers' lung
Aspergillus clavatus
124
farmers lung
spores of Saccharopolyspora rectivirgula from wet hay (formerly Micropolyspora faeni)
125
imaging: upper/mid-zone fibrosis
bronchoalveolar lavage: lymphocytosis
serologic assays for specific IgG antibodies
blood: NO eosinophilia
Diagnosis?
Extrinsic allergic alveolitis ( hypersensitivity pneumonitis)
126
Management of Extrinsic allergic alveolitis ( hypersensitivity pneumonitis)
avoid precipitating factors
oral glucocorticoids
127
Features of acute sarcoidosis
acute:
1. erythema nodosum,
2. bilateral hilar lymphadenopathy,
3. swinging fever,
4. polyarthralgia
128
Mechanism of hypercalcemia in sarcoidosis
macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)
129
Mikulicz syndrome
enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis or lymphoma
130
Heerfordt's syndrome (3)
1. parotid enlargement,
2. fever
3. uveitis
secondary to sarcoidosis
131
Lofgren's syndrome
acute form sarcoidosis characterised by
1. bilateral hilar lymphadenopathy (BHL),
2. erythema nodosum,
3. fever and
4. polyarthralgia.
It typically occurs in young females and carries an excellent prognosis.
132
Stages of sarcoidosis
stage 0 = normal
stage 1 = bilateral hilar lymphadenopathy (BHL)
stage 2 = BHL + interstitial infiltrates
stage 3 = diffuse interstitial infiltrates only
stage 4 = diffuse fibrosis
133
Indications for steroids in sarcoidosis
1. patients with chest x-ray stage 2 or 3 disease who are symptomatic. Patients with asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment
2. hypercalcaemia
3. eye, heart or neuro involvement
134
Factors associated with poor prognosis in sarcoidosis
1. insidious onset, symptoms > 6 months
2. absence of erythema nodosum
3. extrapulmonary manifestations: e.g. lupus pernio, splenomegaly
4. CXR: stage III-IV features
5. black African or African–Caribbean ethnicity
135
respiratory problems may be seen in patients with rheumatoid arthritis:(8)
1. pulmonary fibrosis
2. pleural effusion
3. pulmonary nodules
4. pleurisy
5. bronchiolitis obliterans
6. complications of drug therapy e.g. methotrexate pneumonitis
7. Caplan's syndrome - massive fibrotic nodules with occupational coal dust exposure
8. infection (possibly atypical) secondary to immunosuppression
136
most common form of asbestos-related lung disease
Pleural plaques are benign and do not undergo malignant change. They, therefore don't require any follow-up
137
Treatment of Asbestosis
treated conservatively - no interventions offer a significant benefit.
138
Which asbestos is the most dangerous form ?
Crocidolite (blue) asbestos
139
Treatment of Mesothelioma
palliative chemotherapy and
there is also a limited role for surgery and radiotherapy.
Unfortunately, the prognosis is very poor, with a median survival from diagnosis of 8-14 months.
140
Occupations at risk of silicosis
1. mining
2. slate works
3. foundries
4. potteries
141
Features of silicosis
1. upper zone fibrosing lung disease
2. 'egg-shell' calcification of the hilar lymph nodes
3. It is a risk factor for developing tuberculosis
142
causes of upper zone fibrosis
CHARTS
C - Coal worker's pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
143
Fibrosis predominately affecting the lower zones
idiopathic pulmonary fibrosis
most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
drug-induced: amiodarone, bleomycin, methotrexate
asbestosis
144
Treatment of IPF
1. pulmonary rehabilitation
2. pirfenidone (an antifibrotic agent) may be useful in selected patients
3. many patients will require supplementary oxygen and eventually a lung transplant
145
Prognosis of IPF
poor, average life expectancy is around 3-4 years
146
Cryptogenic organizing pneumonia
- not associated with smoking
- history of non-response to antibiotics
147
Treatment of Cryptogenic organizing pneumonia
Treatment is watch and wait if mild or
high dose oral steroids if severe.
148
Lung carcinoid is associated with……metastasis
Liver metastasis
MRCP Part 1
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