Hersh CIS Pneumo

Question 1

no cell wall

causes microcytic anemia

Answer 1

mycoplasma pneumonia

Question 2

Hyponatremia

Answer 2

• Legionella

Question 3

Positive urinary antigens

Answer 3

– S. pneumo and Legionella

Question 4

Answer 4

mycoplasma pneumonia

Question 5

similar in presentation to Mycoplasma but with a hoarse voice!!!

Answer 5

Chlamydia pneumoniae – similar in presentation to Mycoplasma, hoarse voice!!!

Question 6

Fevers, chills, cough (may be dry), dyspnea (typically with exertion)

Answer 6

CAP atypical pneumonia (legionelle, chlymedia, mycoplasma pneumonia)

Question 7

Follows URI like sx

Answer 7

CAP atypical penumonia

Follows URI like sx: rhinitis, laryngitis, pharyngitis, sinusitis

Question 8

EMPIRIC ABX FOR CAP: ambulatory

Answer 8

macrolide (azithromycin, clarithromycin, erythromycin)

Question 9

1. EMPIRIC ABX FOR CAP in pt w/ncreased risk for drug resistance due to
   
   1. having Abx in the past 90 days
   2. immunosuppression
   3. exposure to kids

Answer 9

FLUOROQUINOLONE OR MACROLIDE + beta-lactam

Question 10

EMPIRIC ABX FOR CAP: hospitalized patients

Answer 10

Hospitalized Patients – FLUROQUINOLONE

Question 11

EMPIRIC ABX FOR CAP: ICU pts

Answer 11

1. ICU
   
   1. Combo of
      
      1. FLUROLOQUINOLONE
      2. antipneumococcal beta lactam
         
         1. ​3rd gen cephalosporin or ampicillin sulbactam
   2. Add piperacillin-tazobactam, cefipime, or a “penem” for Pseudomonal coverabe

Question 12

EMPIRIC ABX FOR CAP: ICU pts needing pseudomonal coverage

Answer 12

1. ICU:
   
   1. FLUROLOQUINOLONE + antipneumococcal beta lactam (3rd gen cephalosporin or ampicillin sulbactam)
   2. Add piperacillin-tazobactam, cefipime, or a “penem” for Pseudomonal coverabe

Question 14

How do you know what to do with a pt presenting with symptoms of pneumonia?

Answer 14

CURB65

1. Confusion = 1 pt
2. Blood Urea nitrogen > 20 mg/l = 1 pt
3. Respiration >/= 30 breaths/min
4. Blood pressure = 1 pt
   
   1. systolic < 90 mmHg
   2. diastolic = 60 mmHg
5. Age >/= 65 = 1 pt

Score

0-1 = low risk, outpatient

2 = moderate severity: short impatient hospitalization or closely supervised outpatient tx

3-5 = severe pneumonia: hospitalization required, consider ICU admission

Question 15

gram negative bacillus (pleomorphic), aerobic, flagellate: what will i grow on?

Answer 15

legionelle

Legionella pneumophilia – gram negative bacillus (pleomorphic), aerobic, flagellate, water lover, urinary antigen

buffered charcoal yeast extract agar

Question 16

gram negative bacillus, encapsulated, pyocyanin and pyoverdine, smells like grapes, water lover, colonizer in CF and bronchiectasis.

Answer 16

Pseudomonas aeruginosa

Question 17

gram negative diplococci, encapsulated (typeable) or no capsule (non-typeable), Chocolate agar (factors V and X), smokers, immunocompromised.

Answer 17

Haemophilus influenzae

gram negative diplococci, encapsulated (typeable) or no capsule (non-typeable), Chocolate agar (factors V and X), smokers, immunocompromised.

Question 18

gram negative DIPLOCOCCUS

fastidious, aerobic. Big time for smokers, COPD, asthmatics, malignancies. Generally exacerbates predisposing conditions and then forms a PNA

Answer 18

Moraxella catarrhalis

– gram negative coccobacillus, fastidious, aerobic. Big time for smokers, COPD, asthmatics, malignancies. Generally exacerbates predisposing conditions and then forms a PNA

Question 19

positive Thompson test, difficulty walking, pain behind ankle

Answer 19

levofloxacin

Question 20

MacConkey agar

Answer 20

What the dickens is MacConkey agar??

