Exam I Study Guide (pneumonia)

Question 1

What is the difference between pneumonia and pneumonitis?

Answer 1

Pneumonia: infection or inflammation of the lung, including the alveolar spaces, parenchyma and interstitial tissue

Some texts use pneumonitis to define inflammation of interstitial tissue and define pneumonia as an infection or inflammation of only the alveolar spaces

Question 2

What are the predisposing factors for pneumonia?

Answer 2

• Loss of cough reflex
• Diminished mucin or cilia function
• Alveolar macrophage interference
• Vascular flow impairments
• Bronchial flow impairments
• Although pneumonia is one of the most common causes of death, it usually does NOT occur in healthy people spontaneously

Question 3

What are they typical signs and symptoms of pneumonia?

Answer 3

Typical symptoms:
• cough
• fever
• fatigue
• myalgia
• increased sputum production (may be rust colored from RBCs and WBCs in secretions)
• may be pleuritic chest pain

Question 4

Difference btw lobar pneumonia, viral pneumonia, or bronchopneumonia?

Answer 4

Bacterial pneumonia has 3 main patterns of gross anatomic distribution:
• lobar pneumonia (entire lobe)
• lobular pneumonia (part of a lobe) • bronchopneumonia (patchy)

Viral pneumonias are frequently “interstitial”, NOT alveolar.

Question 5

lobar pneumonia s/sx

Answer 5

In lobar pneumonia there are four stages of the inflammatory response
• Congestion
• Red hepatization 
• Grey hepatization 
• Resolution

Tx slows or halts the progression through the 4 classic stages of pneumonia

Question 6

viral pneumonia s/sx

Answer 6

Viral pneumonias are frequently “interstitial”, NOT alveolar.

Tends to be a “walking pneumonia” not debilitating

Viral pneumonia presents more commonly with wheezing than does bacterial pneumonia.

Question 7

bronchopneumonia

Answer 7

Acute inflammation of the walls of the bronchioles. Characterized by multiple foci of isolated, acute consolidation, affecting one or more pulmonary lobules.

It is one of two types of bacterial pneumonia as classified by gross anatomic distribution of consolidation (solidifications), the other being lobar pneumonia.

Question 8

What are signs of consolidation?

Answer 8

Signs of lung consolidation:
• Dullness to percussion
• Crackles
• Absent breath sounds

Question 9

What is the difference between congestion and consolidation?

Answer 9

Congestion:
• Dilated capillaries leak protein rich exudate into interstitium
• Intra-alveolar fluid with few neutrophils
• Numerous bacteria present
• Can lead to…

Consolidation:
• Exudative reaction and subsequent solidification
• Might be some fibrosis (longer term)

Question 10

Which organism is responsible for most cases of community acquired pneumonia worldwide?

What are its gram staining properties?

Answer 10

Streptococcus pneumoniae; gm+

Question 11

What are the 4 inflammatory stages described in lobar pneumonia?

Answer 11

• Congestion
• Red hepatization
• Grey hepatization
• Resolution

Question 12

What are the characteristics of red and gray hepatization?

Answer 12

Red Hepatization:
• Red cell (RBC) exudate, neutrophils, and fibrin fill alveolar spaces.
• Gross appearance is red, firm, and airless, (consolidated)
• Hepatization: consistency resembles liver tissue

Gray Hepatization:
• Red cell disintegration, shift to increased fibrinization
• Persistent neutrophils, fibrin, and suppurative exudate
• Alveoli still consolidated
• Gross appearance is greyish brown drier surface

Question 13

In which populations is Haemophilus Pneumonia most prevalent, and what are its gram staining properties?

What is the antibiotic of choice typically for its treatment?

Answer 13

• Gm-
• Most common in children <2 are often thought of as being H. Influenzae until proven otherwise
• Most common pneumonia from COPD in adults
• Bactrim (Trimethoprim- Sulfa) most common treatment

Question 14

What is the 2nd most common cause of pneumonia in people with COPD? What are its gram staining properties?

