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Flashcards in Pneumonia (Nichols) Deck (88):
1

Basic pneumonia definition:

inflammation of lung

2

Almost all acute bacterial pneumonias are _______ before they become pneumonia, and may center around ____ early on

multifocal bronchitis
bronchi

3

Almost all acute bacterial pneumonias
are due to:

aspiration of saliva containing pathogen
(note: term "apiration pneumonia" = gastroesoph contents)

4

Infiltrate = radiologic manifestation of:

pneumonia, edema or hemorrhage --blood, pus or water
(Not Specific)

5

Consolidation = radiologic or phys exam manifestation of:

alveoli filled with blood, pus or water
(Not Specific!!)

6

Most types of pneumonia start with:

acute inflammation (neutrophilic infiltration)

7

What are characteristic of subacute bacterial pneumonia?

foamy macrophages
(subacute = macrophages replacing neutrophils--garbage collectors replacing first responders-- starting about day 3)

8

ALVEOLAR NON-NECROTIZING
Acute Bacterial Pneumonia

Pneumococcus
Legionella
Mycoplasma

9

ALVEOLAR NECROTIZING
Acute Bacterial Pneumonia

Staph aureus
Pseudomonas
Klebsiella

10

INTERSTITIAL NON-NECROTIZING
Acute Bacterial Pneumonia

Mycoplasma

11

Most commonly identified agent of community-acquired pneumonia:
Who is the typical patient?

Streptococcus pneumoniae (“pneumococcus”)

older adults with smoking, COPD, alcoholism, preceding viral infection, etc.

12

Pneumococcus stage 1
Gross?
Micro?

day 1:

G--congestion with exudation of serous and frothy, blood-tinged fluid into alveoli

M--engorged septal capillaries, with a few erythrocytes, edema fluid and bacteria in alveoli

13

Pneumococcus stage 2
Gross?
Micro?

days 2-3:

G--red hepatization with drier, granular, dark red consolidation (~ liver)

M--continuing congestion, extravasation of red cells and numerous neutrophils and abundant fibrin in alveoli, infection spreading through pores of Kohn into adjacent alveoli

14

Pneumococcus stage 3
Gross?
Micro?

days 4-7:

G--grey hepatization with continuing consolidation, but color change to grey

M--degenerating dead cells (neuts, RBC, sloughed pneumocytes and bacteria) in the alveoli; fibrin nets extending through pores of Kohn; foamy macrophages replace neutrophils

15

Pneumococcus stage 4
Gross?

day 8 and following: slimy yellowish exudate, resolution without scarring

16

Pneumococcus symptoms?

fever
cough productive of purulent, blood-tinged (“rusty”) sputum

17

Pneumococcus signs?

fever, tachypnea, pulmonary rales and tubular breath sounds, dullness to percussion

18

Pneumococcus CXR
Rare?
Common?

lobar alveolar consolidation with air bronchograms (rare)

segmental or subsegmental alveolar infiltrates without air bronchograms (common)

19

Pneumococcus diagnostic test results?

G+ sputum with lancet-shaped encapsulated diplococci
Urine antigen test

20

STAPHYLOCOCCUS AUREUS PNEUMONIA
Gross pathology?

heavy plum-colored lungs
>exude bloody fluid on sectioning
>develop numerous small abscesses

21

STAPHYLOCOCCUS AUREUS PNEUMONIA
Micro pathology?

-aggregates of bacteria
-acute bronchitis (necrotizing)
-alveolitis and bronchiolitis + abundant degenerating neutrophils, fibrin, edema fluid, hemorrhage and evolving abscesses

("a b" x3)

22

STAPHYLOCOCCUS AUREUS PNEUMONIA
CXR?

areas of alveolar consolidation in a bronchopneumonia pattern

more commonly than other acute pn: severe, bilateral, abscesses, pleural effusions

23

Staph aureus pneumonia is characteristically:

abscessing

24

When is a lung abscess drained?

it isn't, unless it becomes an empyema

25

How do you isolate Staph aureus cultures?

primarily seen in stains of microbiology laboratory cultures
NOT clinical specimens of pus, sputum, etc.