• Selects for G(-) bacteria, especially enteric bacteria!

Has bile salts and crystal violet in the media: these select for Gram negative bacteria only.

Also, has LACTOSE which selects for fermenters

Question 21

ENCAPSULATED, gram negative, ferments lactose, grows in mucoid colonies. Bulging fissure, currant jelly sputum, immunocompromised and EtOH.

Answer 21

Klebsiella pneumoniae

– ENCAPSULATED, gram negative, ferments lactose, grows in mucoid colonies. Bulging fissure, currant jelly sputum, immunocompromised and EtOH.

Question 22

IS gram negative, but not a lactose fermenter. Additionally, SEVERE pt presentation: fever, headache, weakness, chest pain, dyspnea, pulmonary hemorrhages (bloody sputum)

Answer 22

Yersinia pestis – IS gram negative, but not a lactose fermenter. Additionally, SEVERE pt presentation: fever, headache, weakness, chest pain, dyspnea, pulmonary hemorrhages (bloody sputum)

Question 23

Fast Fermenters

Answer 23

Fast Fermenters: “Lactose? OH-KEE!!!!”

KEE: Klebsiella, E. coli, Enterobacter

Question 24

Slow Fermenters:

Answer 24

CS

Citrobacter, Serratia

Question 25

atypical, no cell wall, extracellular, bullous myringitis, cold agglutinins, scattered pulmonary infiltrates (if anything), younger pts, generally self-limiting, dry cough

Answer 25

Mycoplasma pneumoniae – atypical, no cell wall, obligate intracellular, bullous myringitis, cold agglutinins, scattered pulmonary infiltrates (if anything), younger pts, generally self-limiting, dry cough

Question 26

gram positive diplococci, encapsulated, alpha hemolytic, optochin sensitive, urinary antigen, lobar PNA, MOST COMMON CAUSE OF CAP (and meningitis). Sick patients: fevers, chills, cough, rust colored sputum, dyspnea, and weakness.

Answer 26

Streptococcus pneumoniae – gram positive diplococci, encapsulated, alpha hemolytic, optochin sensitive, urinary antigen, lobar PNA, MOST COMMON CAUSE OF CAP (and meningitis). Sick patients: fevers, chills, cough, rust colored sputum, dyspnea, and weakness.

Question 27

gram negative, non-lactose fermenter, buffered yeast charcoal medial, lover of water systems, hyponatremia, relative bradycardia, can affect multiple people at same time

Answer 27

Legionella pneumoniae – gram negative, non-lactose fermenter, buffered yeast charcoal medial, lover of water systems, hyponatremia, relative bradycardia, can affect multiple people at same time

Question 28

gram positive, catalase and coagulase positive, known to follow viral pneumonia, necrotizing, pulmonary hemorrhages, salmon colored sputum.

Answer 28

**Staphylococcus aureus** – gram positive, catalase and coagulase positive, known to follow viral pneumonia, necrotizing, pulmonary hemorrhages, salmon colored sputum.

Question 29

encapsulated gram negative, lactose fermenter, mucoid colonies, currant jelly sputum....

Answer 29

Klebsiella pneumoniae – encapsulated gram negative, lactose fermenter, mucoid colonies, currant jelly sputum....you can fill in the rest!

Question 30

vaccination against capsular polysaccharide antigens of 23 strains

Answer 30

Pneumovax – against capsular polysaccharide antigens of 23 strains

Question 31

vaccination protective against 13 strains

Answer 31

Prevnar 13 Prevnar 13 – protective against 13 strains

Question 32

who gets the pneumococcal vaccine? what are C/I? when is it administered?

Answer 32

Age ≥65, immunocompromised, asplenic patients, pts 2-64 for risk factors Contraindications: serious allergic reaction to previous vaccination (anaphylaxis) \*\*Hold off on vaccination until your patient’s are better!!!

