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46 Cards in this Set

  • Front
  • Back
What is the most common mechanism for developing pneumonia?
Small volume aspiration
-bugs enter bronchi, attach to bronchial epithelium, overwhelm local immune response, and cause bronchiolitis that then spreads into the alveoli where it causes pneumonia
What would bronchoalveolar lavage of alveoli show?
85% machrophages, 10% lymphocytes

neutrophils are in the pulmonary capillaries waiting to be activated
what happens when the bug reaches the alveoli?
encounters alveolar macrophages first

Divided into 3 categories.
1. easy to eat, easy to kill
2. easy to eat, hard to kill
3. hard to eat, hard to kill
What do macrophages do to activate the immune response?
Macrophages secrete IL-8 and LTB-4 that are chemotactic for neutrophils

They interact with B and T-cells to activate and induce clonal expansion

T cells then secrete cytokines that support macrophage and neutrophil killing

B-cells secrete Ig to help opsonize the organism
What would cause an impaired neutrophil response?
Inborn disease, diabetes, COPD, renal failure

Bone marrow suppression from chemo
What happens if you have an impaired neutrophil response?
You get bacteria that are easy to eat and easy to kill.

GNR, Pseudomonas, Staph aureus, anaerobes, fungia, and even mucor, crypto, aspergillus in long standing neutropenia
What causes a humoral defect?
Multiple myeloma, CLL, asplenia
What do you get with a humoral defect?
becteria that are hard to eat and hard to kill because you can't opsonize encapsulated organisms

Strep pneumo, H influenza, encapsulated gram negatives like Klebsiella
What causes cell-mediated immunity defects?
Immunosuppression- AIDS or transplant
What do you expect with cell-mediated immunity defects?
Get bugs that are easy to eat, hard to kill

Legionella, mycobacteria, Nocardia, Fungi, CMV, PCP, Chlamydia, Listeria

Let's Make Naughty Fucking Cunts Cum Pleasurably Loose
What is the most common infection among secondarily immunosuppressed people?
What could cause acute consolidation?
Bacteria, hemorrhage, PTE, pulmonary edema
What could cause subacute consolidation?
fungal, viral, Nocardia, TB, PCP, drug induced, radiation, tumor
What could cause peribronchial opacities acutely?
Viral or bacterial or pulmonary edema
What could cause subacute peribronchial opacities?
PCP or maybe viral
What could cause acute nodular infiltrates?
Bacterial or pulmonary edema
What could cause nodular infiltrates subacutely?
Fungus, nocardia, TB, PCP
What does neutropenia suggest?
Probably baceterial or maybe fungal if antibiotics don't work

FAGS P = fungi, anaerobes, GNRs, Stap aureus, pseudomonas
What organisms would be suggested by asplenia, multiple myeloma, or chronic lymphoid leukemia?
Some high kicks

Strep pneumo, h. influenza, klebsiella
Where is TB found?
85% in the lungs but can be anywhere
What are the top 4 infectious killers in the world?
1. acute respiratory infection from things like H. influenza
3. Diarrhea
4. TB
What percent of people are infected with TB?
about 1 in 3 worldwide

# of newly infecteds is increasing at 1% each year
How is TB spread?
Mycobacterium tuberculosis is spread through air by droplets
What organisms make up the M. tuberculosis complex?
M. tuberculosis- cause of TB
M. bovis- causes bovine TB and is spread through milk of infected cows and is used to immunize
M. Africanum- in West Africa
M. microti and M. canetti- do not cause disease in humans
If you are exposed to TB will you get sick?
No. Only 30% are even infected. Then 5% progress early to TB while 5% more progress later. 90% never progress and it remains contained.
Does HIV affect the risk of progression?
Yes, it goes from 10% over lifetime to 10% each year.

As the CD4 count drops, the TB infection becomes more widespread. It goes lymphatic, meningitis, disseminated like miliary TB...
How do the presentations vary with HIV and no HIV
Later HIV and AIDS are less likely to have cavities formed with TB.
What are the first line TB drugs?

Pyrazinamide, Isoniazid, Rifampin, Ethambutol, Streptomycin
What are second line TB drugs?
Capreomycin, Amikacin, Kanamycin are injectables

What do you do with uninfected?
Treat prophylactically for 9 months
What has caused an increase in TB?
1. Decline in public health infrastructure
2. Immigration
3. HIV
4. Drug resistant TB
What does MDR mean?
Resistant to Isoniazid and Rifampin
Why treat with more than one drug?
Because there are enough bacilli in a cavitary lesion that some will be naturally resistant to any given drug. If you monotherapy and kill all others, the resistant one will replace them all.
What is the difference between primary and secondary resistance?
Primary is an untreated individual. Secondary is in someone who has had TB treatment for at least 30 days
Explain how you become tuberculin positive.
Enters lungs, passes through alveolar wall and gets into the lymphatics which drain into the bloodstream over the course of 6-8 weeks before it triggers any immune response.
What are the symptoms of TB?
Prolonged and productive cough
Deep chest pain

Fever, chills, night sweats, weight and appetite loss, fatigable

Looks like lymphoma
How do you diagnose TB?
PPD first, then chest xray if positive. Sputum smear if they have symptoms or a positive ppd or xray. Acid fast stain looks for atypical mycobacteria, Nocardia, and Rhodococcus.
Cultures are only used to confirm TB because they take so long.
Should you get a ppd each year if you test positive once?
Once you test positive, don't get them anymore because every time you get the test, you activate more memory cells and develop a significant response including vessicles.

You only need a chest xray from time to time
Where do you expect on chest film with TB?
-typically in apical and posterior segments of upper lobes and superior segments of lower lobes.
-May be atypical in immunosupressed.
-Does not confirm TB
How can you confirm TB?
ONLY BY CULTURE (not chest film)
Describe finding in xray
-Look for peripheral infiltrates plus lymphadenopathy to be the primary complex
-calcifications in lobe is called a Ghon focus.
-calcifications in lobe plus in lymph nodes is called a Ranke complex
What do you stain with for TB?
Acid fast to tell you if you have mycobacteria. Need a culture to differentiate mycobacterium.
What makes TB so bad?
It destroys the lung tissue. You get white caseating necrosis of the lungs and the patient ashyxiates because there is no lung left and what is left is filled with blood. You also get cavities. Most cavities begin in the periphery. The cavity erods through adjacent structures. If it gets to the bronchus it will cause hemoptysis and become very infectious.
what if they have back pain too?
Think Pott's disease which is TB of the spine
Do children's infections act differently than those of adults?
Yes, kids are more likely to have severe diffuse TB with TB meningitis, bone and joint involvement or disseminated TB.

Do not treat kids with Ethambutol because of toxicity in the eyes.

Treat children for 9-12 months and adults for only 6
Is TB different with HIV?
Obviously less likely to have cavities.

Also, they have higher relapse rates. TB drugs interfere with protease inhibitors and there is questionable absorption