1
Q
what does ABPA stand for?
what is it?
A
allergic bronchopulmonary aspergillosis
asthma triggered by exposure to aspergillus fungus
2
Q
what are the 4 types of hypersensitivity reactions?
incl. time before clinical signs, molecular characteristics + examples
A
type 1 - Anaphylaxis/Allergy/Atopy
- <30mins
- IgE, degranulation of mast cells
- hay fever/asthma/allergy/etc
type 2 - antiBodies
- 5-12hrs
- antigen -> formation of IgM + IgG antiBodies which destroy target cells which have antigen
- transfusion reactions/Rh incompatability
type 3 - immune Complex
- 3-8hrs
- antibodies + antigens form complexes that cause damaging inflammation
- SLE/RA/serum sickness
type 4 - Delayed cell-mediated reaction
- 24-48hrs
- antigens activate T cells (all others are B cell related)
- transplant rejection/contact dermatitis (eg poison ivy)
3
Q
what are 3 changes seen in chronic asthma?
A
- bronchiolar wall smooth muscle hypertrophy
- mucus gland hyperplasia
- resp bronchiolitis -> centrilobular emphysema
4
Q
bronchiectasis:
- what is it?
- causes? 5
- signs/symptoms? 3
A
PERMANENT dilation of bronchi + bronchioles dt destruction of the muscle + elastic tissue
- infections (TB, fungal, without Abx)
- CF
- kartagener syndrome (aka primary ciliary dyskinesia)
- bronchial obstruction (tumour, foreign body)
- autoimmune conditions (lupus, RA, IBD, GVHD)
- long-standing cough
- intermittent fever
- copious amounts of foul-smelling sputum
5
Q
what is the technical definition of chronic bronchitis?
A
cough + sputum for 3 months in each of 2 consecutive years
6
Q
what is the pathology of chronic bronchitis?
A
- mucus gland hyperplasia + hypersecretion
- secondary infection by low virulence bacteria
- chronic inflammation
chronic inflammation of small airways -> wall weakness + destruction -> centrilobular emphysema
7
Q
what are the types of emphysema seen in:
- smokers?
- people with a1-antitrypsin deficiency?
A
smokers:
- centrilobular (aka centiacinar)
a1-antitrypsin deficiency
- panlobular (aka panacinar)
8
Q
what are the differences between COPD which is predominantely bronchitis and that which is predominant emphysema:
- age?
- dyspnoea?
- cough?
- infections?
- CXR findings?
- stereotype?
A
predominantely bronchitis:
- age 40-45
- dyspnoea: mild
- cough: lots, copius sputum
- infections: common
- CXR findings: prominent vessels, large heart
- stereotype: ‘blue bloater’
predominant emphysema
- age 50-75
- dyspnoea: severe
- cough: not as much, scanty sputum
- infections: rare
- CXR findings: small heart, hyperinflated lungs
- stereotype: ‘pink puffer’
9
Q
chronic bronchitis + emphysema in coal miners
- what is it? (legally)
- how many years of work qualify?
- what does degree of compensation depend on? 2
A
UK prescribed occupational disease in coal miners
- chronic bronchitis +/or emphysema
> 20 years underground work
- degree of disability
- smoking history
nb no CXR or history of dust exposure needed
10
Q
what features are common to all interstitial lung diseases? 3
A
- increased tissue in alveolar-capillary wall (-> increased gas diffusion distance)
- inflammation -> fibrosis
- decreased lung compliance
11
Q
acute interstitial pneumonia/pneumonitis:
- what is it?
- cause?
- treatment?
- similar to?
A
acute diffuse damage to interstitium of lungs
- short period between beginning of symptoms to resp failure
idiopathic
mechanical ventilation + corticosteroids
- but prognosis poor, only cure is transplant
acute/adult respiratory distress syndrome (ARDS) - aka ‘shock lung’
12
Q
chronic interstitial lung diseases:
- symptoms? 2
- signs? 2
- end-stage sign?
