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Lecture 2
Pulmonary II - Pneumonias
| Question | Answer |
|---|---|
| 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. |
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UVAPATH2
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