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Pulmonology > Fungus, Immunocompromised Pneumonia > Flashcards

Fungus, Immunocompromised Pneumonia Flashcards

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1
Q

define endemic mycoses

A

caused by dimorphic fungi; can cause serious disease in both healthy and immunocompromised pts

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2
Q

define opportunistic mycosis

A

can cause life threatening disease in immunocompromised pts

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3
Q

what is the most common etiologic agents of pulmonary infection by fungi in healthy hosts, cause over 1 million infections/year in the US

A

dimorphic fungi

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4
Q

how and in what form do dimorphic fungi grow, including where

A

grow as yeast in human tissue and as mold under some laboratory conditions (typically room temperature)

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5
Q

after inhalation of dimorphic fungi, what happens to the shit? what do they differentiate into

A

within the lungs, the spores differentiate into yeasts or spherules

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6
Q

are most fungus lung infections self limited or disseminated?

A

most lung infections are self-limited and even asymptomatic, however all can cause pneumonia and disseminate

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7
Q

what are the 4 dimorphic fungi that we talked about?

A

1 - Blastomyces dermatitidis
2 - Histoplasma capsulatum
3 - Coccidioides immitis
4 - Paracoccidioides brasiliensis

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8
Q

what is some of the epidemiology for histoplasma capsulaturm? - where is it found and in what mediums does it grow

A

endemic in Mississippi and Ohio River valleys

grows in soil and bird droppings

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9
Q

For Histo, what is commonly the presenting symptoms

A

asymptomatic pulmonary infection

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10
Q

For Histo with intense exposure, what is the common presenting symptoms?

A

respiratory infection - fever, chills, cough, chest pain

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11
Q

If you have an AIDS pt w/ suspected histo, what are you worried about them developing and what are the manifestations of this?

A

severe disseminated disease
pancytopenia (due to bone marrow infiltration)
Mouth/ GI ulcers
Skin rash (pustules, nodules)

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12
Q

what is the mortality rate of disseminated histo in AIDS pts

A

10%

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13
Q

how do you make the dx of histo based on tissue biopsy?

A

tissue biopsy will show oval yeast cells w/in macrophages

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14
Q

other than tissue biopsy, what are other ways of making dx of histo?

A

serology
urinary antigen
CXR - variable - infiltrates, mediastinal LAD, cavitary lesions

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15
Q

What is the treatment for Histo? one for severe disease, one for otherwise

A

Amphotericin for severe disease

Itraconazole otherwise

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16
Q

what clinical finding in Histo indicates a good prognosis? is it specific for Histo?

A

Erythema nodosum manifests as red, tender nodules (“desert bumps”) on extensor surfaces such as the skin over tibia and ulna - it is delayed cell mediated hypersensitivity that indicates a good, active cell mediated immunity - not specific for Histo - seen in other granulomatous diseases

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17
Q

what fungus is endemic in Ohio/Mississippi River Valley and Missouri and Arkansas River Basins?

A

Blastomyces dermatitidis

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18
Q

where does Blasto grow?

A

moist soil

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19
Q

what is the common clinical manifestation of Blasto

A

asymptomatic respiratory illness -

50% will have cough, chest pain, sputum production, fever/night sweats

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20
Q

How does Blasto usually resolve

A

spontaneously

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21
Q

in what pt populations can disseminated blasto infection be seen? what are the clinical manifestations of dissemination?

A

disseminated disease can be seen in both immunocompetent and immunocompromised
results in ulcerated granulomatous lesions of the skin (70%), bone (33%), GU tract (35%), and CNS (10%)
CNS manifestations can help diff from Histo

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22
Q

How do you make diagnosis of Blastomyces on tissue biopsy? This is high yield

A

Broad Based Bud
Thick-walled yeast cells a single broad based bud
looks like snowman

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23
Q

What other means of dx Blasto?

A

CXR - variable, but can see lobar consolidation, multilobar infiltates, multiple nodules, etc
serology