- examples? 3
A
symptoms:
- increasing dyspnoea (for years)
- dry cough
signs:
- clubbing
- fine crackles
end-stage sign = ‘honeycomb lung’
examples:
- idiopathic pulmonary fibrosis
- many pneumoconioses
- sarcoidosis
- collagen vascular diseases-associated lung diseases
13
Q
idiopathic pulmonary fibrosis:
- which lobes first + worst affected?
- histology?
- histology same as? 2
A
lower lobes affected first + most severely
interstitial chronicinflammation + variably mature fibrous tissue
- adjacent normal alveolar walls
- collagen vascular disease-associated interstitial lungdisease
- asbestosis
14
Q
sarcoidosis in lungs:
- pathology?
- other organs that can be affected?
- what else affected?
- often mistaken for?
- blood test results? 2
- normally seen in?
A
non-caseating pulmonary granulomas
- skin
- heart
- brain
- liver
- hilar lymph nodes
mistaken for TB
- granulomas are necrotic in TB, not in sarcoidosis
- hypercalcaemia
- high serum ACE
young adult women
15
Q
definition of pneumoconioses?
A
non-neoplastic lung diseases due to inhalation of mineraldusts, organic dusts, fumes + vapours
- often occupational
aka ‘the dust diseases’
16
Q
what is cor pulmonale?
A
the enlargement and failure of the right ventricle of the heart as a response to increased vascular resistance (such as from pulmonic stenosis) or high blood pressure in the lungs
17
Q
silicosis:
- cause?
- people affected? 2
- pathology?
- increased risk of?
A
exposure to silica - sand + stone dust
- stone masons
- building site workers
fibrosis + very discrete fibrous silicotic nodules (also found in adjacent lymph nodes)
- lung cancer
18
Q
hypersensitivity pneumonitis:
- aka?
- type of hypersensitivity reaction?
- two examples of types?
- pathology?
- can lead to?
A
extrinsic allergic alveolitis
type 3 (immune Complex)
- ‘farmer’s lung’ - antigens in hay
- ‘pigeon fancier’s lung’ - bird antigens
inflammation around bronchioles, with poorly formed non-caseating granulomas extends alveolar walls
repeated episodes -> interstitial fibrosis
nb reversible in early stages
19
Q
4 major types of primary malignant lung tumours?
A
- small cell carcinoma
non-small cell:
- adenocarcinoma
- squamous cell carcinoma
- large cell undifferentiated carcinoma
20
Q
what is the difference between a sarcoma and a carcinoma?
A
carcinoma: epithelial tissue tumour
sarcoma connective/non-epithelial tissue tumour
21
Q
causes of lung cancer? 5
A
- tobacco smoking
- occupationa/industrial hazards (eg asbestos, uranium, nickel)
- radiation (eg radon mining, post atom bomb)
- lung fibrosis
- genetic mutations
22
Q
lung cancer:
- symptoms? 7
- signs? 3
A
symptoms:
- haemoptysis
- cough
- breathlessness
- fatigue
- weight loss
- hoarse voice (if recurrent laryngeal nerve)
- horner’s syndrome (symp chain)
signs:
- clubbing
- pleural effusion (if spreads to pleura)
- raised ACTH, ADH + PTH
23
Q
where does lung cancer commonly metastasise to? 6
how might these present?
