Chapter 400: Community Acquired Pneumonia Flashcards

Question

Differential diagnosis of recurrent pneumonia

Answer 1

HEREDIATRY DISORDERS 1 - cystic fibrosis 2 - sickle cell disease DISORDERS OF IMMUNITY 1 - HIV/AIDS 2 - bruton agammaglobulinemia 3 - selective immunooglobulin G subclass deficiencies 4 - Common variable immunodeficiency syndrome 5 - severe combined immunodeficiency syndrome 6 - Hyperimmunoglobulin E syndrome 7 - leukocyte adhesion defect DISORDERS OF CILIA 1 - Immotile cilia syndrome 2 - Kartagener syndrome ``` ANATOMIC DISORDERS 1 - Pulmonary sequestration 2 - Lobar emphysema 3 - Gastroesophgeal reflux ( GERD) 4 - Foreign body 5 - Tracheoesophageal fistula ( H type) 6 - Bronchiectasis 7 - Aspiration ( oropharyngeal incoordination) 8- Aberrant bronchus ```

Answer 2

- in viral fever is usually present but generally temp is lower than bacterial. - severe infection: cyanosis. lethargy - Bacterial pneumonia: in older children --> sudden fever, cough and chest pain. splinting on the affected side to minimize pleuritic pain. in infants ==>upper respiratory tract infection, diminished appetitie, abrupt onset of fever, restlessness, and repiratory distress. some infants with bacterial pneumonia may have GI disturbances : vomiting, anorexia, diarrhea and abdominal distention secondary to paralytic ileus. - abdominal pain is common in lower lobe pneumonia

Answer 3

1 - CXR ( PA and lateral view) viral--> hyperinflation with bilateral interstitial inflitrates and peribronchial cuffing. Pneumococcal pneumonia--> typically confluent lobar consolidation Repeat CXR is NOT required for proof of cure in uncomplicated cases. 2 - Peripheral WBC in viral --> WBC normal or elevated but not higher thn 20 000/mm3 with lymphocyte predominanace in bacterial--> WBS between 15000 to 40 000 with granulocyte predominance Large effusion, lobar consolidation and a high fever at onset also suggests bacterial origin. Definitive viral diagnosis --> isolation of virus or detection of viral genome or antigen in respiratory tract secretions. Definitive bacterial diagnosis -->isolation of organism from blood, pleural fluid or lung. blood culture is positive only in 10% of pneumococcal pneumonia. Blood culture is recommended for : 1 - those who fail to improve or have clinical detorioration 2 - those with complicated pneumonia 3 - those requiring hospitalization

Answer 4

1 - age < 6 months 2 - sickle cell anemia with acute chest syndrome 3 - multiple lobar involvement 4 - immunocompromised state 5 - toxic appearence 6 - moderate to severe respiratory distress 7 - requirement of suppplemental oxygen 8 - complicated pneumonia 9 - deydration 10 - vomitng or inability to tolerate oral fluids or medications 11 - no response to appropriate oral antibiotic therapy 12- social factors ( eg: inability of caregivers to administer medications at home or follow up properly)

Answer 5

pleural effusion, empyema, abcess, bronchopleural fistula, necrotizing pneumonia, acute respiratory distress syndrome, hemolytic uremic syndrome, sepsis, extrapulmonary infections ( meningitis, arthritis, pericarditis, osteomyelitis, endocarditis)

Answer 6

1 - Mildly ill child who do not require hospitalization: 1 - Amoxicillin 80-90mg/kg/24hour ( high dose due to emergence of penicillin resistant pneumococci) 2 - Therapeutic alternatives: Cefuroxime axetil and amoxicillin/clavulanate 2 - School age children and in children with M. pneumoniae or C pneumoniae is suggested: Macrolide such as azithromycin is the choice. In adolescents, a respiratory fluroquinolone ( levofloxain, moxifloxacin) maybe considered 3 - Emperic treatment of suspected bacterial pneumonia in hospitalized child: 1 - In areas without substantial penicillin resistance, and fully immunized to H.influenzae type b and S. pneumoniae, and not severely ill --> ampicillin or penicillin G. 2 - children who does not meet above criteria --> Ceftriaxone or cefotaxime 4 - If clinical features suggests staphylococcal pneumonia ( pneumatoceles, empyema), --> initial therapy should also include vancomycin or clindamycin. 5 - Viral pneumonia: antibiotic could be withheld, but 30% of patients with viral pneumonia especially influenza viruses, coexist with secondary bacterial infection. therefore in deteriorating patients antibiotic should be started. 6 - No specific duration is established by studies but generally should be continued until patient is afebrile for 72 hours and total duration should not be less than 10 days. ( or 5 days in azithromycin) Shorter courses of 5- 7 days maybe effective, paticularly in OPD patients. Prolonged treatment not indicated in uncomplicated cases 7 - In developing countries, oral Zinc ( 10mg/day for < 12 months, 20mg/day for more than or equal to 12 months ) reduces mortality in children with clinically defined severe pneumonia.