26

Where would you find legionella?

hide inside amoebae in warm water
(water heaters, shower heads, air conditioners...)

27

LEGIONELLA PNEUMONIA
gross?

bulging firm red or tan areas of consolidation

28

LEGIONELLA PNEUMONIA
micro?

1. acute non-necrotizing alveolitis
2. early infiltration by numerous macrophages + neutrophils

(once subacute > all macrophages)

29

LEGIONELLA PNEUMONIA
symptoms?

cough
high fever, chills, rigors
dyspnea
headache
diarrhea
confusion
myalgia
CP

30

LEGIONELLA PNEUMONIA
signs?

pulmonary rales, relative bradycardia

31

LEGIONELLA PNEUMONIA
CXR?

initially unilateral bronchopneumonic (alveolar) infiltrate
progresses (in 50%) to pleural effusion

32

LEGIONELLA PNEUMONIA
high yield dx tests?

urine antigen
CBC: leukocytosis, thrombocytopenia
Urinalysis: hyponatremia, azotemia,
liver dysfunction
(must culture on special charcoal medium)

33

What are the 3 legionella tip-off?

diarrhea, confusion, hyponatremia

34

PSEUDOMONAS AERUGINOSA PNEUMONIA
gross?

firm red areas of hemorrhagic consolidation

+/- yellow areas of consolidation with a rim of hemorrhage (target lesions)

35

PSEUDOMONAS AERUGINOSA PNEUMONIA
micro?

>acute necrotizing alveolitis
>Pseudomonas vasculitis (bac invading blood vessels from the adventitia) with associated infarction/hemorrhage

36

MYCOPLASMA PNEUMONIA usually affects?

children and young adults
(95% only have URI)

37

MYCOPLASMA PNEUMONIA
micro?

-lymphoplasmacytic bronchiolitis with ulceration
-neutrophils & fibrin in the lumen
-lymphoplasmacytic interstitial pneumonitis
extending out from the bronchiolitis

38

MYCOPLASMA PNEUMONIA
symptoms?

insidious onset of malaise
headache
low-grade fever and chills

followed by **persistent intractable dry cough, pharyngitis, +/- coryza, +/- otitis

39

MYCOPLASMA PNEUMONIA
lab test?

cold agglutinins, titer >1:64

40

MYCOPLASMA PNEUMONIA
CXR?

patchy areas of consolidation or reticulonodular infiltrate

(pl effusion in 20%)

41

Classic mycoplasma pneumonia scenario?

“walking pneumonia”, outpatient young person with a persistent cough and a chest x-ray looking much worse than the patient

42

Primary TB
symptoms?

low-grade fever
(occasionally) chest pain
(rarely) dyspnea from lymph nodes pressing on airways

43

What controls primary TB?

type IV immune response

44

What are Ghon complexes?

1. caseating granuloma lesions, usually peripheral and mid lung (primary TB)
2. enlarged hilar lymph nodes

45

Describe typical reactivation of TB?

-UL
-frequently cavitating

46

Characteristic host response to TB?

caseating granuloma with Langhans type giant cells

47

TB diagnosis occurs via...

culture with PCR

48

TB gross?

tuber lesions + caseation

49

Histoplasmosis is normally from...

fecal-enriched soil in caves, chicken coops in
Mississippi (and Ohio) river valleys

50

Histoplasmosis looks like:

small yeast
(many within phagocytes)

51

Histoplasmosis host response?

caseating granulomatous (if immunocompetent)

52

Histoplasmosis has many similarities to:

TB

53

Histoplasmosis, radiologically?

nodules or masses
(note: these resemble lung CA!)

54

Histoplasmosis, gross pathologically?

nodules or masses
(note: these resemble rheumatoid nodules or old TB granulomas!)

55

How can you tell if a granuloma = Histo?

Methenamine silver stains
(sometimes)

56

Histoplasmosis, microscopically?

alveolar infiltrate of lymphocytes and macrophages, which contain histoplasmosis

57

ASPERGILLOSIS, transmission?

airborne transmission, not contagious

58

ASPERGILLOSIS
3 forms of disease?

