Adult Med

Front 1

Pneumonia: Def

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acute infection of lung parenchyma incl. alveolar spaces and interstitial tissue.

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Common Bacterial PNA causes

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S. pneumoniae
H. influenzae
K. pneumoniae

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Uncommon Bacterial PNA causes

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S. aureus
S.pyogenes
P. aeruginosa
N. meningitis

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Acquiring Bacterial PNA

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Bronchogenic spread of the path.
Incidence increases w/ age.
Above 50, who have an underlying COPD, CV dz, or other chronic dz

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S. pneumoniae etiology

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Affects children and adults. A leading cause of illness in young children. Illness and death for elderly w/ underlying med conditions

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S. pneumoniae organism attacks how?

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Colonizes the upper resp. tract

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What 3 things can S. pneumoniae cause?

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Disseminated invasive infections
PNA and other lower resp tract infections.
URI, incl. otitis media, and sinusitis

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S. pneumoniae is associated with what?

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Pneumococcal bacteremia 60-87%
Severe infections result from bacteria into bloodstream and CNS. Get blood cultures!!!

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H. influenzae and K. pneumoniae are more commonly seen in?

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COPD, ETOH abusers, elderly

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H. influenzae PNA infection causes?

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Pleural effusions (common)
Bacteremia, other infections: Otitis, sinusitis, Meningitis, epiglottitis, facial infection.

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K. pneumoniae PNA population

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ETOH abusers, COPD, Neonates nosocomial

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K. pneumoniae PNA infection causes?

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Large gram neg rod w/ capsule
"Currant Jelly" sputum
Bulging fissure
Lung necrosis

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S. aureus PNA lab results

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Gram positive cocci in clusters

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S. aureus PNA population?

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IVDA, elderly, recent influenza virus infection, CF

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S. aureus PNA S/Sx

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pleuritic CP, asssociates w/mult.thin walled abscesses: pneumatoceles. cardiac murmurs.

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S. aureus PNA other infections:

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endocarditis, abscesses, skin furuncles.

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P. aeruginosa PNA etilogy:

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Often cause of PNA in pt. w/ CF or severely compromised resp. defenses. Pts on ventilator

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P. aeruginosa PNA S/Sx

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Green sputum, fulminating course
necrotizing w/ mult. small and large abscesses, skin lesions ecthyma gangrenosum, gram neg rods (encapsulated in CF pts)

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S. pyogenes PNA

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Less common due to ABX txs.

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N. meningitidis PNA

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Occasionally seen epidemics in military recruits.

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Y. pestis PNA

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infection due to environmental exposure to an infected rat pop.

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B. pseudomallei PNA

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Soil contamination in SE Asia.

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Bacterial Pneumonia S/sx

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malaise, fever, dyspnea, chest discomfort, pleuritic pain, cough productive w/ purulent or blood-tinged sputum, tachypnea, tachycardia, confusion

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PNA chest sounds

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Fine crepitus rales over involved portion of lung. Lobar consolidation results in: dullness to percussion, vocal fremitus, whispered pectoriloquy, brochial breathing (lower airways)

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Bacterial PNA PE shows:

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Pleural effusion s/sx: pleural friction rub, <breath sounds, dull percussion, egophony, referred abd. pain from diaphragmatic inflammation.

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Bacterial PNA labs:

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Sterile sites: Blood cultures, pleural fluid from empyema, special cultures and stains, serologic assays, lung bxs.

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Bacterial PNA CXR results

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*Dense lobar consolidation*
may involve one or more lobes, unilateral or bilateral. Pleural effusion may exist.

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CXR: K. pneumoniae

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"Bulging fissure" sign. Upper lobar consolidation w/a bowing fissure.

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CXR: S. aureus

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Multiple bilateral nodular infiltrates w/ central cavitation. Children: pneumatoceles, bronchopleural fistulas, empyema.

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Bacterial PNA Tx:

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Resp. support w/O2 if needed, ABX on basis of Gram stain, if not performed, ABX on pt age, epidemiology, host risk factors, and severity of illness.

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Bacterial PNA Tx con't

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Hospitalization
Antipyretics
Hydration

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Atypical PNA Bacterial etiologies

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influenza
parainfluenza
RSV
adenovirus

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Atypical PNA Fungi etiologies

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Histoplasma capsulatum (histoplasmosis), Coccidioides immitis (coccidioidomycosis), Pneumocystis carinii (pneumocystosis), Aspergillus fumigatus (aspergillosis)

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Mycoplasma pneumonia etiology

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Most common cause, second only to s. pneumoniae. It is the cause in 20-25% of all age groups, causing prolonged reduced pulm. clearance and hyper-responsive airway.

