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Lecture 2

Pulmonary II - Pneumonias

Recurrent hemoptysis of unknown etiology. 80% of patients are <16 years of age. No sex predilection. No renal involvement. Inflammatory consolidative process involving the lung parenchyma
Most frequent organism involved in bacterial pneumonias Steptococcus pneumoniae 60-80% of all bacterial pneumonias
Organism most commonly involved in pneumonias occurring after viral infection Staphylococcus sp. 10% of all bacterial pnenumonias. Other organisms include Streptococci or H. influenza
Routes of infection for pneumonia (1) Aerogenous (2) Hematogenous (3) Direct Traumatic introduction(1) Aerogenous (2) Hematogenous (3) Direct Traumatic introduction
What are the effect of alcohol on the immune system Impairs macrophage migration to site of infection
Why is COPD a risk factor for bacterial pneumonia infections? Alveolar hypoxia and mucus stasis
Why is CHF a risk factor for bacterial pneumonia infections? Pulmonary edema, which results in alveolar hypoxia
What bacterial organism are sickle cell anemia patients without splenic function at higher risk for? Strepococcus pneumoniae pneumonias. Asplenia secondary to autoinfarction is a complication of sickle cell anemia. Aspelnic patients are susceptible to infections caused by encapsulated bacterial organisms such as Steptococcus penumoniae, Haemophilus infl
Why are cystic fibrosis patients susceptible to recurrent bouts of pneumonia? Viscous mucous and long-standing bronchial obstructions lead to the development of bacterial infections. Cystic fibrosis patients also are susceptible to resistant strains of bacterial pneumonia such as Pseudomonas aeruginosa
Why is renal failure a risk factor for bacterial pneumonia infections? Azotemia
What conditions result in the loss of cough reflex? Altered sensorium: coma, drug overdose, medications, alcoholism, CVA, post-op state. Neuromuscular disease and chest pain inhibit the protective mechanism of the cough reflex. Intact cough reflex is important for the prevention of aspiration.
Symptoms of Bacterial Pneumonia (1) High fever (2) Rigor (3) Dyspnea (4) Productive cough (5) Pleuritic chest pain
Chest x-ray findings of Bacterial Pneumonia (1) Patchy peribronchial opacity or
Stages of Bacterial Pneumonia 1)Congestion and Edema (Onset to Day 2) 2)Red hepatization (Day 2 to 4) 3)Gray hepatization (Day 4 to 8) 4)4)Resolution (Day 8 to 21)
Morphologic change in Pneumonia: Congestion and Edema Occurs between Day of onset to Day 2. Microscopically characterized by the presence of a few neutrophils and bacterial proliferation.
Morphologic change in Pneumonia: Red hepatization Occurs on Day 2 to Day 4. Microscopically characterized by the massive influx of neutrophils, red cells, and fibrin.
Morphologic change in Pneumonia: Gray hepatization Occurs on Day 4 to 8. Microscopically characterized by the disintegration of red cells, the influx of more fibrin, and the replacement of neutrophils with macrophages.
Morphologic change in Pneumonia: Resolution Occurs Day 8 to 21. Microscopically characterized by the clearing of exudates and the reestablishment of normal structure/function.
Common complication of recurrent pneumonia Brochiectasis
What is a complication found in 20-30% of patients with lobar pneumonia? Sepsis or bacteremia which can result in subsequent infection of other organs such as the heart (endocarditis or pericarditis), CNS (meningitis or brain abscess), Joint (arthritis), or kidneys (pyelonephritis).
A lung pathology characterized as a collection of pus in the pleural space. Found in 1% of all treated pneumonia infections. Characterized by persistent fever following apparent recovery from the infection Empyema
Complications of bacterial pneumonia (1) Pleural effusion (2) empyema (3) sepsis (4) organization with fibrosis (4) lung abscess (5) Bronchiectasis (6) glomeruloneprhirtis (7) Septic shock
A lung pathology characterized as a localized accumulation of pus with destruction of the underlying pulmonary parenchyma. Differs from abscesses found in other organs because they can drain to the outside via the bronchial tree. Lung Abscess
Organisms that frequently cause lung abscess formation Typically polymicrobial. Specific organisms include anaerobes, Klebsiella, Pseudomonas, Legionella, Staphylococcus type III, Streptococcus, and anaerobic necrotizing pneumonias.
