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Yr3 Revision > Respiratory IV (Pneumonia; Sarcoidosis) > Flashcards

Respiratory IV (Pneumonia; Sarcoidosis) Flashcards

1
Q

Which atypical pneumonia is most likely to cause erythema multiforme?

Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia

A

Which atypical pneumonia is most likely to cause erythema multiforme?

Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia

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2
Q

Which atypical pneumonia is most likely to cause hyponatraemia?

Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia

A

Which atypical pneumonia is most likely to cause hyponatraemia?

Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia - causes SIADH
Chlamydia psittaci
Q fever pneumonia

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3
Q

Which atypical pneumonia is most likely to caused by hanging out with a parrot?

Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia

A

Which atypical pneumonia is most likely to caused by hanging out with a parrot?

Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia

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4
Q

Which atypical pneumonia is most likely to caused by farm animals?

Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia

A

Which atypical pneumonia is most likely to caused by farm animals?

Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia

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5
Q

Which atypical pneumonia is can cause haemolytic anaemia if left untreated?

Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia

A

Which atypical pneumonia is can cause haemolytic anaemia if left untreated?

Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumonia
Chlamydia psittaci
Q fever pneumonia

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6
Q

What CURB-65 scores would indicate:

Treatment at home [1]
Admission [1]
Intensive care [1]

A

Score 0/1: Consider treatment at home
Score ≥ 2: Consider hospital admission
Score ≥ 3: Consider intensive care

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7
Q

Which type of organisms are most likely to cause HAP? [1]

Which infective organisms are most likely to cause HAP? [4]

A

Gram negative organisms:

PEKA:
Pseudomonas aeruginosa,
Escherichia coli
Klebsiella pneumoniae
Acinetobacter species.

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8
Q

What are the features that would make pneumonia atypical? [4]

A
  • symptoms may be subacute or less severe hence the term ‘walking pneumonia’
  • absence of lobar consolidation on chest x-ray
  • not detectable on Gram stain
  • lack of response to penicillin antibiotics
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9
Q

Which organisms are most likely to cause atypical pneumonias? [5]

A

TOM TIP: You can remember the 5 causes of atypical pneumonia with the mnemonic: “Legions of psittaci MCQs”:

Legions: Legionella pneumophila
Psittaci: Chlamydia psittaci
M – Mycoplasma pneumoniae
C – Chlamydophila pneumoniae
Qs – Q fever (coxiella burnetii)

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10
Q

Atypical pneumonias:

Which type of pneumonia occurs from inhaling infected water from infected water systems, such as air conditioning units? [1]

A

Legionella pneumophila (Legionnaires’ disease)

The typical exam patient has recently had a cheap hotel holiday and presents with pneumonia symptoms and hyponatraemia

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11
Q

Describe the pathological consequences of Legionella pneumophila [2]

A

Causes SIADH: results in hyponatraemia

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12
Q

Comparison of Legionella and Mycoplasma pneumonia

Name three distinguishing features of Leginella pneumonia that would differentiate from Mycoplasma pneumonia

A

Hyponatramia (from SIADH)
Lymphopenia
Diagnosis via urinary antigen

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13
Q

Which drug do you use to tx Legionellas? [1]

A

With erythromycin/clarithromycin

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14
Q

Describe the clinical features of Mycoplasma pneumonia [3]

A
  • prolonged and gradual onset
  • Erythema multiforme RASH: effects 1/3rd of patients on trunks and limbs
  • flu-like symptoms ( classically PRECEED a dry, persistent cough
  • bilateral consolidation on x-ray
  • cold autoimmune haemolytic anaemia
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15
Q

Describe ascultation findings of Mycoplasma pneumonia [1]

A

Coarse crackles will CHANGE to fine crackles at a late phase (3-5 days after initial onset).

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16
Q

If an atypical pathogen such as Mycoplasma pneumoniae is suspected, it is best to confirm the diagnosis using a [] ?