A
- lymph nodes (swollen in neck)
- pleura (pleural effusion)
- liver
- bone (fractures)
- adrenal
- brain (seizures)
24
Q
what electrolyte disturbances are seen in small cell carcinomas? 3
A
- hyponatraemia
- hypokalemia
- hypercalcaemia
25
what is lymphangitis carcinomatosa?
lymphatics within lung are diffusely involved by tumour
26
what % of lung cancer patients are elligable for surgery?
about 10%
- either cancer not resectable of physically not fit enough (as it's major surgery), often both as present late
27
what is the normal lung pleura made up of?
single layer of mesothelial cells (with connective tissue on non-pleural-cavity side)
- on both layers of pleura
secrete hyaluronic acid rich mucinous pleural fluid
28
what are 7 causes of pleural inflammation?
primary inflammatory diseases
- eg SLE, RA
infections
- norm secondary to pneumonias or TB
- primary coxackie B infection
pulmonary infarction
- secondary to pulm arterial thromboembolism
emphysema
- secondary to ruptured bullae
cancer
therapeutic
- pleurodesis, usually with talc, to treat recurrent pleural effusions or recurrent pneumothoraxes
iatrogenic
- radiotherapy to thorax
- immune reactions to drugs
29
pleural inflammation:
- names? 2
- symptom?
- sign?
- associated condition?
- can develop into?
pleurisy or pleuritis
pleuritic chest pain
- sharp localised pain exacerbated by breathing
auscultation of a PLEURAL RUB during breathing
often associated pleural effusion
- weak breath sounds on auscultation
- dull on percussion
pleural fibrosis
30
what are the 2 types of asbestos associated pleural fibrosis?
- level of asbestos exposure?
- symptoms?
- is it elligable for industrial injuries disablement benefit?
parietal pleural fibrous plaques
- low-level exposure
- asymptomatic
- not elligIble
diffuse pleural fibrosis
- high-level exposure
- breathlessness
- elligible
31
what are the effects of pleural fibrosis?
what procedure can be done to reduce these?
- prevent normal expansion + commpression of lung -> breathessness
pleural decortication
- removal of the fibrous tissue
32
what is is called when these fluid are in the pleural cavity:
- serous fluid?
- pus?
- blood?
- lymph?
- air?
serous fluid = pleural effusion
pus = empyema/pyothorax (norm secondary to pneumonia)
blood = haemothorax (norm traumatic or secondary to ruptured thoracic aortic aneurysm)
Lymph = chylothorax (norm trauma to thoracic duct)
air = pneumothorax
33
2 types of pleural effusions = transudates + exudates, what is the difference between them:
- pathology?
- protein content?
- lactate dehydrogenase content?
- causes? (trans = 4, exu = 2)
transudates:
- low capillary osmotic pressure +/or high capillary hydrostatic pressure
- low protein
- low lactate dehydrogenase
- - high vascular hydrostatic pressure (LV failure, renal failure)
- - low capillary osmotic pressure (hypoalbuminaemia - hepatic cirrhosis, nephrotic syndrome)
exudates:
- pathological capillaries loose semi-permeability
- high protein
- high lactate dehydrogenase
- - inflammation (with or without infection)
- - cancer
"stuff to do with osmosis forms a transudate, it is just TRAvelling through, so doesn't leave lots of proteins etc, EXudate can develop into Empyema, everything EXits the capillaries"
34
treatments for pleural effusions? 4
- aspiration of fluid with needle + syringe (ultrasound guided)
- treat underlying cause (if possible)
- pleural drain (for recurrent effusions)
- pleurodesis (for recurrent effusions)
35
what are the 2 different types of pneumothorax?
pathologies?
what can both cause?
open pneumothorax:
- chest wall perforation
- normally traumatic
- connects body surface to pleural cavity
- external air -> pleural cavity during inspiration, reducing potential lung expansion
closed pneumothorax
- lung perforation
- usually not traumatic
- connects lung air spaces to the pleural cavity
- lung air -> pleural cavity during inspiration, reducing potential lung expansion
both can cause: tension pneumothorax
- air in during inspiration but not out during expiration
36
causes of closed pneumothoraxes? 4
ruptured emphysematous bullae
common inflammatory lung diseases
- asthma
- pneumonia
- TB
- CF
traumatic
- lung tears from fractured ribs
iatrogenic
- mechanical ventilation at high pressures
- lung + pleural biopsies
37
pneumothorax:
- symptoms? 2
- signs? 5
symptoms: (small ones may be asymptomatic)
- breathlessness
- pleuritic chest pain
signs:
- cyanosis
- tachycardia
- tracheal deviation (in tension pneumothorax)
- hyperressonant percussion
- reduced breath sounds on auscultation
38
what is the most common type of primary pleural neoplasm?
what 2 cancers often metastasise to the pleura?
malignant mesothelioma
- breast
- lung
39
malignant mesothelioma:
- cause?