Question 33

Gram (-) encapsulated organism that produces pyocyanin

Answer 33

Pseudomonas aeruginosa

Question 34

G+ diplococci (lancet shaped), rust colored sputum, lobar PNA

Answer 34

Streptococcus pneumoniae – G+ diplococci (lancet shaped), rust colored, lobar PNA

Question 35

no cell wall, extracellular, bullous myringitis, anemia, cold agglutinins, younger adults

Answer 35

Mycoplasma pneumoniae - no cell wall, extracellular, bullous myringitis, anemia, cold agglutinins, younger adults

Question 36

gram negative rod, CF, bronchiectasis, green (pyocyanin and pyoverdine), grape smelling, encapsulated, biofilms (alginate)

Answer 36

Pseudomonas aeruginosa – gram negative rod, CF, bronchiectasis, green (pyocyanin and pyoverdine), grape smelling, encapsulated, biofilms (alginate)

Question 37

a gram negative coccobacillus that grows on chocolate agar

Answer 37

Haemophilus influenza

Question 38

non-enveloped, dsDNA, icosahedral virus. Common cold viral keratoconjunctivits conjunctivitis pharyngitis Can cause overlapping symptoms. Viral Cx standard, can use direct assay or enzyme immunoassay.

Answer 38

**Adenovirus** – non-enveloped, dsDNA, icosahedral virus. Common cold, viral keratoconjunctivits, conjunctivitis, pharyngitis. Can cause overlapping symptoms. Viral Cx standard, can use direct assay or enzyme immunoassay.

Question 39

Sx: fevers, chills, myalgias, HA, nasal stuffies, coryza, nonproductive cough. Fever \>38C, LAD. diffuse pneumonitis and hypoxemia. Leukopenia.

Answer 39

A. Orthomyxovirus – 8 segmented (-)ssRNA, Hemagluttinin and Neuriminadase spikes. Sx: fevers, chills, myalgias, HA, nasal stuffies, coryza, nonproductive cough. Fever \>38C, LAD. Can cause diffuse pneumonitis and hypoxemia. Leukopenia is common. Rapid Flu is suboptimal. PCR is preferred. \*\*\*REYE SYNDROME – don’t give ASA to kids!

Question 40

ssRNA. Fever, cough, dyspnea, GI sx (diarrhea, ab pain). Fecal-oral transmission. Travel to ME, esp Saudia Arabia. Thrombocytopenia, lymphopenia/cytosis, transaminitis. SEVERE – ARDS presentation.

Answer 40

C. MERS – Coronavirus, ssRNA. Middle Eastern Respiratory Syndrome. Fever, cough, dyspnea, GI sx (diarrhea, ab pain). Fecal-oral transmission. Travel to ME, esp Saudia Arabia. Thrombocytopenia, lymphopenia/cytosis, transaminitis. SEVERE – ARDS presentation.

Question 41

Travel to China, Hong Kong, Taiwan. Initial flu-like sx and can progress rapidly to ARDS. Cough, difficulty breathing, severe hypoxia.

Answer 41

SARS – Severe Acute Respiratory Syndrome. Coronavirus. Travel to China, Hong Kong, Taiwan. Initial flu-like sx and can progress rapidly to ARDS. Cough, difficulty breathing, severe hypoxia.

Question 42

similar to orthomyxo, history of exposure to dead or sick poultry. Fever (prolonged), cough, dyspnea. RT-PCR. Start with OSELTAMIVIR (same for prophylaxis after exposure)

Answer 42

**H5N1** – similar to orthomyxo, history of exposure to dead or sick poultry. Fever (prolonged), cough, dyspnea. RT-PCR. Start with OSELTAMIVIR (same for prophylaxis after exposure)

Question 43

gram positive, catalase and coagulase positive, necrotizing PNA, golden colony growth, follows flu.