Pathogenesis of lung abscess (1) Accidental inhalation or aspiration of necrotic/caustic material from stomach, oral cavity, or nasopharynx(2) Necrotizing pneumonias (3) Septic embolus from distant infection (4) Pulmonary trauma (5) Secondary infection of bullae in emphysema patients
A lung pathology characterized as persistent dilatation of bronchi, associated with loss of distal and surrounding lung parenchyma typically caused by chronic inflammation and necrosis. Bronchiectasis
What area of the lung most commonly involved in bronchiectasis? Lower lobes of the lung
What is the primary cellular response to viral pneumonia Lymphocytic infiltrates.
Viral infection found typically in children that only involves the bronchioles Respiratory syncytial virus
Viral pneumonia that typically infects patients with Hodgkin’s disease Herpes zoster virus
Virus that causes 50% of interstitial pneumonias in bone marrow transplant patients CMV. Has 80% mortality.
Viral infection that is a major cause of death in transplant patients. CMV
Symptoms of viral pneumonia (1) Fever (2) Dry cough (3) Dyspnea. The clinical symptoms have a more subtle onset and typically less severe than bacterial pneumonia infections.
What percentage of chicken pox patients develop Varicella zoster pneumonia? 15%
What are the characteristic features of atypical pneumonia? Inflammation is more interstitial and less exudative. Immune response is characterized by lymphocytes and monocytes/macrophages. Most severe forms histologically and clinically resemble Diffuse Alveolar Damage (DAD) or Acute Interstitial Pneumonia (AIP)
Bacterial organisms that cause viral-like pneumonias (1) Mycoplasma (2) Chlamydia (3) Rickettsia
An immune reaction mediated by T cells interacting with monocyte/macrophages. Accumulation of macrophages (epithelioid cells) surrounded by a rim of lymphocytes often with an outer rim of fibrous tissue. Epithelioid cells may fuse to become giant cells. Granulomatous inflammation
Diagnostic workup of Tuberculosis (1) Gold standard – culture (2) Microscopy with acid-fast stain (3) Molecular diagnostics
(T or F) Sarcoidosis is associated with non-necrotic granulomatous inflammation True
(T or F) Biologic dust disease is associated with necrotic granulomatous inflammation False
(T or F) Wegener’s Granulmoatosis is associated with necrotic granulomatous inflammation True
Occurs in individuals who have not primarily been exposed to tuberculosis bacteria; often children. Often asymptomatic. Primary Tuberculosis Infection
(T or F) Individuals with primary tuberculosis infection are typically symptomatic. False
Ghon complex Combination of Ghon focus and enlarged regional lymph nodes – Characteristic in only primary tuberculosis infection. Caseous necrosis is present both in the Ghon focus and lymph nodes.
What does a positive PPD result indicate? Indicative of partial immunity and may be a carrier of dormant bacteria in other organs.
Symptoms of secondary tuberculosis infection (1) fever (mid-afternoon) (2) night sweats (3) weakness/fatigability (4) loss of appetite (5) blood-streaked sputum (6) cough (7) dyspnea
Simon’s foci The apical or posterior segments of the upper lobe where secondary pulmonary tuberculosis infection typically begins. The higher PO2 of the upper lobe favor Mycobacterium tuberculosis.
Descirbe a pulmonary tuberculosis Lesion Cavitating lesion found 1-3 cm caseous consolidation within 1-2 cm of pleural surface
A complication of secondary tuberculosis infection. Seeding of distant organs by lymphatic or hematogenous spread. Infected organs are covered with small millet seed-like lesions. Miliary Tuberculosis
(T or F) Cavitation is seen in both primary and secondary tuberculosis infections. False. Only secondary tuberculosis infections.