A

If an atypical pathogen such as Mycoplasma pneumoniae is suspected, it is best to confirm the diagnosis using a NAAT: e.g., polymerase chain reaction [PCR] on nose and throat swabs

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17
Q

Mycoplasma pneumonia may cause what haematological consequence? [1]

A

haemolytic anaemia

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18
Q

Name and describe the rash exhibited by Mycoplasma pneumoniae [2]

A

erythema multiforme:
- Target lesions: pink rings and pale centres

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19
Q

State 4 clinical consequences of untreated Mycoplasma pneumonia [4]

A

Haemolytic anaemia
Erythema multiforme
Encephalitis
Peri / myocarditis

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20
Q

How do you treat Mycoplasma pneumonia? [2]

A

1st line:Erythromycin OR Clarithromycin

2nd line: Doxycycline or a macrolide (e.g. )

Because generally there is no diagnosis of the pathogen at the time of treatment, initiation of the treatment is usually empirical

BMJ BP

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21
Q

State and describe this complication of Mycoplasma pneuomia [2]

A

bullous myringitis: painful vesicles on the tympanic membrane

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22
Q

Which infective organsim causing atypical pneumonia is linked to exposure by bodily fluids of animals? [1]

A

Coxiella burnetii, or Q fever, is linked to exposure to the bodily fluids of animals. The typical exam patient is a farmer with a flu-like illness.

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23
Q

Atypical pneuomonia

[] is typically contracted from contact with infected birds. The typical exam patient is a parrot owner.

A

Chlamydia psittaci is typically contracted from contact with infected birds. The typical exam patient is a parrot owner.

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24
Q

How does PCP usually present? [5]

Pneumocystis jirovecii pneumonia (PCP)

A

dyspnoea
night sweats
dry cough
fever
very few chest signs
Pneumothorax is a common complication of PCP.

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25
Q

What clinical presentation may indicate COVID caused pneuomonia? [1]

A

Silent hypoxia: Patients may not feel particularly short of breath despite having low oxygen saturations

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26
Q

what is HAP definition with regards to timings? [2]

A

HAP = Inpatient > 48hrs or less than ten days post discharge

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27
Q

Elderly patients are less likely to suffer pneumonia from which two pathogens? [2]

A

Mycoplasma pneumoniae
Legionella

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28
Q

Alongside CURB65, describe which test is sometimes used to determine Abx therapy in the primary care setting [3]

A

NICE also mention point-of-care CRP test. This is currently not widely available but they make the following recommendation with reference to the use of antibiotic therapy:

CRP < 20 mg/L - do NOT routinely offer antibiotic therapy

CRP 20 - 100 mg/L - consider a DELAYED antibiotic prescription

CRP > 100 mg/L - OFFER antibiotic therapy

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29
Q

Describe the treatment algorithm for mild / low severity CAP? [2]

A

First line: 5 day course
- Amoxicillin
- If if penicillin allergic: clarithromycin (macrolide) OR doxycycline (tetracycline)

Second line:
- No respond to amoxicillin monotherapy, consider adding, or switching to, a macrolide (e.g., clarithromycin).

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30
Q

How quickly should you try and prescribe treatment for moderate severity pneumonia after hospital admission? [1]

A

This should be within 4 hours of presentation to hospital

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31
Q

Describe the treatment algorithm for confirmed CAP on chest x-ray: presenting in hospital | moderate-severity (CURB-65 = 2)?

A

7-10 day course is recommended

1st line:
- ORAL amoxicillin plus a macrolide: clarithomycin
- For patients who are allergic to penicillin in whom oral antibiotics are contraindicated: second-generation cephalosporin (e.g., cefuroxime) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone)

PLUS
clarithromycin, or intravenous levofloxacin monotherapy

2nd line:
- Change to doxycycline or a fluoroquinolone: ciprofloxacin AND pneumococcal cover: levofloxacin or moxifloxacin

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32
Q

d

What are NICE guidelines about route of administration about Abx? [1]

A

NICE guidelines on antimicrobial prescribing in adults recommend reviewing intravenous antibiotics by 48 hours, and considering switching to oral treatment if possible

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33
Q

Describe the treatment algorithm for confirmed CAP on chest x-ray: presenting in hospital | high-severity (CURB-65 = 3-5)?