- cells/tissues it affects?
- metastasise?
if pleural, 80-90% caused by asbestos
(- thoracic radiation)
(- BRAC1 gene)
mesothelial cells that line serous cavities:
- pleura (92%)
- peritoneum (8%)
- pericardium
- tunica vaginalis
tend not to metastasise widely
- but if they do then go to other lung pleuraor peritoneum etc
40
how do you diagnose a malignant mesothelioma?
- can use imaging but difficult to identify and thus target biopsies at
if the is an accompanying pleural effusion, malignant cells may be shed into this
- therefore effusion cytology may allow an early tissue diagnosis to be made
nb a small tumour can produce a large pleural effusion
then use dyes to work out cell type tumour has grown from to differentiate between mesothelioma + lung tumours
41
what does desmoplasia mean?
the growth of fibrous or connective tissue
so if something is desmoplastic (eg a tumour) then it has low cellular component and is largely connective tissue
42
what is asbestosis?
is it elligible for industrial injuries disablement benefit?
a usual pneumonia-like proggressive pulmonary interstitial fibrosis caused by high level exposure to asbestos dust
- fibrosis of the alveolar walls impairs both gas exchange + lung expansion + contraction during breathing
yes
43
what skin lesions can people exposed to asbestos present with?
asbestos corns
| - benign hyperkeratotic wart-like skin lesions
44
what would lymphoma look like on a chest x-ray
a mass above the mediastinum
| - enlargement of mediastinal lymph nodes
45
what are you likely to hear when auscultating a patient with:
- pneumonia
- interstitial lung disease
pneumonia/infection:
- coarse crackles
- more likely to be localised
interstitial lung disease
- fine crackles
- more likely to be all over lungs
46
name 8 causes of haemoptysis
- TB
- pneumonia
- bronchitis
- aspergilloma
- brochiectasis
- lung cancer
- PE
- aspiration of foreign body
47
in which type of lung cancer can 'keratin pearls' be seen histologically?
squamous carcinomas
48
what metaplastic change is seen in smoker's lungs?
ciliated columnar epithelium -> stratified squamous epithelium
49
what is it called when the lymphatics in the lung are diffusely involved by tumour?
Lymphangitis carcinomatosa
50
what is the most oncogenic type of asbestos?
crocidolite - 'blue asbestos'
"crocodiles are dangerous"
51
what are the differential diagnoses for hilar lymphadenopathy? 4
ie swollen hilar lymph nodes on x-ray
sarcoidosis
infection
- TB
- fungal
neoplastic
- lymphoma
- cancer
inorganic dust disease
- silicosis
52
name of diagnostic skin test used to determine if someone has been exposed to TB?
heaf test
53
condition seen in infants that results in inflammation + oedema of bronchioles + commonly caused by RSV (respiratory syncytial virus)?
bronchiolitis
54
What are the 3 main symptoms of infectious mononucleosis (EBV/glandular fever)?
- fever
- tonsillar pharyngitis
- cervical lymphadenopathy (enlarged cervical lymph nodes)
55
what is a complication of infectious mononucleosis (EBV/glandular fever)?
Splenic rupture
56
What drug should you avoid giving in patients who could have infectious mononucleosis (EBV/glandular fever)? Why?
Ampicillin
| - interaction results in a non-allergic rash = mac-pap rash
57
What would be 3 clinical signs that would suggest a sore throat was caused by Epstein barr virus?