Answer 43

**S. aureus – gram positive,** catalase and coagulase positive, necrotizing PNA, golden colony growth, follows flu.

Question 44

Answer 44

1. Histoplasmosis 1. microconidia found in caves with bat/bird droppings. 2. Dimorphic yeast in body, fungi in natural environment. 3. Narrow-based budding. 4. Mild PNA unless immunocompromised, chronic course. 5. Most resolve on their own. 6. Prevalent in: Ohio, Missouri, and Mississippi River Valleys. Lesions calcify on CXR (coin lesion)

Question 45

Answer 45

1. Histoplasmosis – 1. microconidia found in caves with bat/bird droppings. 2. Dimorphic yeast in body, fungi in natural environment. 3. Narrow-based budding. 4. Mild PNA unless immunocompromised, chronic course. 5. Most resolve on their own. 6. \*\*\*Prevalent in: Ohio, Missouri, and Mississippi River Valleys. Lesions calcify on CXR (coin lesion)

Question 46

Answer 46

Coccidioidomycosis (C. immitis – Valley Fever) – chronic PNA, fungi spherule with endospores, dimorphic, prevalent in Southwest (CA, NM, AZ, San Juaquin River Valley). Some will develop painful erythematous nodular lesions – **ERYTHEMA NODOSUM**. Self-limiting

Question 47

a fungus caused this on a patient in the southwest

Answer 47

**Coccidioidomycosis (C. immitis – Valley Fever)** – chronic PNA, fungi spherule with endospores, dimorphic, prevalent in Southwest (CA, NM, AZ, San Juaquin River Valley). Some will develop painful erythematous nodular lesions – **ERYTHEMA NODOSUM. Self-limiting**

Question 48

chronic PNA, soil with decomposing matter (leaves, wood), BROAD BASED BUDDING YEAST. Can cause SKIN, BONE, and NEURO changes.

Answer 48

Blastomycosis (Blastomyces dermatitidis) – chronic PNA, soil with decomposing matter (leaves, wood), BROAD BASED BUDDING YEAST. Can cause SKIN, BONE, and NEURO changes.

Question 49

Answer 49

Blastomycosis (Blastomyces dermatitidis) – chronic PNA, soil with decomposing matter (leaves, wood), BROAD BASED BUDDING YEAST. Can cause SKIN, BONE, and NEURO changes.

Question 50

FLU PREVENTION: who, vaccine, C/I

Answer 50

recommended that all persons over the age of 6 months of age be vaccinated! Inactivated influenza virus Contraindications: previous allergic reaction, egg allergy (there are alternatives), Guillan-Barre within 6 weeks of previous flu vax.

Question 51

microconidia found in caves with bat/bird droppings. Dimorphic – yeast in body, fungi in natural environment. Narrow-based budding. Mild PNA unless immunocompromised, chronic course. Most resolve on their own. \*\*\*Prevalent in: Ohio, Missouri, and Mississippi River Valleys. Lesions calcify on CXR (coin lesion)

Answer 51

Histoplasmosis – microconidia found in caves with bat/bird droppings. Dimorphic – yeast in body, fungi in natural environment. Narrow-based budding. Mild PNA unless immunocompromised, chronic course. Most resolve on their own. \*\*\*Prevalent in: Ohio, Missouri, and Mississippi River Valleys. Lesions calcify on CXR (coin lesion)

Question 52

chronic PNA, fungi spherule with endospores, dimorphic, prevalent in Southwest (CA, NM, AZ, San Juaquin River Valley). Some will develop painful erythematous nodular lesions – ERYTHEMA NODOSUM. Self-limiting

Answer 52

Coccidioidomycosis (C. immitis – Valley Fever) – chronic PNA, fungi spherule with endospores, dimorphic, prevalent in Southwest (CA, NM, AZ, San Juaquin River Valley). Some will develop painful erythematous nodular lesions – ERYTHEMA NODOSUM. Self-limiting

Question 53

chronic PNA, soil with decomposing matter (leaves, wood), BROAD BASED BUDDING YEAST. Can cause SKIN, BONE, and NEURO changes.

Answer 53

Blastomycosis (Blastomyces dermatitidis) – chronic PNA, soil with decomposing matter (leaves, wood), BROAD BASED BUDDING YEAST. Can cause SKIN, BONE, and NEURO changes.

