Crash Course TB + LRTI Flashcards by Georgia Leggett

Describe the stages of TB

Primary: Initial infection, often in childhood, often asymptomatic

Latent: Suppressed, hangs around in foci

Post-primary: Reactivation of latent, often d.t. immunosuppression

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Give 3 classes of common symptoms of TB

Constitutional: weight loss, fever, night sweats

Pulmonary: Productive cough, haemoptysis

Lymphadenitis: scrofula (cervical)

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What is a ghon focus?

Competent immune system suppresses TB: macrophages form ball around TB = caseating granuloma
(Tuberculoma)

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What is Miliary TB?

Disseminated haematogenous spread
Miliary seed appearance in lungs

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What is Potts disease?

TB of the spine
Back pain
Vertebral collapse
Iliopsoas abscess

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What is TB meningitis?

TB infiltration into the brain (Leptomeningeal enhancement)

Subacute meningitis- meningeal Sx but slow onset over a period of time

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How does genitourinary TB present?

Sterile pyuria- leukocytes on urine dip but no organism detected

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What is the gold standard investigation for active TB?

X3 sputum culture
Sputum culture on Lowenstein-Jensen media

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What may be seen on imaging in TB?

CXR: upper lobe cavitation

CT: consolidation, Ghon focus

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What is a faster test performed for active TB?

Sputum smear + Ziehl-Neelson stain for acid fast bacilli

(can also use auramine rhodamine stain)

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What may be seen on histology in TB?

caseating granuloma (Haematoxylin + eosin stains)

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What is the gold standard test for exposure to TB?

IGRA
Elispot/ Quantiferon
+ve if exposure (active or latent)

Does NOT cross react with BCG

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Which TB test cannot distinguish between exposure to TB and BCG vaccine?

Tuberculin skin tests: Mantoux/ Heaf

Also requires 2 visits

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What is the treatment for TB?

Rifampicin (6)
Isoniazid (6)
Pyrazinamide (2)
Ethambutol (2)

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What drug should be given with Isoniazid? Why?

Pyridoxine (Vit B6)

To prevent peripheral neuropathy

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What is the MOA of Rifampicin?

Inhibits RNA polymerase

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What is the MOA of Isoniazid?

Decreased mycolic acid synthesis (part of cell wall)

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What is the MOA of Pyrazinamide?

Unknown

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What is the MOA of Ethambutol?

Decreased polymerisation of cell wall

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Give 3 side effects of Rifampicin

Orange / red secretions
CYP450 induction
Raised transaminases

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Give 2 side effects of Isoniazid

Peripheral neuropathy (B6 deficiency)
Hepatotoxicity

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Give 2 side effects of Pyrazinamide

Hyperuricaemia
Hepatotoxicity

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Give a side effect of Ethambutol

Optic neuritis
(Pain, vision loss, 1 eye)

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Give 3 second line drugs for TB

Amikacin
Quinolones
Linezolid

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Give 3 drugs to use in multi drug resistant TB

Quinolones Aminoglycosides Cycloserine

What is in the BCG vaccination?

Live attenuated M. Bovis

What drugs are used for latent TB?

Just Rifampicin + Isoniazid

Give 4 risk factors for mycobacterium TB

Travel HIV Close contacts IVDU

Give 3 risk factors for non-tuberculous mycobacterium

>65 Immunosuppression Environmental exposure (water, soil)

What does mycobacterium leprae invade?

Schwann cells + Histiocytes

What are the 2 types of mycobacterium leprae?

PAUCIbacillary tuberculoid MULTIbacillary lepromatous

Give 4 features of paucibacillary tuberculoid leprosy

Few skin lesions Hairless plaques Loss of sensation Robust T cell response

Give 4 features of multibacillary lepromatous leprosy

Multiple skin lesions Thickened dermis Lion like face Poor T cell response

Give 4 features of Mycobacterium ulcerans

Slow growing Insect transmission/ bite Early: painless nodules -> Bairnsdale ulcer/ Buruli ulcer Slow progression into ulceration + deformity

Give 4 features of mycobacterium avium (MAC)

Slow growing Commonly found in soil, food, water May invade bronchial tree or pre-existing bronchiectasis/ cavities (CF, COPD, Aspergillosis etc) if immunocompromised - May cause mycobacteraemia → consider in patients with HIV + longstanding diarrhoea

Give 4 features of mycobacterium marinarum

Slow growing Swimming pool/ aqaurium owners Single or clusters of papules on hands "Swimming pool granuloma"

List 3 fast growing NTM

- Mycobacterium abscessus - Mycobacterium chelonae - Mycobacterium fortuitum

What is Bronchitis? Who is it most commonly seen in? What is the typical cause? What are the X-ray findings? How will the patient present?

Inflammation of medium sized airways Smokers + young kids Viral Minimal CXR findings Patient not too unwell- supportive Tx

What is pneumonia? What are the X-ray findings? What is the typical cause? How will the patient present?

Infection of lung parenchyma Consolidation on CXR Bacterial Patients look sick

What is a lung abscess? How does a patient present? What is often the cause? How is it managed?

