Respiratory Tract Infections Flashcards by Georgia Leggett

What does the term URTI cover?

Sinusitis
Tonsilitis

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What does the term LRTI cover?

Bronchitis
Pneumonia
Empyema
Bronchiectasis
Lung abscess

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Give 5 ways in which respiratory defences can be compromised

Poor swallow: CVA, muscle weakness
Abnormal ciliary function: Smoking, Kartagener’s
Abnormal mucous: CF
Dilated airways: Bronchiectasis
Defects in host immunity: HIV, Drugs

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What is the abnormality seen here?

Double heart border “Sail sign”
Left lower lobe collapse

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What is seen on CT here?

Densely consolidated + collapsed left lower lobe

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18F
Left lower lobe pneumonia
Unwell
Raised WCC + CRP
What is the likely organism?
A. Pseudomonas aeruginosa
B. Mycobacterium tuberculosis
C. Legionella pneumophilia
D. Streptococcus pneumoniae
E. Staphylococcus aureus

D. Streptococcus pneumoniae

30-50% of CAP

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Give 3 features of streptococcus pneumoniae under microscope

Gram +ve cocci (pairs + chains)
Alpha haemolytic
Optochin sensitive

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List 4 symptoms/ signs of S. pneumoniae

Acute onset
Severe pneumonia
Fever, rigors
Lobar consolidation

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What is S. pneumoniae almost always sensitive to?

Penicillin

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What is pneumonia? How sick are patients generally?

Inflammation of lung alveoli
Community acquired or Hospital acquired
5-10% Mortality
20-40% admitted to hospital

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Give 5 common signs/ symptoms of pneumonia

Fever
Cough +/- sputum
SOB
Pleuritic chest pain
Often localising signs + abnormal CXR

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List 4 factors to consider when assessing possibility of pneumonia

Pre-existing lung disease
Immunocompromised
Travel, seasons, epidemics
Exposure to animals

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List the 5 main causative organisms of CAP

Streptococcus pneumoniae
Staphylococcus aureus
Haemophilus influenzae
Moraxella catarrhalis
Klebsiella pneumoniae

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How does age influence susceptibility to different causative organisms for CAP?

0-1m: E. coli, GBS, Listeria monocytogenes
1-6m: Chlamydia trachomatis, S aureus, RSV
6m-5y: M pneumoniae, Influenza
16-30: M pneumoniae, S pneumoniae

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What are the typical causes of CAP? How many cases do they account for?

S pneumoniae
H influenza
85%

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What 4 atypical organisms must be accounted for when treating CAP? Give a feature or exposure associated with each

Legionella: water exposure, A/C
Mycoplasma: barking cough, normal CXR
Coxiella burnetii (Q-fever): farm animals
Chlamydia psittaci: bird exposure

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Give 7 signs that may be found on examination in a patient with CAP

Pyrexia
Tachycardia
Tachypnoea
Cyanosis
Dullness to percussion, tactile vocal fremitus
Bronchial breathing
Crackles

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What investigations should be sent when suspecting CAP?

FBC, U+Es, CRP
BC, Sputum MC+S
ABG
CXR
Urinary antigen: legionella + s aureus

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What is the CURB-65 score designed for?

Predicting mortality of CAP
Score 2: ?Admit
Score 2-5: Manage as severe

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What are the elements of the CURB-65 score?

Confusion
Urea >7 mmol/l
RR >30
BP <90 sys, <60 dia
>65y

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What is bronchitis? Which patients is it mostly seen in?

Inflammation of medium sized airways
Smokers

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List 4 signs/ symptoms of bronchitis

Cough
Fever
Increased sputum production
Increased SOB

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How does bronchitis appear on CXR?

Normal

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List 4 organisms causative of bronchitis

Viruses
S pneumoniae
H influenzae
M catarrhalis

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What is the treatment for bronchitis?

Bronchodilation Physiotherapy +/- Abx

What can be seen here?