Question 54

Culture results from sputum, blood, and urine demonstrate a Gram-negative, aerobic, catalase positive, bacillus that flourishes on BC agar. The organism does not ferment lactose...

Answer 54

Burkholderia cepacia – G(-) bacillus catalase positive, non-lactose fermenter. Grows on BC agar (has crystal violet and bile salts – colonies are pearly gray). Also colonizes CF pts (or with bronchiectasis) and is found on hospital equipment and irrigation systems. VERY HARD TO TREAT, MULTI-ABX resistant

Question 55

G(-) bacillus, oxidase positive, catalase positive, aerobic, pyocyanin/pyoverdine, non-lactose fermenter.

Answer 55

Pseudomonas aeruginosa – G(-) bacillus, oxidase positive, catalase positive, aerobic, pyocyanin/pyoverdine, non-lactose fermenter.

Question 56

Gram (-) bacillus, encapsulated, anaerobic, EtoH, currant jelly sputum, mucoid colonies, bulging fissure, lobar or necrotizing.

Answer 56

Klebsiella pneumoniae – Gram (-) bacillus, encapsulated, anaerobic, EtoH, currant jelly sputum, mucoid colonies, bulging fissure, lobar or necrotizing.

Question 57

Gram (-) coccobacillus, chocolate agar, encapsulated

Answer 57

Haemophilus influenza – Gram (-) coccobacillus, chocolate agar, encapsulated

Question 58

gram (-) bacillus, lactose fermenter, oxidase negative, anaerobic. Opportunistic, mechanical ventilaltion. Coliform bacteria. MOTILE!!!

Answer 58

Enterobacter- gram (-) bacillus, lactose fermenter, oxidase negative, anaerobic. Opportunistic, mechanical ventilaltion. Coliform bacteria. MOTILE!!!

Question 59

... exposure to infected rodents via urine, feces, saliva. Prodromal phase mimics many flu-like syndromes. Rapidly progresses to Hanta CP (cardiopulm) syndrome with RESPIRATORY Distress. Look for clues in History!!! Labs: Thrombocytopenia, leukocytosis, elevated LDH, pulmonary infiltrates B/L

Answer 59

**Bunyavirus – HANTAVIRUS.** Zoonotic, exposure to infected rodents via urine, feces, saliva. Prodromal phase mimics many flu-like syndromes. Rapidly progresses to Hanta CP (cardiopulm) syndrome with RESPIRATORY Distress. Look for clues in History!!! Labs: Thrombocytopenia, leukocytosis, elevated LDH, pulmonary infiltrates B/L

Question 60

ABRUPT high fever, HA, myalgias. Fevers and sx last through duration of illness. May have mild PNA or rapidly progress to respiratory distress. Hepatitis with no jaundice, acute endocarditis, maculopapular rash. Leukocytosis and thrombocytopenia.

Answer 60

**Coxiella burnetti –** **obligate intracellular. Small, gram-negative**. Has ENDOSPORE ABRUPT high fever, HA, myalgias. Fevers and sx last through duration of illness. May have mild PNA or rapidly progress to respiratory distress. Hepatitis with no jaundice, can cause acute endocarditis, maculopapular rash. Leukocytosis and thrombocytopenia. Think shepherds, farmers, cattle birthers.

Question 61

flu symptoms, rapid antigen detection, 8 segmented RNA.

Answer 61

Orthomyxovirus – flu symptoms, rapid antigen detection, 8 segmented RNA.

Question 62

fevers, HA, Aseptic meningitis (possible meningeal signs), severe myalgias. Hepatitis with jaundice, enal failure with nephritis, subconjunctival hemorrhage. Rodents, cattle, horses, sheep goats – watch out for aborted animals

Answer 62

**Leptospirosis** – spirochete. HIGH fevers, HA, Aseptic meningitis (possible meningeal signs), severe myalgias. Hepatitis with jaundice, renal failure with nephritis, subconjunctival hemorrhage. Rodents, cattle, horses, sheep goats – watch out for aborted animals!