Pus filled cavetating lesion in parenchyma Constitutional Sx: FLAWs, swinging fever, weeks ongoing Complication of pneumonia (consider if not responding to Abx) Needs drainage

What is a lung empyema? What is often the cause? How is it managed?

Pus filled collection in a space that already exists e.g. pleural space = Infective pleural effusion Complication of pneumonia Needs drainage

How is pneumonia classified?

CAP: develop in community HAP: develop >48h after hospital admission VAP: develop on ventilator

What is the diagnosis? What can be seen here?

Bronchitis Thickening of central bronchi

What is the diagnosis? What can be seen here?

Pneumonia Right middle lobe consolidation

What is the diagnosis? What can be seen here?

Empyema Looks like pleural effusion- loss of costophrenic angles + meniscus on top

What is the diagnosis? What can be seen here?

Abscess Well circumscribed lesion within parenchyma Air spaces within Cavity walled off with fluid inside

Give 4 features of typical pneumonia presentation

Systemically unwell Rapid onset LOBAR consolidation on CXR Responds to penicillins

Give 2 features atypical pneumonia presentation

Flu-like prodromes, often dry cough, myalgias Respond to macrolides

What is the most common typical pneumonia? Give 3 features

Streptococcus pneumonia Rusty coloured sputum Gram +ve Diplococcus +ve Urine antigen test

List 3 typical pneumonias

Streptococcus pneumoniae (aka pneumococcus) Haemophilus influenzae B (Cavitating lesions) Moraxella catarrhalis

In which patient group is haemophilia influenzae pneumonia more common? What type of organism is this?

COPD Gram -ve coccobacillus

In which patient group is mortadella catarrhalis pneumonia more common? What type of organism is this?

Smokers Gram -ve coccus

What is the treatment of a mild CAP?

Amoxicillin

What are the elements of CURB-65?

Confusion – AMTS < 9 Urea > 7mmol/L Resp. rate > 30 BP < 90/60 65 or older 0-1: Treat at home- amoxicillin 2: Admit- co-amoxicillin + clarithromycin 3+: Admit, co-amoxicillin + clarithromycin, consider ITU

Give 4 causes of atypical pneumonia and their associated exposures

Mycoplasma pneumoniae: young people close proximity e.g. halls Legionella pneumophila: A/C, plumbers, travellers Chlamydia psittaci: Pet birds Coxiella burnetti: Farm animals

Give 4 features of legionella pneumophila

Hepatitis Hyponatraemia Lymphopaenia +ve urine antigen test

Give 2 signs of mycoplasma pneumoniae

Jaundice (cold AIHA) Erythema multiform (Target shaped rash)

Give 4 symptoms of atypical pneumonias

Dry cough Headache Abdo pain Diarrhoea

Which atypical pneumonias cause a culture -ve endocarditis?

Chlamydia psittaci Coxiella burnetti

What investigations are required for atypical pneumonia?

- Sputum MCS - Urine antigen - Serology - Blood film: mycoplasma- cold agglutins

What is the treatment for atypical pneumonia?

Clarithromycin

Give 3 common organisms causing HAP

Pseudomonas aeruginosa Staphylococcus aureus (Cavitating lesions) Klebsiella pneumoniae (ALCOHOLICS) (Cavitating lesions)

Give 3 features of S. aureus pneumonia

Often post- viral influenza Cavitating lesions (abscess) Grame +ve cocci in bunches

Give 4 features of Klebsiella pneumoniae

a/w Alcoholics + aspiration Haemoptysis Cavitating lesions Gram -ve rods, anaerobic

What is the treatment of HAPs?

Ciprofloxacin + Vancomycin Severe: Piperacillin/ tazobactam + Vancomycin

What is the treatment if confirmed MRSA pneumonia?

Vancomycin

What is the treatment if confirmed pseudomonas pneumonia?

Piperacillin/ tazobactam

Give 3 organisms that cause pneumonia in HIV patients

Pneumocystis jirovecii TB Cryptococcus neoformans

Splenectomy patients are more susceptible to which organisms causing pneumonia?

Encapsulated organisms Neisseria Haemophilus Streptococcus

Cystic fibrosis patients are more susceptible to which organisms causing pneumonia?

Pseudomonas aeruginosa Burkholderia cepacia

Infection with which organism is a contraindication for lung transplant in CF patients?

Burkholderia cepacia

Give 2 risk factors for aspergillum pneumonia

Immunocompromised (Neutropenia) Asthma

What must be checked before starting monoclonal therapy?

TB status as can cause TB reactivation

What is the diagnosis? Describe what is seen

PCP Honeycombing, big cystic spaces

What is the diagnosis? Describe what is seen

PCP Batwing shadowing- ground glass shadowing

What is seen on CXR in aspergillus pneumonia?

Halo sign

What is the treatment for aspergillus pneumonia?

Amphotericin B

Give 2 symptoms of pneumocystis jirovecii pneumonia

Dry cough SOBOE (insidious onset)

What is the treatment for pneumocystis jirovecii pneumonia

Co-trimoxazole

What antibiotics should be used for anaerobes causing pneumonia ?

Metronidazole