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CPC 2 (haemoptysis) Flashcards

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1
Q

History of haemoptysis

A 
Source
Volume
Frequency
Admixed or alone
Fresh or old
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2
Q

Investigations for someone with haemoptysis, chest pain, fever, wheeze, crepitations

A

Bloods: FBC, U&Es, LFT, inflammatory markers. Troponin I and D-dimer.
Imaging: CXR, ECG
Special tests: autoimmune screen.

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3
Q

Mechanisms of causes of haemoptysis

A 
Neoplasia
Infection 
Inflammation
Impaired clotting
Raised pulmonary pressure
Aberrant anatomy.
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4
Q

Pulmonary vasculitis is often associated with…

A

necrosis of vessels

systemic vasculitis.

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5
Q

Vasculitides affecting large vessels

A

Giant cell arteritis, Takayashu ateritis, Behcet’s disease.

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6
Q

Churg-strauss syndrome is also called…

A

eosinophilic granulomatosis with polyangiitis

allergic granulomatosis

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7
Q

Vasculitides affecting middle sized vessels

A

Polyarteritis nodosa (rare in lungs), Kawasaki vasculitis.

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8
Q

Vasculitides affecting small vessels

A

Wegener granulomatosis, Churg-Strauss syndroome, microscopic polyangitis.

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9
Q

Vasculitis radiology

A

Can be VERY VARIABLE.

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10
Q

Takayashu ateritis

A

Affects large blood vessels.
Affects mostly young asian women.
Causes intimal proliferation and fibrosis of media and adventitia.
Results in luminal narrowing, occlusion, aneurysms.

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11
Q

Medium vessel arteritis

A

Very rare, uncommon in lungs.

Generally in children under 5 years.

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12
Q

Diffuse alveolar haemorrhage (vasculitis)

A

Generally from small vessel vasculitis.
Results in haemoptysis, with diffuse alveolar infiltrates. Causes a drop in haematocrit.
Can vary in appearance from ground glass to consolidation.

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13
Q

Causes of non-infectious vasculitis

A

Immune complexes
Anti-neutrophil cytoplasmic antibodies (ANCA)
anti-endothelial cell antibodies.

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14
Q

ANCA

A

Antibodies against cytoplasm of neutrophils (probably cross reactive). These activate neutrophils, which show MPO and PR3 on their surface.

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15
Q

Treatment of vasculitis

A

Need to be careful; immunosuppression improves immune-mediated vasculitis but worsens infectious vasculitis.

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16
Q

Origin of cells in granulomatous inflammation of the lungs

A

Bone marrow haematopoietic stem cells become monocytes which become tissue macrophages/histiocytes which try to contain the ineradicable offending material.

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17
Q

Types of granuloma

A

Inert foreign material granulomas

Immune granulomas caused by agents able to induce granulomas (mycobacteria, fungi, parasites).

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18
Q

Differentials for granulomatous disease

A

Infectious

Non-infectious - auto-immune or due to exposure.

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19
Q

Commonest causes of community acquired pneumonia

A

streptococcus pneumonia

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20
Q

Cause of pneumonia in patients with alcoholism

A

Can be Klebsiella pneumonia. Gives a red currant jelly sputum. Can be acutely necrotising. High mortality rate even with treatment (50%).

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21
Q

Risk factors for community acquired pneumonia

A 
Age extremes
Impaired gag-reflex / muco-ciliary escalator. 
Non-functioning spleen
Impaired immunity
Chronic heart/lung/liver conditions
Smoking/alcoholism.
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22
Q

Treatment of choice for community acquired pneumonia.

A

B-lactam antibiotic (amoxicillin) +/- clarithromycin.

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23
Q

Forms of aspergillus lung infections

A

Allergic pulmonary aspergillosis
Aspergilloma in pre-existing lung cavities
Invasive pulmonary aspergillosis in immunosuppression.

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24
Q

S. Aureus pneumonia - associations and effect

A

Associated with PVL

Causes cavitating lesions and lung abscess.

