Pneumonia and Tuberculosis

Question 1

How does a Ghon Complex form from a Ghon Focus?

Answer 1

Following invasion of nearby lymph nodes

Question 2

How does a Ranke complex form from a Ghon Complex?

Answer 2

Via fibrosis and calcification

Question 3

What type of Hypersensitivity Reaction is associated with the Inflammatory changes in Tuberculosis?

Answer 3

Type 4 Hypersensitivity

Question 4

Discuss the microbiology of Tuberculosis

Answer 4

Rod shaped, aerobic bacilli with a mycolic acid cell wall. Acid fast, thus stains red on a Ziehl Neelson stain

Question 5

Why does TB commonly affect the upper lobes of the lung?

Answer 5

More aerobic conditions in upper lobes

Question 6

How can Miliary TB affect the brain, kidneys, liver, lymph nodes, adrenal glands and lumbar vertebrae?

Answer 6

Brain - Meningitis
Kidneys - Sterile pyuria
Liver - Hepatitis
Lymph Nodes - Cervical Lymphadenopathy (Scrofula)
Adrenal Glands - Addison's Disease
Lumbar Vertebrae - Pott's Disease

Question 7

Why might the Interferen Gamma release assay be preferred over the Mantoux test?

Answer 7

Is more specific to TB, and is unlikely to be positive from BCG vaccine

Question 8

What are some symptoms of TB?

Answer 8

Coughing >3 weeks, Haemoptysis, Chest pain, Unintentional weight loss, Fatigue, Fever, Night sweats, Chills

Question 9

What are some reasons for false negatives on the Mantoux Test?

Answer 9

Miliary TB, Sarcoidosis, HIV, Lymphoma

Question 10

What is the treatment for Active Tuberculosis?

Answer 10

RIPE (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) for 2 months, followed by RI for 4 months

Question 11

What is the treatment for Latent Tuberculosis?

Answer 11

3 months of RIP (Rifampicin, Isoniazid, Pyrazinamide) or 6 months of IP

Question 12

Give examples of sets of patients who may be indicated for Directly Observed Treatment (DOT)?

Answer 12

• Homeless people with TB
• All prisoners with TB
• TB Patients with poor compliance

Question 13

What is the main X-Ray finding in patients with Pneumonia?

Answer 13

Lung consolidation (lungs filled with liquid > air)

Question 14

Discuss the elements of the CURB-65 screening tool for Pneumonia in community

Answer 14

C: Confusion (< 8/10 on Mental Test Score)
R: Respiratory Rate (>30/min)
B: Blood Pressure (<90/60 mmHg)
65: Age (>65)

If 0 -> Manage in Community
If 1 -> Assess O2 sats and perform CXR. O2 should be >92% and CXR should be normal. If abnormal -> hospital
If 2 -> Hospital

Question 15

What addition is added to CRB65 in assessing patients for Pneumonia when they are in hospital?

Answer 15

CURB65

U: Urea (>7mmol/L)

Question 16

What is the most common cause of Community Acquired Pneumonia? What type of pneumonia picture does it cause?

Answer 16

Streptococcus Pneumoniae (80% of cases)
Lobar pneumonia

Question 17

Which bacteria causing pneumonia is associated with COPD patients?

Answer 17

Haemophilus Influenzae

Question 18

State three causes of Atypical Pneumonia? What makes these bacteria atypical?

Answer 18

Mycoplasmia pneumonae
Chlamydophila pneumoniae
Legionella pneumoniae

Atypical because they do not have a cell wall

Question 19

Which bacteria causing pneumonia is associated with alcoholics and diabetics? What is the characteristic finding on CXR? What is the characteristic sputum description

Answer 19

Klebsiella pneumoniae
On CXR: Cavitation of Upper Lobes
Red currant jelly sputum

Question 20

Which fungi causing pneumonia is associated with immuno-compromised patients?

Answer 20

Pneumocystis jiroveci

Question 21

Outline the Point-of-care CRP test used for patients with pneumonia

Answer 21

If CRP <20 = do not give ABX
If CRP 20-100 = consider delayed ABX
If CRP >100 = give ABX

Question 22

What is the treatment for community acquired pneumonia with a CURB65 score < 1?

Answer 22

5 days of Amoxicillin or Macrolide ABX

Question 23

What is the treatment for community acquired pneumonia with a CURB65 score < 3?

Answer 23

7-10 days of Amoxicillin + Macrolide ABX

Question 24

State the four stages of Pneumonia

Answer 24

1. Congestion
2. Red Hepatisation
3. Grey Hepatisation
4. Resolution

Question 25

What is the risk of mortality in pneumonia patients with CRB-65 scores of 0, 1 - 2 and 3 - 4?

Answer 25

0: low risk (less than 1% mortality risk) 1 or 2: intermediate risk (1‑10% mortality risk) 3 or 4: high risk (more than 10% mortality risk)

Question 26

What skin lesions are commonly associated with Community Acquired Pneumonia?