Answer 7

48 to 96 hours of initiation of antibiotics

Answer 8

1 - complication such as empyema 2 - Bacterial resistance 3 - non bacterial etiologies such as viruses or fungi and aspiration of foreign bodies or food 4 - bronchial obstruction from endobronchial lesions, foreign body or mucous plugs 5 - preexisting diseases such as immunodeficiencies, ciliary dyskinesia, cystic fibrosis, pulmonary sequestration or congenital pulmonary airway malformation, ( formerly called as cystic adenomatoid malformation) 6 - other non infectious causes ( including bronchiolitis obliterans, hypersensitivity pneumonitis, eosinophilic pneumonia, aspiration, and granulomatosis with polyangiitis, formerly known as Wegener granulomatosis) * Repeat CXR is first step to determine reason of delay * Bronchoalveolar lavage indicated in children with respiratory failure * High resolution CT scans may identify complications or anatomic reasons for poor response

Answer 9

direct spread of bacterial infection within thoraci cavity ( pleural effusions, empyema, pericarditis) or bacteremia and hematologic spread

Answer 10

hematologic spread of pneumococcal or H influenzae tybe b infection

Answer 11

S aureus S pneumoniae S pyogenes * many effusions that complicate bacterial pneumonia are sterile * Universal 16S ribosomal RNA gene polymerase chain reaction identify bacterial genome and can determine bacterial etiology of effusion if culture is negative

Answer 12

- based on stage ( exudative, fibrinopurulent, organizing) - USG and CT are helpful in determining the stage - therapy include: antibiotics and drainage with tube thoracostomy - other approaches include use of intrapleural fibrinolytic therapy ( urokinase, streptokinase, tissue plasminogen activator) and selected video assisted thoracoscopy to debride or lyse adhesions and drain loculated areas of pus.

Answer 13

Vaccination - in 2000 7 valent pneumococcal conjugate vaccine ( PCV 7) was licensed in recommended - in 2010 13 valent pneumococcal conjugate vaccine (PCV13) was licensed in US Expansion of influenza vaccine recommendation to include children more than 6 months. Measles vaccine greatly reduced measles related pneumonia deaths

Answer 14

``` Appearence : clear cell count ( per mm3) : <1000 cell type: Lymphocyte, monocyte Lactase dehydrogenase: < 200U/L pleural fluid : serum LDH ratio --> < 0.6 Protein > 3 g --> unusual PLeural fluid: serum protein ration --><0.5 Glucose : normal pH : normal ( 7.40 - 7.60) Gram stain : Negative Cholesterol : - PLeural cholesterol : serum cholesterol ratio --> < 0.3 ``` * low Glucose or pH maybe seen in malignant effusion, TB, esophageal rupture, pancreatitis ( positive pleural amylase ), rheumatologic disease ( eg SLE)

Answer 15

Appearence : cloudy or purulent cell count ( per mm3) : often > 50000 ( cell count has limited predictive value) cell type: polymorphonuclear leukocytes ( neutrophils) Lactase dehydrogenase: more than two-thirds upper limit of normal for serum lactate dehydrogenase ( LDH) pleural fluid : serum LDH ratio --> > 0.6 Protein > 3 g --> common PLeural fluid: serum protein ration --> >0.5 Glucose : low ( < 40mg/dL) pH : low < 7.10 Gram stain : occasionaly positive ( less than one third of cases) Cholesterol : >55mg/dL PLeural cholesterol : serum cholesterol ratio --> > 0.3

Chapter 400: Community Acquired Pneumonia Flashcards

(39 cards)