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24
Q

What is the treatment of blasto? one for severe dz, one in general

A

Amphotericin for severe dz

Itaconazole otherwise

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25
describe the cutaneous lesions seen in Blasto
verucous (wart like lesion), can be ulcerated, gray to violet colored
26
what fungus is endemic in Southwestern US and Latin America
Coccidioides Immitis (this is one of the most defining features)
27
what is the pathogenesis of coccidioides (what happens in the lung)
in the lungs, large spherules form and are filled w/ endospores. Upon rupture of spherule wall, endospores are released and differentiate to form new spherules
28
what is the most common clinical manifestation of Coccidioides?
most infections asymptomatic
29
For symptomatic Coccidioides infxns, what will you see
mild influenza-like illness w/ fever and cough ("valley fever") in 10% can see erythema nodosum
30
what popoulations are more susceptible to dissemination by Coccidioides, and what are the most common sites of dissemination
African Americans, Filipinos, and women in 3rd trimester of pregnancy Bone, meninges, skin
31
For Coccidioides, what is the most distinguishing dx feature
eosinophilia
32
what are other means of diagnosing Coccidioides
serology spherules seen microscopically skin test reativity (not very common)
33
what is the treatment for Coccidioides with persistent lung lesions of disseminated disease
Amphotericin
34
what is the treatment for Coccidioides meningitis
Fluconazole - can cross BBB | also use in long term suppression to prevent recurrence
35
what fungal infxn is common in rural latin America, especially Brazil?
Paracoccidioides brasiliensis
36
what are the clinical manifestations of Paracoccidioides
mild respiratory infection which can progress w/ dissemination development of oral, nasal, and facial nodular ulcerated lesions and submandibular LAD *** This is much more extensive lesions than a blasto disseminated infxn
37
what is the Dx for paracoccidioides? tissue biopsy and serology
tissue biopsy shows yeast cells w/ multiple buds | serology (looks like the wheel of a ship)
38
what is the tx for Paracoccidioides
several months of Itraconazole | Amphotericin for severe disease
39
what is the buzzword for the microscopic appearance of Paracoccidioides
pilot wheel configuration
40
where do you find Aspergillus fumigatus?
Mr. Worldwide
41
what type of fungi (morphology?) is Aspergillus, and where does it grow
mold with septate hyphae | grow on decaying vegetation producing chains of conidia
42
what are some of the features of an Aspergillus infection? 1) something that produces hempotysis 2) something you can detect via a titer, 3) appearance of expactorations 4) disease process
1) fungus ball formed within cavities of the lungs, can produce hemoptysis 2) allergic infection of the bronchi that produces asthmatic symptoms and high IgE titer 3) allergic infection of bronchi - causes expectoration of brownish bronchial plugs containing hyphae 4) invasive PNA producing hemmorrhage, infarction, and necrosis
43
What pt population is highest risk factor for Aspergillus? esp producing hemorrhage and shit
those with hematologic malignancies and neutropenia - invasive PNA producing hemorrhage is common cause of death in these pts
44
how do you make dx of Aspergillus via tissue biopsy? this is high yield
septate, acute angle branching hyphae | radiating chains of conidia
45
what is a dx feature of Aspergillus seen on CT scan?
halo sign - areas of focal hemorrhage around the lesion | can see single or multiple nodules with or without cavitation
46
what is the first line treatment of Aspergillus
Voriconazole
47
if pts do not tolerate Voriconazole well, what is alternative tx for Aspergillus
Amphotericin or echinocandins
48
what do you need to do in Aspergillus pts to control the hemoptysis
remove the fungus balls
49
what do you use to treat ABPA? (allergic bronchopulmonary Aspergillosis)
steroids and antifungal agents
50
what are opportunistic infections caused by bread mold?
Mucormycosis
51
give 4 examples of Mucormycetes
Mucor, Rhizopus, Cunninghamella, Lictheimia
52
what are 5 risk factors for Mucormycosis
``` Diabetes neutropenia iron overload burns/surgical wounds corticosteroid use ```
53
how is mucormycosis transmitted? what does it invade in host?
transmitted by airborne spores | invades tissue and angioinvasive - pts w/ reduced host defenses
54
besides penumonia, what are 2 clinical manifestations of Mucormycosis
1) invasive rhinocerebral sinusitis, frontal lobe abscesses | 2) cutaneous infections
55
describe the pathogenesis of invasive rhinocerebral sinusitis and frontal lobe absceses seen in mucormycosis
it originates in the paranasal sinuses and spreads tothe orbit, hard palate and brain
56
what is the presentation of a pt w/ mucormycosis w/ the rhinocerebral shitusitis and front lobe asses? mortality rate
headache and facial pain | carries a high mortality rate
57
what are the defining features of mucormycosis on biopsy? high yield, must know
nonseptate broad hyphae with frequent right angle branching spores in a sporangium (as oppo to conidia for aspergillus)
58
what is the treatment for Mucormycosis? what is an alternate?
treat the underlying disorder Amphotericin + surgical resection of necrotic infected tissue alternate - Posaconazole can also be used
59
what kind of organism is Pneumocystic jiroveci?
yeast
60
what are the most common symptoms of Pneumocystis infxn
most infxns are asymptomatic
61