DOUBLE CHECK

A

1st line:
- A broad-spectrum beta-lactamase-resistant penicillin: amoxicillin/clavulanate plus a macrolide: clarithromycin
- If allergic to penicillin: second-generation cephalosporin (e.g., cefuroxime) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone) PLUS a macrolide (e.g., clarithromycin)

2nd line:
- Doxycycline OR
- Cefalexin OR
- Trimethoprim

3rd Line:
- levofloxacin

BMJ BP

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34
Q

In patients with suspected or confirmed Staphylococcus aureus MRSA infection, what are the two treatments? [2]

A

IV Vancomycin
OR
IV teicoplanin

with or without

Rifampicin (orally or intravenously)

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35
Q

State the treatments for these atypical pneumonias [5]

A

A: Clarithromycin (orally or intravenously)

B: Fluoroquinolone (ciprofloxacin) (orally or intravenously)

C: Amoxicillin (orally) or
D: benzylpenicillin
(intravenously)

E: Doxycycline (orally)

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36
Q

In patients with suspected or confirmed Staphylococcus aureus non-MRSA infection, what are the two treatments? [2]

A

Flucloxacillin (intravenously)

with or without

Rifampicin (orally or intravenously)

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37
Q

What is the treatment algorithm for mild to moderate symptoms/signs and not at higher risk of resistance for HAP? [2]

How long for? [1]

A

5 day prescription

ORAL:
- amoxicillin/clavulanate (aka Co-amoxiclax)
- If allergic: Doxycycline
Cefalexin (use caution in penicillin allergy)
Trimethoprim/sulfamethoxazole

NICE

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38
Q

What is the treatment algorithm for severe symptoms/signs and not at higher risk of resistance for HAP? [2]

How long for? [1]

A

1st line:
- piperacillin/tazobactam OR
- ceftazidime OR
- cefuroxime OR
- meropenem

2nd line:
- levofloxacin

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39
Q

In severe pneumonia, strong suspicion of what needs to be suspected? [1]

How do you manage this? [1]

A

Pneumonia is one of the main sources of sepsis

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40
Q

State 4 potential extra -pulmonary complications of pneumonia [5]

A

Bacteremia and sepsis
Acute kidney injury (AKI): esult from sepsis, hypovolemia, or drug-induced nephrotoxicity
Pericarditis: direct extension of pneumonia or hematogenous spread

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41
Q

Label the progress expected post-pneumonia from 1 week - 6 months

A

1 week:
- Fever should have resolved

4 weeks:
- Chest pain and sputum production should have substantially reduced

6 weeks:
- Cough and breathlessness should have substantially reduced

3 months
- Most symptoms should have resolved but fatigue may still be present

6 months:
- Most people will feel back to normal.

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42
Q

All patients with moderate-severe pneumonia should have what investigations? [3]

(NICE & BTS)

A

All in patients:
- CXR
- FBC (WCC raised; CRP raised)
- U&E
- LFTS
- Oxygen sats

Moderate-Severe:
- Blood and sputum culture
- Pneumococcal urinary antigen
- Legionella urinary antigen + sputum

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43
Q

All patients with severe + outbreaks of pneumonia should have what investigations? [3]

(NICE & BTS)

A

All in patients:
- CXR
- FBC (WCC raised; CRP raised)
- U&E
- LFTS
- Oxygen sats

Moderate-Severe:
- Blood and sputum culture
- Pneumococcal urinary antigen
- Legionella urinary antigen + sputum

Severe+:
- Mycoplasma PCR
- Chlamydophilia PCR
- Viral PCR

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44
Q

Urine dipstick tests are only currently available for which two pathogens? [2]

A

Pneumococcal
Legionella

BUT - don’t give data on sensitivity

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45
Q

BTS Guidelines:

Gram negative enteric bacilli are rec. to be treated with which drugs? [3]

A

Cefuorxime 1.5g TDS
Cefotaxime 1-2g TDS
Ceftriaxone 1-2g BD IV

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46
Q

BTS guidelines:

What are the treatments for

S. aureus non-MRSA? [1]
S. aureus MRSA? [2]

A

S. aureus non-MRSA: flucloxacillin

S. aureus MRSA: vancomycin OR linezolid OR teicoplanin +/- rifampicin

47
Q

How long after the pneumonia do you check up on patients? [1]

A

6 weeks

48
Q

Which groups are given a seasonal influenza vaccine? [5]

A
  • All 65+ & 2-4
  • Healthcare workers

> 6months in the following groups:
- Asthma
- COPD
- Chronic resp, heart, kidney, liver or neurological disease
- Diabetes
- IS
- Pregnant women

49
Q

A 69-year-old male is investigated by the respiratory team for worsening shortness of breath and cough over the past nine months. He has never smoked and is usually fit and well. The only significant history of note is that he has taken up pigeon racing since retiring. Following investigation, the patient is diagnosed with interstitial pneumonia.

Which of the following organisms is most commonly associated with interstitial pneumonia?