Cavitation on LHS

56M Left lower lobe pneumonia Haemoptysis Cavitation on CXR What organism would you suspect? A. S pneumoniae B. H influenzae C. S aureus D. Klebsiella pneumoniae

B. H influenzae

Give 3 features of H influenzae under the microscope

Gram -ve Cocco-bacilli Stain on Chocolate agar May produce B-lactamase

Give 2 epidemiological features of H influenzae

15-35% CAP More common with pre-existing lung disease

What is seen here?

Bilateral interstitial change

62M smoker SOB Confused Bilateral interstitial change Hyponatraemic What is the likely organism? A. Moraxella catarrhalis B. Mycobacterium tuberculosis C. Legionella pneumophilia D. Cytomegalovirus E. Staphylococcus aureus

C. Legionella pneumophilia

What similarity to atypical organisms share?

No cell wall thus cell-wall active abx e.g. penicillin ineffective Often extra pulmonary features e.g. hepatitis, low Na

How is legionella transmitted? What culture is required to grow it on?

Inhalation of infected water droplets e.g. A/C, fountain Buffered charcoal yeast extract agar

What agents are required to treat atypical pneumonias?

Targeting protein synthesis: Macrolides e.g. Clarithromycin, Erythromycin Tetracyclines e.g. Doxycycline

Atypical organisms account for ... CAP? How do they usually arise?

20% Flu-like prodrome before fever + pneumonia

Give 4 symptoms/ manifestations of legionella pneumophila pneumonia

Confusion Abdo pain Diarrhoea Multi-organ failure

What blood results are associated with legionella pneumophila pneumonia?

Hyponatraemia Lymphopenia

What investigations should be sent for legionella pneumophila pneumonia?

Legionella urinary antigen Sputum/ blood sample

In which organisms is Coxiella burnetii common? How is Coxiella burnetii transmitted?

Domestic/ farm animals Aerosol/ milk transmission

How is Coxiella burnetii pneumonia and Chlamydia psittaci pneumonia diagnosed?

Serology

In which organisms is Chlamydia psittaci common? How is Chlamydia psittaci transmitted?

Birds Inhalation

What can be seen here?

Homogenous shadowing/ shadowing with meniscus level on RHS

74F SOB, fever, right sided pleuritic chest pain Reduced percussion note + decreased air entry right base Right lower lobe pneumonia On standard abx Not improving What is the probable diagnosis? A. TB B. Empyema C. Mesothelioma D. MRSA pneumonia E. Aspiration pneumonia

B. Empyema

What can be seen here?

Large empyema with collapsed lung underneath

Why are empyemas difficult to treat?

Wall around them + pus itself is very acidotic which inactivates abx

What 7 reasons may explain why a pneumonia is failing to improve with treatment?

Empyema/ abscess Proximal obstruction: tumour Resistant organism, inc. TB Not receiving/ absorbing abx Immunosuppression Lung cancer Cryptogenic organising pneumonia

Describe the radiograph. What is this characteristic of?

Patchy to speckled infiltration Ground glass appearances SARS-CoV-2

What can be seen here?

RHS apical shadowing

21M from Ecuador Cough and weight loss RUZ shadowing on CXR What is the causative organism? A. S aureus B. Aspergillus fumigatus C. Mycobacterium tuberculosis D. H influenzae E. Pneumocystis jiroveci

C. Mycobacterium tuberculosis

Why is TB sometimes referred to as "the White Plague"?

Sometimes there is a complete "white out" of chest on CXR

Give 5 clues that suggest TB

Ethnicity Prolonged prodrome Fevers +/- Night sweats Weight loss Haemopytsis

What is commonly found on CXR in TB?

Upper lobe cavitation (can vary- abscess, miliary seeding pattern)

What staining is used to identify TB?

Auramine stain Ziehl-Neelsen stain

What can be seen here?

Smear +ve ZN stain TB = red rods Acid fast bacilli

What is hospital acquired pneumonia? What investigation is desirable?