- symmetrically inflamed tonsils
- soft palate inflammation
- posterior cervical lymphadenopathy (ie enlarged cervical lymph nodes)
58
what is the most common bacterial cause of a sore throat?
Group A beta-haemolytic streptococcus (GABHS)
| - ‘strep throat’
59
name 5 viruses which commonly cause pharyngitis (+ tonsillar pharyngitis)
- rhinovirus
- coronavirus
- parainfluenza
- influenza (A+B)
- adenovirus
60
what is the name of the criteria that’s used to establish whether a sore throat is caused by a bacterial infection? What 4 factors does it use?
Centor criteria
- tonsillar exudate
- tender anterior cervical lymphadenopathy
- fever over 38 degrees
- absence of cough
if 3 or 4 of above are met, the positive predictive value is 40-60%
- if none or 1 criteria is met the negative predictive value is 80%
61
what tests would be performed in suspected infectious mononucleosis (EBV)? 2
- Blood sample for monospot
OR
- EBV serology
62
When should you give antibiotics for sore throats?
- non-severe acute tonsillar pharyngitis, if symptoms >a week + getting worse
- severe acute tonsillar pharyngitis
- quinsy
- epiglottitis
63
What are the 3 main symptoms of infectious mononucleosis (EBV/glandular fever)?
- fever
- tonsillar pharyngitis
- cervical lymphadenopathy (enlarged cervical lymph nodes)
64
what is a complication of infectious mononucleosis (EBV/glandular fever)?
Splenic rupture
65
What drug should you avoid giving in patients who could have infectious mononucleosis (EBV/glandular fever)? Why?
Ampicillin/amoxicillin
| - interaction results in a non-allergic rash = mac-pap rash
66
What would be 3 clinical signs that would suggest a sore throat was caused by Epstein barr virus?
- symmetrically inflamed tonsils
- soft palate inflammation
- posterior cervical lymphadenopathy (ie enlarged cervical lymph nodes)
67
what is the most common bacterial cause of a sore throat?
Group A beta-haemolytic streptococcus (GABHS)
| - ‘strep throat’
68
name 5 viruses which commonly cause pharyngitis (+ tonsillar pharyngitis)
- rhinovirus
- coronavirus
- parainfluenza
- influenza (A+B)
- adenovirus
69
what is the name of the criteria that’s used to establish whether a sore throat is caused by a bacterial infection? What 4 factors does it use?
Centor criteria
- tonsillar exudate
- tender anterior cervical lymphadenopathy
- fever over 38 degrees
- absence of cough
if 3 or 4 of above are met, the positive predictive value is 40-60%
- if none or 1 criteria is met the negative predictive value is 80%
70
When should you give antibiotics for sore throats?
- non-severe acute tonsillar pharyngitis, if symptoms >a week + getting worse
- severe acute tonsillar pharyngitis
- quinsy
- epiglottitis
71
Epiglottitis:
- normally viral or bacterial?
- What used to be most common cause?
- Other causative organisms? 2
- Management?
Almost always bacterial
Haemophilus influenza type b (Hib) was commonest cause
- now vaccinated against (but adults + unvaccinated kids still at risk)
- streptococcus pneumoniae
- group A strep
securing airway + oxygenation is priority!!
Then:
- blood cultures + epiglottic swabs (have anaesthetist on standby when inspecting throat!)
- IV antibiotics
- Analgesia
If Hib epiglottitis, inform public health
72
What are the risk factors for otitis externa? 5
- swimming (or other water exposure) (aka ‘swimmer’s ear’)
- trauma (eg ear scratching, cotton swabs)
- occlusive ear devices (eg hearing aids, ear phones)
- allergic contact dermatitis (eg due to shampoos, cosmrtics)
- dermatological conditions (eg psoriasis)
73
Otitis externa:
- symptoms? 3
- Definition of acute vs chronic?
- Typically unilateral or bilateral?