Haemophilus

Klebsiella

Streptococcus

Staphylococcus

Mycoplasma

A

Mycoplasma

50
Q

Define what is meant by sarcoidosis [1]

A

A chronic granulomatous disorder of unknown aetiology, commonly affecting the lungs, skin, and eyes.

It is characterised by accumulation of lymphocytes and macrophages and the formation of non-caseating granulomas in the lungs and other organs.

Although lungs and lymph nodes are involved in more than 90% of patients, virtually any organ can be involved.

51
Q

TOM TIP: The typical MCQ exam patient for a presentation of sarcoidisis consistents of what presentation? [4]

A

20-40 y/o black women
Dry cough
SOB
Nodules on shin (erythema nodosum)

52
Q

Describe the pathophysiology of sarcoidosis

A

Sarcoidosis is characterized by an exaggerated immune response, leading to the formation of non-caseating granulomas.:

Antigen presentation
- In genetically susceptible individuals, exposure to a yet unidentified antigenic stimulus triggers the activation of antigen-presenting cells (APCs), such as dendritic cells and macrophages, which present the antigen to CD4+ T-helper cells.

T cell activation:
- APCS & CD4+ Thelpers interacting causes differentation of T helpers into Th1 and Th17s
- Th1 cells: secrete IFN-y & IL-2
- Th17 cells secrete IL-17; IL2-21 & IL-22

Granuloma formation:
- All the cytokines recruit macrophages
- Macrophages transfrom into multinucleated giant cells and create non-causeating granulomas
- The granulomas isolate the antigenic stimulus; limiting tissue damage

Fibrosis:
- In severe cases, sarcoid granulomas lead to fibrosis and therefore organ failure and dysfunction

53
Q

State what is meant by Lofgren’s syndrome [1]

How does Lofgren’s syndrome usually present? [4]

A

Lofgren’s syndrome is an acute form of the disease characterised by:
- bilateral hilar lymphadenopathy (BHL)
- erythema nodosum
- fever
- polyarthralgia.

It usually carries an excellent prognosis

54
Q

Explain what is meant by Heerford’ts syndrome [1]

What is the classical presentation? [3]

A

Heerfordt’s syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis

55
Q

Describe the clinical features of sarcoidosis if each of the following are effected:

  • Skin [3]
  • Lungs [3]
  • Systemically [3]
A

Skin:
- Erythema nodosum - raised, red, tender painful subcut nodules across both shins. Over time they appear as bruises
- Papular sarcoidosis: multiple papules develop, generally on the head and neck or areas of trauma.
- Lupus pernio: specific to sarcoidosis and presents with raised purple skin lesions, often on the cheeks and nose.

56
Q

What is the name for this symptom of sarcoidosis

Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome

A

What is the name for this symptom of sarcoidosis

Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome

57
Q

What is the name for this symptom of sarcoidosis

Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome

A

What is the name for this symptom of sarcoidosis

Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome

58
Q

What is the name for this symptom of sarcoidosis

Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome

A

What is the name for this symptom of sarcoidosis

Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome

59
Q

Describe the manifestation of sarcoidosis if the effects the following systems:

Pulmonary [3]
Liver [5]
Systemic [3]

A

Lungs:
* Mediastinal lymphadenopathy
* Pulmonary fibrosis
* Pulmonary nodules

Liver:
* Liver nodules
* Cirrhosis
* Pruritis
* Jaundice
* Cholestasis

Systemic Symptoms:
* Fever
* Fatigue
* Weight loss

60
Q

Describe the manifestation of sarcoidosis if the effects the following systems:

CNS [3]
Eyes [3]
Heart [3]

A

Eyes:
* Uveitis
* Conjunctivitis
* Optic neuritis

Heart:
* Bundle branch block
* Heart block
* Myocardial muscle involvement

Central nervous system:
* Nodules
* Pituitary involvement (diabetes insipidus)
* Encephalopathy

61
Q

Describe the manifestation of sarcoidosis if the effects the following systems:

PNS [2]
Bones [3]
Kindey [3]

A

Kidneys:
* Kidney stones (due to hypercalcaemia)
* Nephrocalcinosis
* Interstitial nephritis

Peripheral Nervous System:
* Facial nerve palsy
* Mononeuritis multiplex

Bones:
* Arthralgia
* Arthritis
* Myopathy

62
Q

Which symptoms would indicate that a patient is sufferinf from uveitis? [3]

A

Photophobia
Red painful eye
Blurred vision

63
Q

Describe the CXR that would suggest sarcoidosis [5]

A
  • bilateral hilar lymphadenopathy
  • right paratracheal adenopathy
  • bilateral pulmonary infiltrates, predominantly in the upper lobes
  • pleural effusions (rare)
  • egg shell calcifications (very rare)

Chest x-ray demonstrates upper zone reticulonodular opacities with extensive mediastinal and hilar nodal enlargement. Stage II sarcoidosis with both nodal and parenchymal disease.