Answer 14

Moraxella Catarrhalis
• 2nd most common COPD pneumonia, after haemophilus
• Gram negative coccobacillus, like H. Flu

Question 15

Which populations most often get Klebsiella Pneumoniae? What are its gram staining properties?

Answer 15

• Gm-
• Debilitated malnourished people
• Alcoholics with pneumonia are often thought of as having Klebsiella until proven otherwise

Question 16

What organisms are presumed to be present in a patient with cystic fibrosis and pneumonia? Gram staining properties?

Answer 16

Pseudomonas Aeruginosa
• Gm-
• Usually not community acquired but nosocomial
• Cystic Fibrosis patients with pneumonia are presumed to have Pseudomonas until proven otherwise

Question 17

How is Legionella transmitted and what is unusual about the organism’s morphology?

Answer 17

• Often in outbreaks
• Often Lobar
• Spread by water “droplets” (e.g., h2o storage/tx systems)
• Often immunosuppressed patients
• Legionella pneumophila is the agent of Legionnaires disease
• FLAGELLUM :-D… no need to aspirate - can swim to lungs.

Question 18

What are the atypical pneumonias and what is walking pneumonia. Are cultures helpful?

Answer 18

Atypical: caused by less typical pathogens, or cell wall deficient bacteria, AKA “walking pneumonia”
• Mycoplasma pneumoniae
• Chlamydia spp. (C. pneumoniae, C.
psittaci, C. trachomatis)
• Legionella (may also be listed here)
• Coxiella burnetti (Q fever)
• Viruses: RSV, parainfluenza virus, Varicella, influenza A and B, adenovirus, SARS
• Interstitial, NOT alveolar

Cultures are NOT helpful

Question 19

What finding on the tympanic membrane of a person with pneumonia might indicate the causative organism is Mycoplasma pneumoniae?

Answer 19

bullous myringitis

Is usually caused by a virus or mycoplasma pneumoniae.

Question 20

What is unusual about the original location of viral vs. bacterial pneumonia?

Answer 20

Viral is frequently “interstitial”, not alveolar.

Bacterial is alveolar.

Question 21

What is the most common viral pneumonia overall, and what is the most common viral pneumonia of infants and young children.

Answer 21

• Respiratory syncytial virus (RSV) is most common overall, and in infants/young children.
• Viral pneumonia in adults most commonly due to influenza A or Varicella-zoster - RSV less commonly.

Question 22

What is an oxygen tent?

Answer 22

An oxygen tent consists of a canopy placed over the head and shoulders, or over the entire body of a patient to provide oxygen at a higher level than normal. Usually used for children/infants instead of ventilator.

Question 23

What virus is responsible for SARS and how is it confirmed?

Answer 23

SARS (Severe Acute Respiratory Syndrome)

• Corona virus
• Confirmed by PCR (like most other NON-bacterial pneumonias)

Question 24

What is nosocomial pneumonia and what are its most common causes?

Answer 24

Acquired in HOSPITALS (also called “hospital acquired”, versus “community acquired” pneumonias)

CAUSES:
• Debilitation
• Catheters, Ventilators
• Enterobacter, Pseudomonas
• Staph (MRSA)
  - MR=Methicillin Resistant
• Klebsiella
• E. coli
• S. pneumoniae H. influenzae

Question 25

What are the characteristics and common organisms of aspiration pneumonias and what do they often lead to?

Answer 25

• Unconscious patients
• Patients in prolonged bed rest
• Lack of ability to swallow or gag
• Usually caused by aspiration of gastric contents
• Posterior lobes (gravity dependent) most commonly involved, especially the superior segments of the lower lobes
• Often lead to abscesses
• Strep, Staph, H.Flu, Pseudomonas are the most frequent secondary pathogens

Question 26

What is the difference between a pleural effusion and an empyema? How might you tell the difference on CXR?