- otalgia (ear pain)
- pruritis (itchy)
- non-mucoid ear discharge
```
acute = symptoms <3/52
chronic = symptoms >3/52
```
```
acute = norm unilateral
chronic = norm bilateral
```
74
Acute otitis externa:
- normal cause?
- complication?
- Investigations?
- management?
90% bacterial
necrotising (malignant) otitis externa
- ear swab or pus sample for culture
for necrotising OE: CT temporal bone + bone biopsy (blood cultures if systemically unwell)
- remove/modify precipitating factors
- remove pus/debris from ear = ‘toileting’ the ear
- analgesia
- topical antibiotics for mild- moderate (ie ear drops)
- systemic Abx for severe
75
Malignant (necrotising) external otitis:
- what is it?
- Most commonly occurs in? 2
- Symptoms/signs? 4
- Treatment?
When EO spreads to skull base (can be life threatening)
- elderly diabetic
- immunocompromised
- severe pain
- otorrhoea (ear discharge)
- granulation tissue in canal floor
- cranial nerve palsys are possible
min 6 weeks Abx
76
chronic otitis externa:
- symptoms? 2
- what ear canal looks like?
- Normal causes? 2
- Treatment?
- pruritis (itching)
- mild discomfort
erythematous external canal that’s normally devoid of wax (often bilateral)
- white keratin debris may fill ear canal + over time, canal wall skin -> thickened, narrowing the canal
- allergic contact dermatitis (eg chemicals in shampoos/cosmetics)
- generalised skin conditions (eg atopic dermatitis, psoriasis)
treat underlying cause
77
Otitis media (OM):
- what is it?
- Normal cause?
- Features of uncomplicated acute OM? 5
- Features of complicated acute OM? 4
- Severe complication?
Middle ear inflammation (fluid present in middle ear, behind ear drum)
Viruses!
Uncomplicated:
- mild pain
- <72 hrs duration
- absence of severe systemic symptoms
- temp <39 deg
- no ear discharge
complicated:
- severe pain
- perforated ear drum (+/or discharge)
- purulent discharge (+/or perforation)
- bilateral infection
mastoiditis
78
what is the pinna?
another name for it?
externally projecting part of the ear
auricle
79
mastoiditis:
- what is it?
- what influences likelihood of getting it? 2
- clinical features? 5
- Investigation?
- Treatment?
Infection of the mastoid bone + air cells
- more likely if a child
- more likely if didn’t get Abx for otitis media
features:
- fever
- posterior ear pain
- local erythema over the mastoid bone
- oedema of the pinna
- posteriorly + downward displaced auricle
CT always required (need to know extent of infection)
- analgesia
- IV antibiotics +/- mastoidectomy
80
Pinna cellulitis
- what is it?
- Cause?
- Treatment?
Cellulitis of the ear
Associated with trauma (normally ear piercing)
Bacterial infection
Antibiotics
81
Pneumonia:
- what is it?
- Clinical definition?
- 2 anatomical patterns?
Infection affecting the most distal airways + alveoli – formation of an inflammatory exudate
Lower respiratory tract infection with consolidation on x-ray
Bronchopneumonia
- patchy distribution centred on inflamed bronchioles + bronchi then spread to surrounding alveoli
lobarpneumonia
- affects a large part, or the entirety, of a lobe
82
what are 90% of lobarpneumonia caused by?
s. pneumonia
83
what are the 4 different types of pneumonia? (defined by where infection occurred)
- definitions?
