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Pulmonology > Nichols Doc > Flashcards

Nichols Doc Flashcards

1
Q

Infiltrate

A

The term for a radiologic manifestation of pneumonia or edema or hemorrhage

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2
Q

Consolidation refers to

A

manifestations of alveoli filled with with water, blood, pus

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3
Q

Most types of pneumonia start how?

A

acute inflammation due to neutrophil prescence

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4
Q

Most types of pneumonia go on to the subacute phase around the 3 day mark when…

A

macrophages replace neutrophils….Think of Macrophages as the garbage clean-up of the cell.

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5
Q

Alveolar non-necrotizing pneumonia is most commonly due to what>

A

Strep Pneumo, Legionella, or Mycoplasma

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6
Q

Alveolar necrotizing pneumonia is often due to>

A

Staph aureus, Klebsiella, Pseudomonas

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7
Q

Strep Pneumo stains what and look like what

A

Gram positive (purple) Lancet shaped diplococci

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8
Q

Pneumolysin is a virulence factor for which bug and what does it do>

A

Strep Pneumo, It binds to cholesterol in cell membranes and forms pores at that area. The cells it binds to are erythrocytes and leukocytes.
ALSO…It is the reason that sputum in Strep Pneumo is rusty, the pneumolysin lyses red blood cells and the iron is absorbed into the sputum and coughed up

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9
Q

Four phases of Pneumococcal Lobar Pneumonia: Gross Path

A

Congestion: Serous, frothy, blood tinged fluid in alveoli
Red Hepatization: Days two and 3
Grey Hepatization: Day 4-7
Resolution- Day 8

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10
Q

Microscopic Pathology of Pneumococcal Pneumonia

A

Phase 1- Engorged Septal capillaries, edema fluid, bacteria,
Phase 2- Continuing Congestion, extravasation of red cells, infection spreading through pores of kohn
Phase 3- degenerating dead cells, fibrin nets through pores of kohn, foamy macros

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11
Q

Symptoms of strep pneumo in younger ppl

A

single severe shaking chill (rigor), fever, cough with RUSTY SPUTUM, pleuritic chest pain

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12
Q

Symptoms of pneumococcal strep pneumo in older ppl

A

confused, tired, cold, may not have cough or fever

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13
Q

Signs of strep pneumo

A

Fever, Tachypnea, pulmonary Rales, dullness to percussion, chest x-ray shows lobar consolidation.

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14
Q

In what % of strep pneumo cases is a blood culture positive

A

Less than 25%.

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15
Q

Urine test for strep pneumo

A

Pretty good

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16
Q

Treatment for strep pneumo

A

Any beta lactam

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17
Q

Microbiology of Legionella

A

gram neg

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18
Q

Pathogenesis of LEgionella

A

Live in warm water. Can hide inside amoeba. Once they are inhaled or aspirated they attach to respiratory epithelium by pili or flagella. After they are phagocytosed they prevent phagosome lysosome fusion.

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19
Q

Gross pathology of Legionella

A

Bulging Firm rubbery area of consolidation

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20
Q

What is unique about the microscopic pathology of Legionella

A

Tons of macrophages early on.

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21
Q

SYmptoms of Legionella

A

Chills, rigor, high fever, dyspnea, headache, DIARRHEA, myalgia, chest pain. GI symptoms suggest Legionella

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22
Q

Neurologic signs that suggest Legionella

A

confusion

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23
Q

Blood test results that suggest Legionella

A

hyponatremia (sodium less than 130)

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24
Q

Best way to test for legionella

A

Urine test….they wont grow on gram stain, you can sometimes see them on Dieterle stain but its hard to differentiate them from debris

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25
Q

Treatment of Legionella

A

Newer macrolides (azithromycin) or quinilones (levlofloxacin)

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26
Q

When is Mycoplasma most common

A

Fall and winter

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27
Q

If a bunch of high school kids or college kids get a walking pneumonia, it is most likely

A

Mycoplasma

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28
Q

What do Mycoplasma Pneumoniae look like on Gram stain

A

Invisible

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29
Q

Microscopic pathology to note for mycoplasma

A

Alveolar type 2 hyperplasia

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30
Q

Symptoms of mycoplasma to note

A

headache, anorexia, malaise, dry cough!!!