Question 63

gram negative, intracellular, endospore. HIGH fevers (don’t relent), HA, myalgias. Mild PNA or respiratory distress. Hepatitis with NO jaundice! Leukocytosis and thrombocytopenia.

Answer 63

**Coxiella burnetti** – gram negative, intracellular, endospore. HIGH fevers (don’t relent), HA, myalgias. Mild PNA or respiratory distress. Hepatitis with NO jaundice! Leukocytosis and thrombocytopenia. Shepherds, cattle birthers, etc

Question 64

**gram negative aerobic** **abrupt onse**t of nonspecific sx: fevers, chills, HA, abdominal pain, diarrhea. **Ulceroglandular ds** – most common. Single lesion at a **tick bite** site with a **central eschar** with assc. **Adenopathy**.-pleural effusions with different opacification patterns.

Answer 64

**Francisella tularensis** – gram negative aerobic. abrupt onset of nonspecific sx: fevers, chills, HA, abdominal pain, diarrhea. Ulceroglandular ds – most common. Single lesion at a tick bite site with a central eschar with assc. Adenopathy. Pulmonary tularemia - pleural effusions with different opacification patterns. See next slide.

Question 65

no cell wall abrupt HA, dry cough, myalgias, dyspnea. CXR – indistinguishable from many bacterial and viral PNA. Can have epistaxis and splenomegaly.

Answer 65

**Chlamydia psittacosis** **–** obligate intracellular, gram negative, no cell wall. Reservoir – birds. Can see with pet shop owners and vets, ducks, turkeys. Obtain – inhaled bird feather dust, infected feces. Sx: abrupt HA, dry cough, myalgias, dyspnea. CXR – indistinguishable from many bacterial and viral PNA. Can have epistaxis and splenomegaly. History is paramount!

Question 66

obligate intracellular, no cell wall, EB (infectious aspect!!) and RB, follows URI, HOARSNESS.

Answer 66

Chlamydia pneumoniae – obligate intracellular, no cell wall, EB (infectious aspect!!) and RB, follows URI, HOARSNESS.

Question 67

no cell wall, bullous myringitis, cold agglutinins, generally follows URI.

Answer 67

Mycoplasma pneumoniae – no cell wall, bullous myringitis, cold agglutinins, generally follows URI.

Question 68

generally ELEVATED in bacterial infections

Answer 68

Procalcitonin = generally ELEVATED in bacterial infections

Question 69

Neutropenic and Cystic Fibrosis

Answer 69

Neutropenic and Cystic Fibrosis – Pseudomonas

Question 70

Asplenic

Answer 70

Asplenic (susceptible to encapsulated organisms) – Klebsiella, S. pneumoniae, H. influenzae, Nisseria sp,

Question 71

Smokers, COPD

Answer 71

Smokers, COPD – Moraxella, H. influenzae

Question 72

Alcoholics

Answer 72

Alcoholics – Klebsiella

Question 73

S/P influenza –

Answer 73

S/P influenza – S. aureus

Question 74

Bird handlers

Answer 74

Bird handlers – C. psittaci

Question 75

Animal breeders (incl. vets)

Answer 75

Animal breeders (incl. vets) – Coxiella burnetti (Q fever)

Question 76

Hunters, Rabbit Exposure, Lawn Care

Answer 76

Hunters, Rabbit Exposure, Lawn Care – Francisella tularensis

Question 77

Sputum characteristics: Rust colored

Answer 77

Rust colored: S. pnuemoniae

Question 78

Sputum characteristics: Salmon colored

Answer 78

Salmon colored: S. aureus

Question 79

Currant jelly colored sputum

Answer 79

Currant jelly colored: K. pneumoniae

Question 80

Possibly green tinged sputum

Answer 80

Possibly green tinged: P. aeruginosa

Question 81

Foul-smelling sputum

Answer 81

Foul-smelling: anaerobes

Question 82

Answer 82

abscess: CAVITATION WITH AIR FLUID LEVEL

Question 83

Answer 83

interstitial pneumonia

Question 84

Answer 84

lobar pneumonia