Atypical Mycobacterial infection common in AIDS and other immunodeficiency states Mycobacterium avium-intracellulare
Aytpical Mycobacterial infection associated with hairy cell leukemia Mycobacterium kansasii
(T or F) Mycobacterium avium-intracellulare is associated with caseating granulomatous inflammation False. Histologically, it is characterized by non-coalescing granulomas randomly scattered in the parenchyma. Granulomas have a lymphocytic cuff and are non-caseating.
Endemic area for Histoplasmosis Ohio-Mississippi Valley. 80-90% of the population is positive for this organism.
Endemic area for Blastomycosis North America, Mississippi-Ohio River and Middle Atlantic
Endemic area for Coccidiomycosis Southwestern United States. 80% of the population is positive for this organism.
Endemic area for Cryptococcosis Worldwide
Endemic area for Aspergillosis Ubiquitous and nosocomial
Endemic area for Candidiasis Ubiquitous
Source of Histoplasmosis Soils contaminated by bird droppings
Microscopy of Histoplasmosis Oval yeasts with narrow-based bud (3-5um)
Microscopy of Blastomycosis Yeasts with broad-based buds (5-25 um)
Describe the clinical disease of Histoplasmosis Similar to tuberculosis with latent, primary, disseminated and chronic states
Describe the clinical disease of Blastomycosis Primary infection is pulmonary. Dissemination is common and usually to skin. Lung disease can be solitary or progressive.
Morphology of Coccidioidomycosis Thick-walled, non-budding spherule 20-60um in diameter filled with endospores
Describe the clinical disease of Coccidioidomycosis 60% of infected individuals are asymptomatic. Have flu-like symptoms. Primary pulmonary disease typically has no lymph node involvement. Dissemination is possible.
Source of Coccidioidomycosis Dust, sand, dry soil
Source of Cryptococcosis Soil contaminated with pigeon droppings
Morphology of Cryptococcosis Oval yeast with unequal budding. Yeast have a polysaccharide-rich capsule (mucicarmine (+)). Visualized with India-ink stain.
Describe the clinical disease of Cryptococcosis Variable clinical disease. Immunocompetent patient have chornic granulomatous inflammation. Multiplication of organism in alveoli and consolidation with little reaction occurs in immunodeficient states. Dissemination is also common in immunodeficiency.
Morphology of Aspergillosis Dichotomous 45 degree branching hyphae
A fungal pneumonia that affects 40% of patients with acute leukemias Aspergillosis
What is aspergilloma? Secondary colonization of tumors by aspergillosis
What is allergic Bronchopulmonary Aspergillosis? Colonization with allergic reaction
Morphology of Mucormycosis Large irregular nonparallel hyphae
Describe the clinical disease of Murcomycosis Capable of being angioinvasive, necrotizing, or form fungal balls
Morphology of Candidiasis Budding yeast and pseudohyphae
Patients at risk for pulmonary candidal infection (1) Immunocompromised states (2) Deep infections (3) Patients with indwelling venous catheters (4) Prolonged antibiotic use (5) Severe burns (6) Major abdominal surgery
Predisposing conditions for Fungus Ball Formation (1) COPD (2) Bronchiectasis (3) Healed cystic tuberculosis (4) Pulmonary infarction (5) Lung carcinoma. Fungus balls typically form in cystic necrotic cavities.
(T or F) Candidiasis infection can form abscesses True
Opportunistic pneumonia that commonly occurs in AIDS patients. PCP. 40% of these patients have concurrent CMV pneumonitis
Histopathologic features of PCP Interstitial pneumonia/diffuse alveolar damage with frothy esoinophilic exudates and interstitial plasma cells
Morphology of Pneumocystis carinii 4-6 micron cysts on GMS with helmet shapes and 1-2um dots (trophozoites) on Giemsa stain
A lung pathology characterized by fat droplets in the setting of pneumonic pathology Lipid pneumonia
Pathogenesis of aspiration of large particle Post-obstructive pneumonia
Pathogenesis of aspiration of gastric contents Chemical like burn with hemorrhagic necrosis and DAD. May have evidence of foreign (food) material.
Created by: UVAPATH2