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25
Host factors affecting TB risk
``` Previous exposures Extremes of age Nutritional status Living conditions Other underlying medical conditions Immunosuppression ```
26
Environmental factors affecting TB risk
Endemic infection Homelessness Drug and alcohol misuse Imprisonment
27
Pathogenesis of TB
Bacilli taken up by macrophages, which then go to lymph nodes resulting in Type 1 cytokines which lead to accumulation of macrophages/histiocytes and granuloma formation. This leads to necrosis, with some of the bacilli dying, extensive tissue necrosis, cavitation and spread.
28
Diagnosis of TB
Microscopy, culture, molecular methods (PCR, DNA probes).
29
Treatment of TB
2 months of pyrazinamide ad ethambutol, 6 months of isoniazid and rifampicin.
30
Rifampicin action
Blocks mRNA synthesis
31
Isoniazid action
Inhibits mycolic acid synthesis
32
Pyrazinamide action
Inhibits mycolic acid synthesis.
33
Ethambutol action
Inhibits polymerisation oof arabinoglycan.
34
Causes of haemoptysis
Can be airways disease (common), pulmonary parenchymal diseases, or pulmonary vascular diseases.
35
Airways causes of haemoptysis
Inflammatory Neoplasm Foreign body Fistula
36
Pulmonary parenchymal causes of haemoptysis
Inflammatory Coagulopathy Iatrogenic (Cocaine induced, catamenial)
37
Pulmonary vascular causes of haemoptysis
PE pulmonary AV malformation Elevated capillary pressure Iatrogenicc
38
Stain to show fungi
Grocott stain
39
Stain to show mycobacteria
Ziehl-Neelson stain
40
How much fluid does the pleural space typically contain?
10-20 ml
41
Imaging signs of pleural effusion
Meniscus sign. Homogenous density, density in dependent portion, loss of normal silhouette, with/w'out mediastinal shift.
42
50 ml in the pleural space - appearance on plain film
Loss of CP angles in lateral view
43
175 ml in the pleural space - appearance on plain film
Loss of lateral CP angle in PA view
44
500 ml in the pleural space - appearance on plain film
Ipsilateral hemidiaphragm PA view.
45
Types of pleural effusion
Subpulmonic Pleural fluid in fissure Encysted pleural fluid Loculated effusions (usually haemothorax or empyema)
46
Imaging for pleural effusions
CXR, US and CT
47
Ultrasound for pleural effusion; which type gives echogenic image?
Exudate, haemorrhage, empyema, chylothrorax
48
Ultrasound for pleural effusion; which type gives anechoic image?
Transudate or more rarely, exudate
49
Effusion secondary to heart failure (appearance)
Bilateral or right-sided, improves with diuresis.
50
Malignant effusions - appearance on CT
unilateral pleural effusion with nodular irregular pleural thickening.
51
Main primary sites causing metastatic pleural effusions to the pleura
Lungs > breast > lymphoma or leukaemia.
52
What is the main primary malignancy of the pleura?
Malignant pleural mesothelioma (mostly caused by asbestos exposure)
53
Presentation of mesothelioma
Chest pain and dyspnoea Bloody pleural effusion May be locally invasive
54
Types of mesothelioma
Epitheloid, sarcomatoid, biphasic, desmoplastic
55
Prognosis of mesothelioma
10 months
56
Benign lung tumour
Hamartoma - usually an incidental finding.
57
Broad types of lung cancer
Non-small cell lung cancer, endocrine and rarities.
58
Types of endocrine lung cancer
Small cell, large cell neuroendocrine, carcinoid
59
Common causes of haemoptysis
Bronchiectasis, bronchial carcinoma, pulmonary infarction, bronchitis and infections.
60
Common causes of massive haemoptysis
Bronchiectasis, TB or cancer.
61
Use of 5% saline neb
Encourage productive coughing if sputum hard to obtain.
62
Top 4 causes of haemoptysis
* Bronchiectasis (including cystic fibrosis) * Acute or chronic bronchitis * Malignancy * Infections
63
Probable cause of haemoptysis with history of chronic cough and sputum production extending back many years
Bronchiectasis
64
Probable cause of haemoptysis with history of smoking, shortness of breath on exertion, wheeze, cough and sputum
Bronchitis
65
Probable cause of haemoptysis with smoking history, asbestos exposure or weight loss. May also have a history of background shortness of breath or wheeze if co-existing COPD. History of recurrent pneumonias.
Malignancy
66
Probable cause of haemoptysis with history of fevers, sweats, cough and sputum production.
Bacterial pneumonia
67
Probable cause of haemoptysis with night sweats, fevers, cough, sputum and weight loss often over a period of many weeks. History of immune deficiency or high risk behaviours (e.g. sexual history, iv drug use).
TB
68
Probable cause of haemoptysis with history of COPD or TB.
Aspergilloma
69
Probable cause of haemoptysis with history of immobility or long distance travel, painful/swollen legs or shortness of breath.
PE
70
Probable cause of haemoptysis with history of epistaxsis or other ENT disease, fevers, night sweats.
Wegener's granulomatosis
71
Probable cause of haemoptysis with history of recurrent bruising or bleeding, use of anti-coagulants.
Coagulopathy
72
Probable cause of haemoptysis with history of rheumatic fever, shortness of breath
MV disease, LVF
73
Connective tissue disorders associated with pulmonary vasculitis
Rheumatoid arthritis SLE systemic sclerosis
74
Vasculitides associated with presence of anti-neutrophil cytoplasmic antibodies
Churg-Strauss syndrome, microscopic polyangiitis and Wegener's granulomatosis.
75
Probably cause of haemoptysis with clubbing
Bronchiogenic carcinoma or bronchiectasis.
76
Probable cause of haemoptysis with lymphadenopathy
Bronchogenic carcinoma.
77
Why should you check the nasal passage in an examination for haemoptysis
Ulcerations are seen there in Wegener's granulomatosis.
78
What bloods would you do and why for haemoptysis
FBC - infection, inflammation, blood loss. CPR, ESR - infection/inflammation U&Es - dehydration and renal impariment. Also hyponatraemia in some bronchogenic malignancies. ANCA - Wegener's granulomatosis. Blood cultures - if infection suspected. Coag screen.
79
Local complications of lung cancer
Recurrent laryngeal nerve palsy, phrenic nerve palsy, SVC obstruction, Horner's syndrome, rib erosion, pericarditis, AF.
80
What does the following case suggest? A 48-year-old male presents with a 8 week history of epistaxis and nasal stuffiness. On examination there is evidence of nasal crusting. A chest x-ray demonstrates multiple cavitary lesions.
Granulomatosis with polyangiitis (Wegener's granulomatosis)
81
What are the features of granulomatosis with polyangiitis?
upper respiratory tract: epistaxis, sinusitis, nasal crusting lower respiratory tract: dyspnoea, haemoptysis rapidly progressive glomerulonephritis ('pauci-immune', 80% of patients) saddle-shape nose deformity also: vasculitic rash, eye involvement (e.g. proptosis), cranial nerve lesions

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