64
Q

What are the red circles outlining in this CXR of a ptx with sarcoidosis? [1]

A

Egg shell calcifications

Figure. PA and lateral chest x-rays demonstrate bilateral egg shell calcification of the hilar lymph nodes. See red circles.

65
Q

State the 5 different CXR stages of sarcoidosis [5]

A

A chest x-ray may show the following changes:

  • stage 0 = normal
  • stage 1 = bilateral hilar lymphadenopathy (BHL)
  • stage 2 = BHL + interstitial infiltrates (granulomas in the lungs)
  • stage 3 = diffuse interstitial infiltrates only
  • stage 4 = diffuse fibrosis
66
Q

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

A
  • stage 0 = normal
  • stage 1 = bilateral hilar lymphadenopathy (BHL)
  • stage 2 = BHL + interstitial infiltrates
  • stage 3 = diffuse interstitial infiltrates only
  • stage 4 = diffuse fibrosis
67
Q

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

A

stage 1: bilateral hilar lymphadenopathy
Bilateral hilar lymphadenopathy. No lung infiltrations are shown. No fibrosis.

68
Q

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

A

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

69
Q

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

A

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

There is diffuse reticulonodular
pattern, the lung parenchyma is distorted by fibrosis, and
the right hilum is retracted due to right upper lobe fibrosis

70
Q

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

A

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

Stage 2 sarcoidosis with bilateral hilar and right
paratracheal adenopathy and diffuse reticulonodular disease
pattern in the lungs. The appearance is of fine lines and tiny
nodules.

71
Q

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

A

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

72
Q

What is the name for this symptom of sarcoidosis

Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome

A

What is the name for this symptom of sarcoidosis

Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome

73
Q

Describe why sarcoidosis may lead to hypercalcaemia [1]

A

Hypercalcaemia is seen in around 15% of cases.:
* This occurs due to the uncontrolled synthesis of 1,25-dihydroxyvitamin D3 by macrophages in causing 1-α hydroxylation of 25-hydroxyvitamin D and so increases levels of activated vitamin D
* This leads to increased levels of calcium.

74
Q

Describe the treatment plan for sarcoidosis for symptomatic patients / moderate & severe disease [4]

A

First line: Prednisolone:
- High-dose induction: typically 20 - 40mg each day for 4 - 6 weeks
- Dose tapering: the initial dose is gradually reduced (e.g. 5mg every two weeks)
- Maintenance dose: typically 5 - 10mg each day

Second-line agents: classical immunosuppressants
- Methotrexate (first line)
- Azathioprine
- Mycophenolate mofetil.

Third line / refractory disease: biologic therapies
- infliximab
- adalimumab

Lung transplantation

75
Q

Severe sarcoidosis can lead to which two lung pathologies? [2]

What would indicate lung transplantation for sarcoidosis ptx? [2]

A

Advanced pulmonary fibrosis
Pulmonary hypertension

76
Q

What would you prescribe alongside long-term corticosteroids to avoid unwanted side effects of the steroids? [1]

A

Bisphosphonates protect against osteoporosis whilst on long-term steroids.

77
Q

Describe a GUM implication of sarcoidosis [1]

A

Polyuria and polydipsia: increased macrophages caused increaesd Ca2+

78
Q

Describe the diagnosis pathway for sarcoidosis

A
79
Q

Which investigational modality is increasingly used for sarcoidosis? [1]

A

PET scanning

80
Q

What treatment might be given to for treating skin sarcoid? [1]

A

Hydroxychloroquine

81
Q

Raised serum ACE is indicative of sarcoidosis. Name 4 other pathological states where you might see a raised serum ACE [4]

A

Raised serum ACE may also be moderate in human immunodeficiency virus (HIV), histoplasmosis, diabetes mellitus, hyperthyroidism, tuberculosis and leprosy.