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M. pneumonia etiology con't

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AKA: Walking or Eaton agent PNA
Incubation: 10-21 days, occurs year round, > in adolescents/ young adults M>F, Person-person transmission.

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M. pneumonia S/Sx initial:

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resembles influenza: malaise, sore throat, dry cough +/- productive, sputum mucoid, mucopurulent, blood streaked. Dz. progresses gradually, Acute sx for 1-2 weeks, spontaneous recovery.

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M.pneumonia severe S/Sx:

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ARDS, maculopapular rashes in 10-20%,important dx tool. Erythema multiforme or SJS syndrome. PE unimpressive compared to pt c/o or CXR changes.

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M.pneumonia Labs:

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Gram stain: sparse bacteria, pmn's & mononuclear cells, clumps desquamated resp. epithelial cells. WBC: norm or slight elev. Difficult to grow culture 7-21 days. ELISA, IgM by latex agglutination, Indirect flourescent antibody test, compliment fixation test

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M.pneumonia Cold agglutination

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Positive if 4 fold > in titer w/ sequential specimens or single titer>/=1:64, most practical method of confirming dx, use serologic assays 2-4 wks post onset.

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M.pneumonia Tx

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Most pts recover w/ or w/o tx. Mycoplasmas don't respond to abx that interfere w/ cell walls, including beta-lactam abx. TCN or erythromycin for adults or Erythromycin for kids<8years.

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Clamydia pneumonia etiology

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C.pneumoniae
C.trachomatis
C.psittaci

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C.pneumonia S/Sx

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Resembles M.pneumonia, primarily in older children and young adults. Pharyngitis, bronchitis, pneumonitis, persistent cough, fever, sputum production. C. trachomatis is common cause of pneumoia in infants age 3-8wks

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C.pneumonia Labs

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Cultures, direct stains w/ immunoflourescence or polymerase chain reaction. Serial serological tests to show seroconversion. Very expensive tests

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C.pneumonia Tx

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Response slower than M.pneumonia
Cx may recur if tx is stopped early. TCN or erythromycin, for 10-21 days as for M.pneumonia.

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C. psittacosis

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Infectious PNA transmitted to humans from certain birds.

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C. psittacosis etiology

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Parrots, parakeets, lovebirds, poultry, pigeons, canaries,Snowy Egrets, Herring gulls, Petrels, Fulmars

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Psittacosis Def

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Caused by inhaling dust from feathers or excreta of infected birds or bite. Poss. from inhaling infected droplets of pts. Human- human transmission is assoc. w/ virulent strains`

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Psittacosis S/Sx

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1-3wk incubation, onset abrupt & insidious,gradual fever remains elevated for 2-3wks, chills, malaise, cough, PNA & consolidation w/ secondary lung infection.

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Psittacosis Severe S/Sx

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Progressive, pronounced increase in resp. rate & pulse bad sign. 30% mortality rate in untreated severe cases. Convalescence may be long in severe cases.

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Psittacosis Tx

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Avoid sick birds, TCN 1-2 G/day or Doxycycline 100mg po, tx should be for 10 days at least. Strict bed rest, O2 prn, cough control as needed

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Legionnaires Dz

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> 30 species Legionella, 19 causitive agents: L.pneumophilia most common, L.micdadei next, L.bozemanii & L.dumoffii last.

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legionnaires' Dz

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>30 species, Most common L.pneumophila, L.micdadei, L.bozemanii, L.dumoffii.

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Legionnaires' Risk factors

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> middle age men, smokers, etoh abusers, immunosuppressed esp. corticosteroids

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Legionnaires' etiology

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Outbreaks in bldgs., hotels & hosp. in A/C and showerheads. Contaminated H2O supply w/ organisms.

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Legionnaires' S/Sx

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Incubation 2-10 days, Malaise, fever, HA, myalgias (Prodrom). Cough w/o production the w/ mucoid sputum, >fever, poss. diarrhea, brady, alt. mental status

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Legionnaires Labs

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WBC: 100000-15000, Legionella stained w/ Dieterle silver & direct flourescent antibody stain.Urine test available and can culture Legionella.

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Legionnaires' CXR

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Unilat. patchy alveolar infiltrates, progressing to bilat. and pleural effusions common. Lung abscesses may occur and embolic emboli

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Legionnaires' Tx

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Erythromycin DOC, w/ Rifampin in severe cases. Tx should be for 3 weeks to prevent relapse. Ciprofloxacin and Azithromycin used also.