1. allergy
2. colonization
3. invasion (lung nodules or masses; occurs with corticosteroids, immunosuppression, etc)

59

ASPERGILLOSIS
symptoms?

fever
hemoptysis
pleuritic CP
(cough, dyspnea)

60

ASPERGILLOSIS
microscopically?

regular septate hyphae with dichotomous acute angle branching
-invades bronchus

61

What is particularly bad about the progression of ASPERGILLOSIS infection?

angioinvasive = causes hemorrhage and infarction

62

Diagnostic tests for Aspergillosis?
What would confirm the dx?

1. serum test for galactomannan (limited usefulness)
2. culture or biopsy (also not awesome)

Aspergillus fruiting body

63

CRYPTOCOCCUS
Where do you find this?

yeast found in soil and pigeon poop

64

CRYPTOCOCCUS
transmission?

airborne transmission, not contagious

65

CRYPTOCOCCUS
Most common form of infection?
Second most common?

1. meningitis
2. lung nodules/masses
(occ. interstitial pneumonia)

66

CRYPTOCOCCUS
Primary virulence factor?

anti-phagocytic capsule

67

CRYPTOCOCCUS
Primary host defense?

cell-mediated immunity
macrophage response, sometimes with discrete granulomas or giant cells

68

CRYPTOCOCCUS
microscopically?

faintly basophilic or translucent yeast with large surrounding clear space in H&E-stained tissue

69

CRYPTOCOCCUS
Diagnosis?

morphology
antigen test
culture

70

CRYPTOCOCCUS
Histologic confirmation?

mucicarmine stain
(red = +)

71

PNEUMOCYSTIS JIROVECII PNEUMONIA
2 main characteristics?

1. fungus which behaves like a protozoan
2. opportunistic pathogen in patients with
deficient cell-mediated immunity (AIDS, etc.)

72

PNEUMOCYSTIS JIROVECII PNEUMONIA
Symptoms?

insidious onset of dyspnea, fever, and non-productive cough

73

PNEUMOCYSTIS JIROVECII PNEUMONIA
Signs?

tachypnea with no rales or rhonchi

74

PNEUMOCYSTIS JIROVECII PNEUMONIA
CXR?

bilateral hazy interstitial infiltrates which become dense alveolar infiltrates

75

PNEUMOCYSTIS JIROVECII PNEUMONIA
Gross?

heavy, diffusely consolidated, tan lungs

76

PNEUMOCYSTIS JIROVECII PNEUMONIA
Micro?

foamy eosinophilic, sparsely cellular, centro-alveolar “honeycomb” exudate

+/- lymphoplasmacytic interstitial pneumonia

77

PNEUMOCYSTIS JIROVECII PNEUMONIA
Diagnosis?
What would you NOT use?

Demonstration of helmet-shaped org in biopsy, smear, aspirate or lavage using:
1. cyst stains (e.g. Grocott, methenamine silver)
2. trophozoite
3. immunostains

Cannot culture this--it doesn't grow!

78

Type 2 pneumocyte hyperplasia is seen in what 2 conditions?

interstitial pneumonias
acute lung injury

79

Chronic pneumonias tend to be (etiology):

fungal, mycobacterial, toxic, autoimmune or idiopathic

80

Chronic pneumonias tend to be (lung pattern):

interstitial
nodular
both

81

What two causes of chronic pneumonia are often chronic and nodular?

fungal
mycobacterial

82

INTERSTITIAL chronic pneumonias (3):

Pneumocystis
Sarcoidosis
Toxoplasmosis

83

NODULAR chronic pneumonias (6):

TB
Histoplasmosis
Aspergillosis
Cryptococcosis
Coccidioidomycosis
Blastomycosis

"BITCHY Nodules = Blasto, asperg-i-llosis, Tb, Coccidio, Histo, crYpto

84

Most common causes of viral pneumonia?

influenza
RSV

85

What virus causes interstitial pneumonias in immunocompromised patients?

Cytomegalovirus (CMV)

86

What virus causes nodular pneumonias in immunocompromised patients?

Herpes simplex virus (HSV)

87

Viral pneumonias tend to be (interstitial/nodular)

interstitial

88

What are Ghon focuses?

grey/white caseating granulomas (necrotic centers)

FYI: "complex" = this + hilar lymphadenopathy