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31
Q

Signs to note for mycoplasma

A

maculopapular skin rash

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32
Q

Treatment

A

Azithromycin or levofloxacin

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33
Q

Staph Aureus risk factors

A

staph skin infection, nursig home residence, recent hospitalization, endotracheal intubation

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34
Q

Virulence factors for staph aureus

A

exotoxins, protein A which binds to TNF receptor and opens up a path for invasion, drug resistance

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35
Q

Gross path for staph aureus

A

PLUM COLORED LUNGS, BLOODY FLUID COMES OUT ON SECTIONING< MANY SMALL ABCESSES, some pleuritis and effuision

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36
Q

Symptoms of staph

A

cough comes on late, dyspne, fever, chills

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37
Q

Diagnosis

A

Gram stain, look for leukocytosis on CBC

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38
Q

Treat staph with

A

oxacillin for meth sensitive or vancomycin for mrsa

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39
Q

Pseudomonas mostly always affects patients who are where?

A

Hospital

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40
Q

Pathogenesis of Pseudomonas

A

once ingested it attaches to resp epithelium. Resistant to many common ABs

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41
Q

Virulence of Pseudomonas

A

Resistant to many abs, forms a biofilm,

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42
Q

Gross pathology of pseudomonas to note

A

firm red areas of hemorrhagic consolidation +/- yellow areas of consolidation with hemorrhage

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43
Q

Microscopic path to note for pseudomonas

A

acute necrotizing alveolitis, with long thin bacili invading blood vessels.

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44
Q

Symptoms for pseudomonas

A

Productive cough, confusion, dyspnea, fever chills,

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45
Q

Helpful hints for Dx of pseudomonas

A

Look for long thin gram negative bacilli with pointed ends. Culture should have a sweet grape like odor

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46
Q

Treat pseudomonas with

A

a beta lactam that works and a quinilone

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47
Q

Major risk factor for TB

A

HIV

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48
Q

other TB risk factors

A

Man, poor, black, Spring time, Elderly

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49
Q

What are the four possible outcomes after inhalation

A

1) Clearance 2) Primary Infection 3) Latent infection 4) Reactivated infection

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50
Q

Gross Pathology

A

Caseating granuloma, Gray-white, central necrosis

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51
Q

What is a ghon foci

A

1.5 cm gray white caseating granuloma with central necrosis

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52
Q

What is a ghon complex

A

A ghon foci with hilar lymph node involvement

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53
Q

Microscopic pathology of TB

A

Multinucleated giant cells with a lymphocyte collar, few dark red beaded bacili on acid fast stain. Sometimes neutrophilic necrotizing pneumonia

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54
Q

Symptoms to note for TB

A

night sweats, anorexia, wt. loss, fever, VERY FEW RESPIRAOTRY Symptoms. May have mild cough with hemoptysis

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55
Q

Diagnosis of TB

A

chest x ray showing consolidation of upper lobes. Chest x-ray and acid fast culture should get you where you need to go.

56
Q

What is one giveaway for TB

A

Pneumonia associated with hilar lymphadenopathy

57
Q

Treat for TB

A

RIPE for 8 weeks, RI for 18

58
Q

TB wanna-be

A

Histoplasmosis

59
Q

Most Histoplasmosis infections are mild, but some can be severe under what circumstances

A

AIDS, immunosuppresion therapy for transplants

60
Q

Pathogenesis of histo

A

Inhalation, bat crap and chicken crap. Much like TB, the spores get into the alveoli, are phagocytosed but not killed nless they are activated by T cells which have had antigen presented to them. Granulomas form.

61
Q

Symptoms of histoplasmosis

A

Fever, chills cough, anorexia, SUBSTERNAL CHEST PAIN THAT IS WORSE ON INHALATION

62
Q

Diagnosis of histo

A

biopsy, culture, antigen test. Biopsy can yield definite diagnosis, culture takes up to 6 weeks

63
Q

Treatment of histo

A

itraconazole for mild-moderate, amphotericin for severe

64
Q

Aspergillus pneumonia

A

remember 45 degree branching septate hyphae

65
Q

Classic triad of aspergillous symptoms

A

fever, pleuritic chest pain, hemoptysis

66
Q

Diagnosis of aspergillous

A

Biopsy, culture, serum test for galactomannan

67
Q

Be sure to differentiate aspergilous pneumonia from aspergillous colonization and allergic bronchopulmonary aspergillosis

A

ok

68
Q

Cryptococcal pneumonia comes from

A

Cryptococcus fungi

69
Q

Is cryptococal pneumonia common?