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Atypical Pneumonia: Viruses

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Bronchiolar epithelium invaded, causes bronchiolitis. Infection mobes to pulm. interstitium and alveoli causing PNA

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Atypical PNA Virus pathology

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Affected areas: congested, poss hemorrhagic, inflammatory rx composed of mononuclear cells. Alveoli contain fibrin, mono. cells, neutrophils, hyaline mem.

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Atypical PNA: S/Sx

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HA, fever, myalgia, cough w/ scanty sputum. Flu: epidemics

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Atypical PNA: Labs

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WBC: low, poss. norm, elevated w/ superinfection. Sparse bacteria, monocytes dominate smears of sputum. Throat wash, viral culture, serologic assay.

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Atypical PNA: CXR

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Interstitial PNA or peribronchial thickening most common. Lobar consolidation and pleural effusion not common but may occur.

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Atypical PNA: TX

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Acyclovir. CMV PNA tx w/ Ganciclovir and Immune globulin.

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Atypical PNA: Viruses complications

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Superimposed bacterial infection
S.pneumoniae, S.aureus, Haemophilus influenza, group A hemolytic streptococci, Neisseria meningitis.

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Atypical PNA: Fungi

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Histoplasma capsulatum (histoplasmosis)
Coccidioides immitis (coccidioidomycosis)

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Histoplasmosis def

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Dz causes by Histoplasma capsulatum, causes primary pulm. lesions and hematogenous dissemination.

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Histoplasmosis etiology

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H.capsulatum grows in soil, becomes airborne when disturbed, inhalation of spores cause infections. No person-person transmission

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Histoplasmosis Acute S/Sx

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Asymptomatic; non-specific fever, cough, malaise.Acute PNA sometimes evident w/CXR

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Histoplasmosis Progressive Disseminated S/Sx

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Uncontrolled hematogenous spread from lungs, hematosplenomegaly, lymphadenopathy, oral or GI ulcers. Occur most in infants and immunocompromised. Defining opportunistic infections for AIDS

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Histoplasmosis Chronic Cavitary S/Sx

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Pulm. lesions that are often apical and resemble cavitary TB. Worsening cough & dyspnea progressing to resp dysfunction. No dissemination occurs.

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Histplasmosis Labs: Smears and cultures

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Stained tissue samples: clusters of sm. oval yeast cells w/in macrophages, blood monocytes, or neutrophils. Wright's or Giemsa stain: Intracellular yeasts.

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Histoplasmosis Labs: Serology

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Culture:sputum, lymph nodes, bone marrow, liver bx, blood, urine. Antigen can be detected.

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Histoplasmosis: Tx

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Acute: self-limiting. Chronic: death from resp. insufficiency. Untreated progressive disseminated mortality >90%. Itraconozole or Ampho B IV

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Coccidioides immitis Def

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Caused by fungus, acute benign asymptomatic or self-limiting resp. infection.

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Coccidioidomycosis etiology

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Endemic in SW, central valley CA
AZ. Infections by inhalation of spores in dust. Spherules enlarge then rupture. Lesions form granulomatous coin lesions.

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Primary Coccidioidomycosis: S/Sx

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Asymptomatic non-specific resp. sx flu-like. Scattered rales, w/ or w/o dullness. Leukocytosis, eosinophilia. Desert rheumatism syndrome.

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Progressive Coccidioidomycosis Risk Factors

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HIV, immunosuppressive tx, 2nd half of preg. or postpartum, age, ethnic background (Filipino Blacks, Am. Indian, Hispanic, and Oriental)

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Progressive Coccidioidmycosis S/Sx

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Dev. over weeks, months, years after infection. Men > women, low grade fever, anorexia, wt loss, weakness. Pulm inf. may cause cyanosis, dyspnea, bloody sputum.

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Coccidioidmycosis Labs

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Culture tissues or fluids, silver or PAS stain, complement fixation for IgG anticoccioidal antibodies the most useful test. Titers >1:4 are consistent w/ infection.

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Coccidioidmycosis Tx

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Primary: no tx; fluconazole for mild-mod., Ampho B for severe. Meningeal: months to lifelong tx
Untreated: usually fatal

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Pneumocystosis

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P.carnii found in rats, P.jiroveci affects humans. Occurs in 80% of AIDS pts. CXR: diffuse interstitial pattern Bactrim/Septra tx.

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Aspergillosis

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Occrus w/ tissue invasion or immunologic response ie: severe asthma exacerbation. Immune competent pt: chronic sinusitis. Invasive dz in HIV/AIDS necrotizing PNA disseminating throughout body.