Pneumocystis and immunosuppressed patients - what are we worried about?
PCP - pneumocystis carinii pneumonia | carinii = jiroveci
62
what pt population specifically are we worried about Pneumocystis in?
AIDS pts | common opportunistic infxn, one of leading causes of death in AIDS pts
63
What is the pathogenesis of Pneumocystis jiroveci?
cysts in alveoli produce inflammatory responses, resulting in forthy exudate that blocks oxygen exchange
64
how does the Pneumocystis organism get into tissue?
Pneumocystis does not invade lung tissue
65
How does the immune system clear the pneumocystis organism? What is the importance of this?
CD4+ T cells recruit monocytes and macrophages which are responsible for clearance of the organism AIDS pts - a CD4 count less than 200 is main risk factor for getting pneumocystis infxn
66
what are 5 clinical manifestations of PCP
``` dry cough dyspnea that is progressive Fever tachypnea hypoxemia ```
67
What are CXR findings in PCP?
diffuse, bilateral, interstitial, or alveolar infiltrates | CXR normal in up to 1/4
68
what is another clinical manifestation that can occur from PCP
pneumothorax
69
you see an AIDS pt that is dyspnic and hypoxemic, but has a normal CXR - can this be PCP?
yes - negative CXR does not rule out
70
what is the O2 sat of a pt w/ PCP, and why
O2 sats low, in the 80s - the frothy exudate is blocking gas exchange
71
dx of PCP - what stains can you use to visualize cysts?
visualization of cysts by methenamine silver, Giemsa stain or other stains
72
What is the appearnace of PCP on microscopic examination
helmet shaped cells
73
what are 2 other dx techniques used in PCP
fluorescent antibody staining | PCR on respiratory tract specimens
74
what is the first line treatment for PCP
trimethoprim-sulfamethoxazole (Bactrim)
75
what are the 3 options for 2nd line tx of PCP
Clindamycin/Primaquine Atovaquone Pentamidine
76
PCP prophylaxis in AIDS pts what level of CD4 count what 3 medications
AIDS pts w/ CD4 count less than 200 | Bactrim, Dapsone, Atovaquone
77
in genenral, what is cryptococcus neoformans? and where is it found?
yeast present in soil and bird (pigeon) droppings
78
what is the morphology of crypto (high yield)
oval budding yeast with wide polysaccharide capsule; | forms narrow-based bud**
79
what specific disease are you worried about in crypto infxn of immunocompromised pts
meningitis | most common life-threatening disease in AIDS pts
80
what other disease are you worried about with crypto infxn of either immunocompromised or immunocompetent what are the symptoms in each case
pneumonia immunocompetent - asymptomatic immunocmpromised - fever, chest pain, dyspnea, cough, and hemoptysis
81
what is the appearance of crytpo on CXR
nodules and or ground glass opacities
82
what is morphology of cytomegalovirus
DNA enveloped virus similar in morphology and structure to other Herpes viruses
83
what is pathogenesis of CMV
enters latent state primarily in monocytes and can be reactivated when cell-mediated immunity is decreased
84
what common disease process commonly develops in immunosuppressed pts (transplants) w/ CMV
pneumonitis
85
what disease processes develop in AIDS pts w/ CMV
colitis and retinitis | typically NOT pneumonitis
86
what is the appearance of CMV on CXR?
diffuse infiltrates, ground glass opacities
87
What is a characteristic finding of CMV pneumonitis on biopsy of lung tissue
viral inclusion body
88
if you see pneumonia and a brain abscess, what bug should you be thinking abou
Nocadria asteroides - causing nocardiosis
89
``` Nocardia asteroides - aerobic or anaerobic? where found? morphology? gram stain? weakly also stain what? ```
``` aerobes found in the soil thin branching filaments gram + many isolates weakly acid fast ```
90
Nocardiosis, immunocompromised pt - what disease process and predilection for what tissue
produces lung infection and may disseminate, has predilection for brain tissue
91
Nocardiosis - what specific pathologic findings do you see in lungs
pneumonia, lung abscesses w/ cavity formation, lung nodules or empyema
92
how do you dx nocardiosis?
gram stain/ acid-fast stain | culture
93
tx for nocardiosis
Trimethoprim-sulfamethoxazole (Bactrim), sometimes combination therapy is needed, ressitance can occur, sensitivities should be performed
94
Ohio/Mississippi River Valleys, Intracellular, found in phagocytes
Histo
95
Ohio/Mississippi River Valleys, Missouri and Arkansas River basins Broad based bud
Blasto
96
"Valley fever" Southwestern US and Latin America Pregnant Women, African Americans and Filipinos at risk for dissemination to bones and meninges Eosinophilia
Coccidioides immitis
97
yeast w/ multiple buds, "pilot wheel" configuration Rural Latin America, espp Brazil Oral, nasal, facial nodular ulcerated lesions
Paracoccidioides
98
How often do AIDS pts get Aspergillus infxn? and why?
AIDS pts do not get Aspergillus - AIDS pts are lymphopenic and susceptibility to Aspergillus is being neutropenic
99
what is the most common opportunistic infxn in AIDS pts
PCP (pneumocystis)
100
why can you not use traditional antifungals on pneumocystis
it does not contain ergosterol
101
compare and contrast the morphology of Aspergillus and Mucor on tissue biopsy 1 - septate or non 2 - angle of branching 3 - spores
Aspergillus - septate hyphae, acute angle branching, radiating chains of conidia Mucor - nonseptate hyphae, 90 degree angle branching, spores in sporangium
102
pneumothroax - what fungus are you worried about
pneumocystis

Pulmonology (31 decks)

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