A

No way….seen rarely in AIDS pts, or other immunosuppresed pts. Never in children. More common in blacks

70
Q

DX of cryptococcus

A

Culture is fast and easy on standard media. takes less than 48 hours. Serum antigen test is pretty easy in folks with immunodeficiency

71
Q

What percentage of lung cancers develop in active or recently active smokers

A

85%

72
Q

The three major types of lung cancer

A

small cell 15%, squamous cell 20%, adenocarcinoma 40%

73
Q

adenocarcinoma

A

malignant epithelial tumor with glandular features

74
Q

Most common mutation in adenocarcinoma

A

KRAS

75
Q

5 Patterns of adenocarcinoma

A

Acinar (making glands), papillary, micropapillary (bad prognosis), solid (also bad), lepidic (spreading within alveoli better prognosis).

76
Q

Treatment of adenocarcioma

A

surgery ir early stage, erlotinib (for EGFR mutation)

77
Q

Adenocarcinoma is the most likely cancer to be responsive to targeted therapy

A

truth

78
Q

bronchioalveolar carcinoma is now called

A

adenocarcinoma in Situ

79
Q

Adenocarcinoma in situ is cahracterized by what?

A

non-destructive growth along intact alveoloar septa

80
Q

Two types of adenocarcinoma in situ

A

mucinous and non-mucinous

81
Q

Non-mucinous found predominantly in who and characterized by what

A

smokers, ground glass, EGFR mutation, evolves from terminal respiratory unit (type II pneumocytes and Clara Cells)

82
Q

Mucinous

A

Evolves from broonchiolar epithelium, commonly presesnts as pneumonia type infiltrate on x-ray, KRAS mutation

83
Q

Symptoms of adenocarcinoma in situ

A

Most have none. If they do have symptoms though, they often mimic pneumonia with productive cough

84
Q

How is adenocarcinoma in situ diagnosed?

A

Discovered on radiology (nodules frequently have ground glass appearance) but a biopsy or cytology needed for actual diagnosis.

85
Q

Treatment of Adeno in situ

A

surgical resection, if inoperable: Erlotinib for EGFR positive tumors, Paclitaxel for EGFR negative

86
Q

What paraneoplastic syndrome might squamous cell carcinoma cause

A

Hypercalcemia due to production of a parathyroid hormone like substance

87
Q

Where does sqquamous cell carcinoma arise>

A

2/3 aris from main, lobar, segmental, or subsegmental bronchi….centrally

88
Q

What type of lung cancer is most likely to cavitate

A

squamous

89
Q

Squamous is also associated with these other complications

A

post-obstructive pneumonia, mucous lugging, abcess, bronchiectasis.

90
Q

Symptoms of squamous cell carcinoma

A

cough with hemoptysis, dyspnea, weight loss, anorexia

91
Q

Major mode of diagnosis for squamous cell

A

H&E stain of biopsy,

92
Q

Most common gene mutation in squamous cell

A

k63,, nearly 100%

93
Q

What is the most aggressive lung cancer type

A

Small cell carcinoma

94
Q

Where is small cell carcinoma typically located

A

Central, parabronchial, multifocal necrosis and metastatic tumor in lymph nodes and liver, bones, brain, adrenal

95
Q

Signs of small cell carcinoma

A

facial, cervical, arm edema. Venous engorgement, Pemberton’s sign= development of facial flushing

96
Q

Diagnosis

A

H&E stain biopsy

97
Q

Primary sites of lung metastases

A

breast, colon, stomach

98
Q

Gross path of metastatic lung cancer

A

small, numerous (generally smaller than primary neoplasms), rounder, more evenly contoured, generally peripheral and not endobronchial

99
Q

Larger cannonball metastases most commonly from

A

breast

100
Q

What is lymphangitic carcinomatosis

A

When metastatic disease fills lymphatics and infiltrates interstitium without creating masses