Answer 26

Herpes Labialis

Question 27

What is the treatment for community acquired pneumonia with a CURB65 score > 3?

Answer 27

7-10 days of Coamoxiclav or | 7-10 days of Macrolide and Cefuroxime

Question 28

Most Non-tuberculous Mycobacteria (NTM) which are bacteria that can't cause TB but can cause respiratory disease is due to what?

Answer 28

Myocobacterium avium

Question 29

PNEUMONIA 1. Which is the most common cause? 2. Which one is associated with COPD? 3. Which one is associated with HIV? 4. Which one is associated with children? 5. Which one is associated with parrots? 6. Which one is associated with animals? 7. Which one is associated with influenza? 8. Which one is associated with hyponatremia? 9. Which one is associated with cold sores? 10. Which one is associated with Erythema Multiforme? 11. Which one is associated with alcoholics and diabetics? 12. Which one is associated with cystic fibrosis? 13. Haemophilus influenza is associated with? 14. Staph aureus is associated with? 15. Strep pneumonia is associated with? 16. Pneumocystis jiroveci is associated with? 17. Klebsiella is associated with? 18. Legionella is associated with? 19. Mycoplasma is associated with? 20. Chlamydia is associated with? 21. Coxiella burnetii is associated with? 22. Chlamydia psittaci is associated with? 23. What are the atypical causes of pneumonia? Why are they atypical? 24. Discuss the CURB-65 assessment 25. Discuss what the actions are for the scores 26. Discuss the CRP point of care test and score 27. What are some investigations for patients with suspected pneumonia? 28. What is the treatment for mild CAP? 29. What is the treatment for mod / severe CAP? 30. What is the treatment for pneumocystis jiroveci? 31. What are treatment options for atypical pneumonias?

Answer 29

1. Strep pneumoniae 2. Haemophilus influenzae 3. Pneumocystis jiroveci 4. Chlamydophila pneumonia 5. Chlamydia psittaci 6. Coxiella burnetti 7. Staph aureus 8. Legionella pneumoniae 9. Strep pneumoniae 10. Mycoplasma pneumoniae 11. Klebsiella pneumoniae 12. Staph aureus, pseudomonas aueriginosa 13. COPD 14. Influenzae 15. Cold sores 16. HIV, CD4 < 200 17. Alcoholics, diabetics 18. Hyponatraemia, deranged LFTs, air conditioning 19. Erythema multiforme 20. Children 21. Q fever, infected animals 22. Parrots 23. Legions of ptsitacci MCQs (Legionella, Psitacci, Mycoplasma, Chlamydia, Q fever / Coxiella) 24. Confusion (8/10), Urea >7, RR >30, BP <90/60 25. 0 = consider home treatment, 1-2 = hospital admission, 3 = ICU assessment 26. If <20 = no ABX, 20-100 = delayed prescription, >100 = immediate ABX 27. Basic Obs, resp exam, COVID-19 test, FBC (neutrophillia), U&Es (hyponatraemia), CRP, ABG (type 1 rep failure), Sputum culture, CXR 28. 5 day course Amoxicillin 29. 7-10 day course Amoxicillin + Macrolide 30. co-tramoxazole 31. macrolides, fluoroquinones, tetracyclines

Question 30

TUBERCULOSIS 1. What is the main investigation to SCREEN for latent TB? 2. What investigations can diagnose ACTIVE TB? What would you find? 3. Outline how the Mantoux test is performed 4. Side-effect of Rifampicin? 5. Side-effect of Isoniazid? 6. Side-effect of Pyrazinamide? 7. Side-effect of Ethambutol? 8. Which test is very important before beginning TB therapy? 9. What is the management for Active TB? 10. What is the management for Latent TB? 11. What should be co-prescribed with Isoniazid, why? 12. What are the features of TB?

Answer 30

1. Mantoux test 2. CXR: Upper lobe cavitation, bilateral hilar lymphadenopathy. Sputum smear, red for Ziehl-Neelsen Stain, Sputum culture for drug sensitivities, NAAT 3. 0.1ml of 1/1000 PPD (Purified Protein Derivative) is injected intradermally. The size of induration is then measured 2-3 days later. < 6 mm = Negative. 6 - 15 mm = Positive. > 15 mm = Strongly Positive 4. Hepatitis, orange secretions, liver enzyme inducer 5. Hepatitis, Peripheral neuropathy, liver enzyme inhibitor 6. Hepatitis, GOUT 7. Optic neuritis 8. LFTs, visual acuity 9. 2 months of RIPE, followed by 4 months of RI 10. 3 months of RI, or 6 months of I 11. Pyridoxine, to reduce likelihood of peripheral neuropathy 12. Cough +/- haemoptysis, night sweats, lymphadenopathy, weight loss