Answer 26

Pleural effusion is excess fluid that accumulates in the pleural cavity, the fluid-filled space that surrounds the lungs.

Pleural empyema, also known as pyothorax or purulent pleuritis, is empyema (an accumulation of pus) in the pleural cavity that can develop when bacteria invade the pleural space, usually in the context of a pneumonia.

Question 27

Which type of pneumonia causes lung abscesses, and what are their common characteristics?

Answer 27

Any pneumonia which is severe and destructive, and un-treated enough.
Abscess morphology:
• Size may be 1-2mm to 5-6 cm
• May be single or multiple
• In any part of lung

Abscess due to aspiration
• Usually single, and in R lung (more vertical)\
Abscesses due to pneumonia, bronchiectasis:
• Usually multiple, basal, diffusely scattered

Question 28

What is a bronchopleural fistula?

Answer 28

A bronchopleural fistula (BPF) is a fistula between the pleural space and the lung. It sometimes develops following pneumonectomy or an infection (pneumonia). It may also develop when large airways are in communication with the pleural space following a large pneumothorax or other loss of pleural negative pressure, especially during positive pressure mechanical ventilation.

Question 29

What 4 organisms are we talking about when we refer to “Chronic Pneumonias?”

Answer 29

Chronic by classification, but “granulomatous” by histology
• Tb
• Histoplasmosis 
• Blastomycosis
• Coccidiomycosis

Question 30

What is the difference between a Ghon focus and a Ghon complex?

Answer 30

Ghon focus:
• Initial infection location
• ~ 2 - 3 weeks after development it undergoes caseous necrosis
• TB bacilli drain out towards the hilar lymph nodes

Ghon complex:
• Ghon focus with hilar lymph node involvement
• May calcify and be seen on CXR

Question 31

What type of necrosis occurs within a TB granuloma?

Answer 31

Caseous granuloma: granuloma with central (cheese curd-like) necrosis, characteristic of TB infection

Question 32

What percentage of pulmonary TB is latent? What percentage reactivates and what percentage immediately becomes active after the initial infection?

Answer 32

1-5% active after initial infection.

90-95% is latent.

5-10% reactivates

Question 33

Why and how does TB reactivate?

What is miliary TB?

Answer 33

TB may remain inactive in the Ghon complexes for months to decades

Secondary TB (aka reactivation TB):
• Poor nutritional status, concurrent infection or other health problems may result in Ghon complex breakdown and Mycobacterium release

Miliary TB
• Infection progresses to cavitation’s of the lung and systemic dissemination (occurs in 1 – 3% of TB cases)
• Infection invades the circulatory system
• Millet- like seeding of TB bacilli in the lungs and other organs

Question 34

Describe the cellular makeup of a TB granuloma.

Answer 34

• Macrophages, T cells, B cells, and fibroblasts aggregate to form a granuloma
• Lymphocytes surround infected macrophages
Granuloma functions to:
• Prevent dissemination of Mycobacteria
• Provide a local environment for communication of cells of the immune system.

Question 35

What are the common signs and symptoms of the chronic pneumonias like TB and those that are fungal?

Answer 35

May be Asx or have sx that include: 
• Fever (late afternoon, night sweats) 
• Cough
• Ranging from non- productive to severe with sputum or hemoptysis with late stages
• Pleuritic chest pain
• Dyspnea
• Hemoptysis
• Weight loss, cachexia 
• Fatigue

Question 36

What is pulmonary hypertension?

Answer 36

Pulmonary hypertension (PH) is an increase of blood pressure in the pulmonary artery, pulmonary vein, or pulmonary capillaries, together known as the lung vasculature, leading to shortness of breath, dizziness, fainting, leg swelling and other symptoms. Pulmonary hypertension can be a severe disease with a markedly decreased exercise tolerance and heart failure.