101
Q

Diagnosis

A

radiology detects them but biopsy is required because fungal, mycobacterial and autoimmune diseases have similar appearances

102
Q

What are some risk factors for pulmonary embolism that you are likely to forget

A

oral contrceptives, ptregnancy

103
Q

Do small emboli usually cause infarction>

A

generally not because of dual blood supply

104
Q

What about intermediate emboli

A

Can cause infarction if bronchial circulation is poor

105
Q

Large emboli

A

Can cause saddle embolus where the block the pulmonary trunk. may cause cor pulmonale and immediate death

106
Q

Pneumocystis jirovecii is what type of microorganism

A

fungus

107
Q

Pneumocystis jirovecci most commonly infects what type of pts

A

AIDS…its an opportunistic bacteria. The prototype pneumonia in immunocompromised pts

108
Q

Characteristics of pneumocystis infection?

A

Heavy consolidation

109
Q

Symptoms of pneumocystis

A

insidious onset of progressive dyspnea, cough, fever

110
Q

Signs of pneumocystis

A

Elevated LDH. decreased diffusion capacity

111
Q

DX of pneumocystis

A

detection of bug in sputum stains, immunostains (regular method)cyst stains such as methenamine silver

112
Q

Treatment of Pneumocystis

A

Trimethorphim

113
Q

Prognosis

A

93% survival in AIDS pts

114
Q

Most common presentation of pulmonary embolism

A

Dyspnea

115
Q

Fat embolism is what?

A

globules of fat travelling in the vascular circulation

116
Q

Fat embolism syndrome features

A

hypoxemia, neurological impairment and petechial rash (1-3 days after trauma)

117
Q

fat embolism most commonly follows

A

single long bone fractures and bilateral femoral fractures

118
Q

Symptoms of fat embolism

A

dyspnea, confusion

119
Q

DX:

A

Be sure there is arterial hypoxemia, cerebral dysfunction, skin rash.

120
Q

Air embolism

A

gas present in circulation

121
Q

How does it happen

A

most common is the disconnection or breakage of vascular catheterization, keeping the pt upright when inserting catheter, deep inspiration during inertion or removal, surgery with an opening higher than the heart, traumatic blod vessel rupture,

122
Q

Symptoms of air embolism

A

dyspnea, sense of impending doom, lightheadedness or dizzines

123
Q

signs of air embolism

A

gasp or cough when air enters pulmonary circulation, mill wheel heart murmur, tachypnea, tachycardia,

124
Q

Acute lung injury

A

non-cardiogenic pulmonary damage manifested by edema with an inflammatory or fibrosing response

125
Q

Characteristics of acute lung injury

A

starts as interstitial edema which moves into alveolus. It is due to dysregulated inflammation. Increased permeability of microvascular barriers leads to extravascular accumulation of protein rich fluid.

126
Q

Histologic hallmark of the exudative phase of acute lung injury

A

alveolar hyaline membranes

127
Q

Histologic hallmark of proliferative phase

A

chronic interstitial inflammation

128
Q

PaO2/FiO2 over 200

A

needs to be presesnt

129
Q

What is radiation pneumonitis

A

acute lung injury occuring 1-2 mths after radiation

130
Q

micropathology of radiation pneumonitis

A

atypical type 2 pneumocyte hyperplasia and blood vessel injury

131
Q

Viral pneumonia tends to be interstitial

A

true

132
Q

Influenza and RSV are the most common viral pneumonias

A

true

133
Q

Cytomegalovirus causes interstitial pneumonia in immunocompromised pts.

A

true

134
Q

Foamy Macrophages are characteristic of which time frame of bacterial pneumonia

A

subacture (day 3 and after)

135
Q

Pneumococcal Pneumonia typically causes an alveolar exudate that is rich in what?

A

FIbrin

136
Q

For Legionella think ADAM….

A

He is in a warm pool, in an amoeba brand swimsuit, firm, bulging, rubbery mass, confused, shitting himself, with low sodium (salt rings around lips) AT THE SPORTSPLEX

137
Q

Staph Chest x-ray findings

A

Alveolar consolidation in a bronchopneumonic pattern, rapidly progressive- bilateral- multilobar abscesses and pleural effusions

Pulmonology (41 decks)

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