Pneumonia onset >48h in hospital Often previous abx +/- ventilator Bronchial lavage to differentiate upper respiratory from lower respiratory flora

List 3 main causes of HAP

31%: Enterobacteriaciae e.g. E. coli, K. pneumoniae 19%: S. aureus 17%: Pseudomonas spp

64M Treated for LN TB Increasing SOB over 1m Non-productive cough Bilateral ground-glass shadowing What is the likely organism? A. Aspergillus fumigatus B. H1N1 Swine flu C. Mycoplasma pneumoniae D. Cytomegalovirus (CMV) E. Pneumocystis jiroveci

E. Pneumocystis jiroveci

What can be seen here?

Bilateral ground glass shadowing

Give 2 facts about Pneumocystis jirovecii

Protozoan Ubiquitous in environment

Give 5 features of Pneumocystis jirovecii presentation

Insidious onset Dry cough Weight loss SOB Malaise

What is the classic CXR finding of Pneumocystis jirovecii?

"Bat's wing" Bilateral ground glass shadowing

What investigation and treatment is needed for Pneumocystis jirovecii?

Ix: Immunofluorescnece on BAL Rx: Septrin (Co-trimoxazole)

What is the walking test suggestive of Pneumocystis jirovecii?

attaching O2 sats probe + asking patient to walk will show desaturation on exertion

What prophylaxis should those on immunosuppressants take against Pneumocystis jirovecii?

Septrin

22M Chemo for leukaemia Prolonged neutropenia <1.0 Ongoing fevers Abx failed Interstitial change on CT What is the likely organism? A. MRSA B. Aspergillus C. Tuberculosis D. CMV E. Drug reaction

B. Aspergillus

What can be seen on this CT?

Interstitial changes

What are the 3 types of aspergillus?

Allergic bronchopulmonary aspergillosis Aspergilloma Invasive aspergillosis

Give 3 features of allergic bronchopulmonary aspergillosis

Chronic wheeze Bronchiectasis Eosinophilia

Give 2 features of Aspergilloma

Aspergilloma fungal ball in pre-existing cavity (often from TB) May cause Haemoptysis

Which patients are susceptible to invasive aspergillosis? What treatment is required?

Immunocompromised Rx: Amphotericin B

Which LRTIs are HIV patients particularly susceptible to?

PCP TB Atypical mycobacteria

Which LRTIs are neutropenic patients particularly susceptible to?

Fungi e.g. Aspergillus spp

Which LRTIs are bone marrow transplant patients particularly susceptible to?

CMV

Which LRTIs are splenectomy patients particularly susceptible to?

Encapsulated organisms: S. pneumoniae H. influenzae Malaria

What samples should ideally be sent prior to antibiotics administration?

Sputum/ induced sputum Blood cultures

For which species are urine antigen tests available?

S. pneumoniae Legionella pneumophila

When are antibody tests useful in respiratory tract infections?

In organisms difficult to culture e.g. Chlamydia + Legionella Only useful in paired serum samples e.g. at presentation + 14d later Look for rise in antibody over time

What is the empirical therapy for mild-moderate CAP?

Amoxicillin Or erythromycin/ clarithromycin

What is the empirical therapy for moderate-severe CAP?

Needing admission: Augmentin (co-amoxiclav) + Clarithromycin Allergic: Cefuroxime + Clarithromycin

What is the empirical therapy for HAP?

1st: Ciprofloxacin +/- Vancomycin 2nd/ ITU: Piptazobactam + Vancomycin

What specific therapy is used for MRSA HAP?

Vancomycin

What specific therapy is used for pseudomonas HAP?

Piptazobactam or Ciprofloxacin +/- Gentamicin

What can be recommended to prevent pneumonia?

Smoking cessation Vaccination: Flu, pneumovax, COVID-19

Respiratory Tract Infections Flashcards

(83 cards)