Community acquired pneumonia (CAP)
Hospital acquired pneumonia (HAP)
- pneumonia developing >48hrs after hosp admission
Ventilator acquired pneumonia (VAP)
- subgroup of HAP
- pneumonia developing >48hrs after ET intubation + ventilation
aspiration pneumonia
- resulting from abnormal entry of fluids (eg food, drink, stomach contents) into LRT
- patient norm has impaired swallow (eg stroke or parkinsons)
84
what sort of organisms cause:
- ‘typical’ CAP? (+5 examples)
- ‘atypical’ CAP (+5 examples)
‘typical’ = have cell wall
- strep pneumonia
- haemophilus influenza
- Moraxella catarrhalis
- Staph aureus
- Klebsiella pneumonia
‘atypical’ = no/atypical cell wall
- mycoplasma pneumonia
- legionella pneumophilia
- chlamydophila pneumoniae
- chlamydophila psittaci
- coxiella burnetii
your leg and your cock get chlamydia
85
‘typical’ pneumonia
- symptoms? 5
- signs? 4
symptoms:
- fever/chills
- productive cough
- mucopurulent sputum
- pleuritic chest pain
- general malaise (fatigue, anorexia)
signs:
- tachypnoea
- tachycardia
- hypotension
- exam findings: dull to percuss, reduced air entry, bronchial breathing
nb usually rapid onset (though not as acute as PE/cardiac)
86
mycoplasma pneumoniae (causes an ‘atypical’ pneumonia)
- commonly affects?
- Main symptom?
- Diagnosis?
- Rare complications? 4
Children + young adults (autumn epidemics every 4-8 years)
Cough
Serology (difficult to culture)
- pericarditis
- arthritis
- guillain-barre*
- peripheral neuropathy
87
legionella pneumophilia (causes an ‘atypical’ pneumonia)
- where norm get infection from?
- Signs/symptoms? 7
- Abnormal blood results? 2
Colonises water piping systems
- outbreaks associated w showers, air con units, humidifiers
- high fevers
- rigors
- cough: dry initially, becoming productive
- dyspnoea
- vomiting
- diarrhoea
- confusion
- deranged LFTs
- hyponatraemia
88
chlamydophila psittaci (causes an ‘atypical’ pneumonia)
- infection associated with?
- Associated symptoms/conditions?
Exposure to birds
- rash
- hepatitis
- haemolytic anaemia
- reactive arthritis
consider in those w pneumonia, splenomegaly + hx of bird exposure
89
what acronym is used to assess disease severity in pneumonia?
What does each bit stand for?
CURB-65
```
C – confusion
U – urea (>7mmol/L in blood)
R – resp rate >30
B – blood pressure (systolic <90 or diastolic <60)
65 – age >65 years
```
score of 1 given to each feature
score of 0-1 = home management
score of 2 = hosp management
score of 3-5 = hosp (assess for ITU admission)
90
what is the management of any type of pneumonia?
- ABC
- Then prompt Abx therapy
As part of circulation:
- gain IV access + give IV fluids if haemodynamically unstable + urinary catheter to monitor urine output
91
what are the possible complications of pneumonia? 3
- pleural effusion
- empyema
- lung abscess
92
what are the most common viral causes of pneumonia in:
- adults? 3
- children? 2
- immunocomprimised? 4 (+ above causes)
```
adults:
- influenza A + B
- adenovirus
- varicella zoster virus (VZV)
children:
- RSV
- Parainfluenza
Immunocompromised:
- measles
- herpes simplex (HSV)
- cytomegalovirus (CMV)
- HHV-6
```
93
What are the symptoms of normal (uncomplicated) influenza? 5
| - how long do these normally take to resolve?
- fever
- headache
- myalgia
- DRY cough
- sore throat
2-3 weeks
94
what is a complication of varicella zoster virus infection in adults?