82
Q

Define what is meant by sarcoidosis [1]

A

A chronic granulomatous disorder of unknown aetiology, commonly affecting the lungs, skin, and eyes.

It is characterised by accumulation of lymphocytes and macrophages and the formation of non-caseating granulomas in the lungs and other organs.

Although lungs and lymph nodes are involved in more than 90% of patients, virtually any organ can be involved.

83
Q

TOM TIP: The typical MCQ exam patient for a presentation of sarcoidisis consistents of what presentation? [4]

A

20-40 y/o black women
Dry cough
SOB
Nodules on shin (erythema nodosum)

84
Q

Describe the pathophysiology of sarcoidosis

A

Sarcoidosis is characterized by an exaggerated immune response, leading to the formation of non-caseating granulomas.:

Antigen presentation
- In genetically susceptible individuals, exposure to a yet unidentified antigenic stimulus triggers the activation of antigen-presenting cells (APCs), such as dendritic cells and macrophages, which present the antigen to CD4+ T-helper cells.

T cell activation:
- APCS & CD4+ Thelpers interacting causes differentation of T helpers into Th1 and Th17s
- Th1 cells: secrete IFN-y & IL-2
- Th17 cells secrete IL-17; IL2-21 & IL-22

Granuloma formation:
- All the cytokines recruit macrophages
- Macrophages transfrom into multinucleated giant cells and create non-causeating granulomas
- The granulomas isolate the antigenic stimulus; limiting tissue damage

Fibrosis:
- In severe cases, sarcoid granulomas lead to fibrosis and therefore organ failure and dysfunction

85
Q

State what is meant by Lofgren’s syndrome [1]

How does Lofgren’s syndrome usually present? [4]

A

Lofgren’s syndrome is an acute form of the disease characterised by:
- bilateral hilar lymphadenopathy (BHL)
- erythema nodosum
- fever
- polyarthralgia.

It usually carries an excellent prognosis

86
Q

Explain what is meant by Heerford’ts syndrome [1]

What is the classical presentation? [3]

A

Heerfordt’s syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis

87
Q

Describe the clinical features of sarcoidosis if each of the following are effected:

  • Skin [3]
  • Lungs [3]
  • Systemically [3]
A

Skin:
- Erythema nodosum - raised, red, tender painful subcut nodules across both shins. Over time they appear as bruises
- Papular sarcoidosis: multiple papules develop, generally on the head and neck or areas of trauma.
- Lupus pernio: specific to sarcoidosis and presents with raised purple skin lesions, often on the cheeks and nose.

88
Q

What is the name for this symptom of sarcoidosis

Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome

A

What is the name for this symptom of sarcoidosis

Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome

89
Q

What is the name for this symptom of sarcoidosis

Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome

A

What is the name for this symptom of sarcoidosis

Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome

90
Q

What is the name for this symptom of sarcoidosis

Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome

A

What is the name for this symptom of sarcoidosis

Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome

91
Q

Describe the manifestation of sarcoidosis if the effects the following systems:

Pulmonary [3]
Liver [5]
Systemic [3]

A

Lungs:
* Mediastinal lymphadenopathy
* Pulmonary fibrosis
* Pulmonary nodules

Liver:
* Liver nodules
* Cirrhosis
* Pruritis
* Jaundice
* Cholestasis

Systemic Symptoms:
* Fever
* Fatigue
* Weight loss

92
Q

Describe the manifestation of sarcoidosis if the effects the following systems:

CNS [3]
Eyes [3]
Heart [3]

A

Eyes:
* Uveitis
* Conjunctivitis
* Optic neuritis

Heart:
* Bundle branch block
* Heart block
* Myocardial muscle involvement

Central nervous system:
* Nodules
* Pituitary involvement (diabetes insipidus)
* Encephalopathy

93
Q

Describe the manifestation of sarcoidosis if the effects the following systems:

PNS [2]
Bones [3]
Kindey [3]

A

Kidneys:
* Kidney stones (due to hypercalcaemia)
* Nephrocalcinosis
* Interstitial nephritis

Peripheral Nervous System:
* Facial nerve palsy
* Mononeuritis multiplex

Bones:
* Arthralgia
* Arthritis
* Myopathy

94
Q

Which symptoms would indicate that a patient is sufferinf from uveitis? [3]

A

Photophobia
Red painful eye
Blurred vision

95
Q

Describe the CXR that would suggest sarcoidosis [5]

A
  • bilateral hilar lymphadenopathy
  • right paratracheal adenopathy
  • bilateral pulmonary infiltrates, predominantly in the upper lobes
  • pleural effusions (rare)
  • egg shell calcifications (very rare)

Chest x-ray demonstrates upper zone reticulonodular opacities with extensive mediastinal and hilar nodal enlargement. Stage II sarcoidosis with both nodal and parenchymal disease.