- who is this most likely to affect? 4
- symptoms? 3
VZV pneumonia
- immunocomprimised
- adults w chronic lung disease
- smokers
- preganant women (not more likely to affect but, if infected, worse prognosis)
insidious onset 1-6 days after rash appears, progressive symptoms:
- tachypnoea
- dyspnoea
- dry cough
95
who is pneumonia caused by cytomegalo virus likely to affect? 2
- transplant recipients (esp lung)
| - HIV patients
96
Bronchiectasis:
- symptoms? 4
- management in infective exacerbations? 4
- breathlessness
- chronic cough
- mucopurulent sputum production
- recurrent infections
- antibiotics
- effective clearance of resp secretions (eg physiotherapy, postural drainage)
- nutritional support
- annual influenza vaccine
97
who is given the:
- pneumococcal vaccination? 3
- Annual flu jab? 3
Pneumococcal:
- patients w chronic heart, lung + kidney disease
- patients with splenectomy
- infant vaccination schedule
annual flu:
- 2-17 yr olds
- over 65s
- chronic disease, multiple comorbidities
98
allergic bronchopulmonary aspergillosis (ABPA):
- who it affects? 3
- clinical presentation?
- Diagnosis? 3
- View on CT scan?
- Treatment? 2
- atopy
- asthma
- CF
worsening asthma + lung function
- high total IgE
- specific IgE to aspergillus
- positive seum IgG to aspergillus
may demonstrate central bronchiectasis
- corticosteroids
- antifungal therapy
99
pulmonary aspergilloma:
- who affects?
- Symptoms/signs? 5
- Diagnosis? 2
- Complication?
- Treatment? 2
People with old cavities (eg caused by TB, sarcoidosis)
- cough
- haemoptysis
- weight loss
- wheeze
- clubbing
nb some are asymptomatic
- CXR/CT thorax
- positive test for aspergillus IgG antibody
massive haemoptysis
- surgical resection
- antifungals (injected into cavity or orally)
nb 10% resolve spontaneously
100
pneumocystis jiroveci pneumonia
- what causes it?
- Who gets it?
- Symptoms? 4
- Diagnosis?
- Treatment? 3
Fungus
- but lacks ergosterol in its cell wall so is not susceptible to a number of antifungals
insidious onset of:
- fever
- dyspnoea
- non-productive cough
- reduced exercise tolerance (get very SOB on exertion)
PCR to detect P. jiroveci DNA from induced sputum (hard to find in expectorated sputum)
- supportive care
- antimicrobials
- steroids
101
pulmonary nocardiasis
- causative organism?
- Who affects? 2
- Clinical presentation?
- Treatment? 2
Inhalation of nocardia asteroides
- immunosuppressed
- pre-existing lung condition
presentation/clinical findings are variable, making diagnosis hard
- supportive care (ABC etc)
- antibiotics (several months)
nb this is rare, even in affected groups
102
respiratory TB
- natural history of disease?
- % of primary infections which are symptomatic?
Organisms are inhaled, depending on host’s immune system infection will either become quiescent or progress and/or disseminate
- reactivation of disease may occur later in life, particularly in immunocompromised
90% asymptomatic
103
what is disseminated TB called?
Miliary TB
104
respiratory TB
- symptoms? 5
- diagnosis?
- Treatment?
- Prevention?
- chronic productive cough
- haemoptysis
- weight loss
- fever
- night sweats
interferon gamma release assays (IGRA) +/- tuberculin skin test
- mantoux can be used (doesn’t differentiate active from latent disease)
combined antibiotics for 6 months
give BCG to infants/kids in high prevalence areas
nb TB is a notifiable disease (to public health) + contract tracing occurs
105
what criteria is used to define an exudate in a pleural effusion?
what are the detils of this?
lights criteria
- Effusion protein/serum protein ratio greater than 0.5
- Effusion lactate dehydrogenase (LDH)/serum LDH ratio greater than 0.6
- Effusion LDH level greater than two-thirds the upper limit of the laboratory's reference range of serum LDH
effusion is likely to be exudative if any one of these criteria is filled
106
which type of lung cancer most commonly causes paraneoplastic syndromes?
small cell carcinomas
nb these still rarely cause them though
eg:
- syndrome of inappropriate antidiuretic hormone secretion (SIADH)
- cushings syndrome etc
107
which lobe of the lung is TB most likely to affect?
upper lobe
aka apical shadow