96
Q

What are the red circles outlining in this CXR of a ptx with sarcoidosis? [1]

A

Egg shell calcifications

Figure. PA and lateral chest x-rays demonstrate bilateral egg shell calcification of the hilar lymph nodes. See red circles.

97
Q

State the 5 different CXR stages of sarcoidosis [5]

A

A chest x-ray may show the following changes:

  • stage 0 = normal
  • stage 1 = bilateral hilar lymphadenopathy (BHL)
  • stage 2 = BHL + interstitial infiltrates (granulomas in the lungs)
  • stage 3 = diffuse interstitial infiltrates only
  • stage 4 = diffuse fibrosis
98
Q

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

A
  • stage 0 = normal
  • stage 1 = bilateral hilar lymphadenopathy (BHL)
  • stage 2 = BHL + interstitial infiltrates
  • stage 3 = diffuse interstitial infiltrates only
  • stage 4 = diffuse fibrosis
99
Q

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

A

stage 1: bilateral hilar lymphadenopathy
Bilateral hilar lymphadenopathy. No lung infiltrations are shown. No fibrosis.

100
Q

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

A

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

101
Q

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

A

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

There is diffuse reticulonodular
pattern, the lung parenchyma is distorted by fibrosis, and
the right hilum is retracted due to right upper lobe fibrosis

102
Q

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

A

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

Stage 2 sarcoidosis with bilateral hilar and right
paratracheal adenopathy and diffuse reticulonodular disease
pattern in the lungs. The appearance is of fine lines and tiny
nodules.

103
Q

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

A

Which stage of sarcoidosis is depicted in this CXR?

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

104
Q

What is the name for this symptom of sarcoidosis

Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome

A

What is the name for this symptom of sarcoidosis

Papular sarcoidosis
Lupus pernio
Erythema nodosum
Lofgrens syndrome

105
Q

Describe why sarcoidosis may lead to hypercalcaemia [1]

A

Hypercalcaemia is seen in around 15% of cases.:
* This occurs due to the uncontrolled synthesis of 1,25-dihydroxyvitamin D3 by macrophages in causing 1-α hydroxylation of 25-hydroxyvitamin D and so increases levels of activated vitamin D
* This leads to increased levels of calcium.

106
Q

Describe the treatment plan for sarcoidosis for symptomatic patients / moderate & severe disease [4]

A

First line: Prednisolone:
- High-dose induction: typically 20 - 40mg each day for 4 - 6 weeks
- Dose tapering: the initial dose is gradually reduced (e.g. 5mg every two weeks)
- Maintenance dose: typically 5 - 10mg each day

Second-line agents: classical immunosuppressants
- Methotrexate (first line)
- Azathioprine
- Mycophenolate mofetil.

Third line / refractory disease: biologic therapies
- infliximab
- adalimumab

Lung transplantation

107
Q

Severe sarcoidosis can lead to which two lung pathologies? [2]

What would indicate lung transplantation for sarcoidosis ptx? [2]

A

Advanced pulmonary fibrosis
Pulmonary hypertension

108
Q

What would you prescribe alongside long-term corticosteroids to avoid unwanted side effects of the steroids? [1]

A

Bisphosphonates protect against osteoporosis whilst on long-term steroids.

109
Q

Describe a GUM implication of sarcoidosis [1]

A

Polyuria and polydipsia: increased macrophages caused increaesd Ca2+

110
Q

Describe the diagnosis pathway for sarcoidosis

A
111
Q

Which investigational modality is increasingly used for sarcoidosis? [1]

A

PET scanning

112
Q

What treatment might be given to for treating skin sarcoid? [1]

A

Hydroxychloroquine

113
Q

Raised serum ACE is indicative of sarcoidosis. Name 4 other pathological states where you might see a raised serum ACE [4]

A

Raised serum ACE may also be moderate in human immunodeficiency virus (HIV), histoplasmosis, diabetes mellitus, hyperthyroidism, tuberculosis and leprosy.

114
Q
A

a prolonged PR interval

Yr3 Revision (37 decks)

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