Respiratory Block - Goljan Viruses/bugs/etc...

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Rhinovirus

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- Most common cause of the common cold
- Transmitted by hand to eye-nose contact
- Other causes of colds—coronaviruses, adenoviruses, influenza C virus, coxsackievirus

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Coxsackievirus

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- Acute chest syndrome: fever with pleuritis

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RSV

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- Most common viral cause of atypical pneumonia and bronchiolitis (wheezing) in children; otitis media in older children
- Occurs in late fall and winter
- Rapid diagnosis with antigen detection in nasopharyngeal wash
- Passive immunization: palivizumab (monoclonal antibody) reduces hospitalization rates

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Parainfluenza

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- Most common cause of croup (laryngotracheobronchitis) in infants
- Inspiratory stridor (upper airway obstruction) due to submucosal edema in trachea; brassy cough; signs of respiratory distress
- Anterior x-ray of neck shows "steeple sign." representing mucosal edema in the trachea (site of obstruction)
- Bronchiolitis in infants
- Treatment: cold water humidifiers and aerosolized racemic epinephrine

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CMV

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- Common pneumonia in immunocompromised hosts (e.g., bone marrow transplants, AIDS)
- Enlarged alveolar macrophages/pneumocytes, contain basophilic intranuclear inclusions surrounded by a halo.

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Influenzavirus

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- Type A viruses are most often Involved
- Hemagglutinins bind virus to cell receptors in the nasal passages
- Neuraminidase dissolves mucus and facilitates release of viral particles
- Influenza A; worldwide epidemics; pneumonia may be complicated by a superimposed bacterial pneumonia (usually Staphylococcus aureus)
- Influenza B: causes major outbreaks
- Antigen drift: minor mutation; does not require new vaccine
- Antigen shift: major mutation in hemagglutinin or neuraminidase; new vaccine required
- Clinical: fever, headache, cough, myalgias, chest pain
- Vaccination: mandatory for people > 65 years old, people wilh chronic illnesses
- Treatment: neuraminidase inhibitors zanamivir. oseltamivir
- Associations: Reye syndrome with salicylate ingestion; Gulllain-Barre syndrome

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Rubeola

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- Fever, cough, conjunctivitis, and excessive nasal mucus production
- Koplik spots in the mouth precede onset of lhe rash
- Warthin-Finkeldey multinucleated giant cells are a characteristic finding

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SARS

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- Infects lower respiratory tract and then spreads systemically
- First transmitted lo humans through contact with masked palm civets (China) and then from human-to-human contact through respiratory secretions (e.g., hospitals, families)
- Develop severe respiratory infection
- Diagnose with viral detection by PCR assay or detection of antibodies

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Hantavirus pulmonary syndrome

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- Transmission: inhalation of urine/feces from deer mice in Southwestern United States
- Pulmonary syndrome; ARDS, hemorrhage, renal failure
- Diagnosis; detect viral RNA in lung tissue
- No effective treatment
- High mortality rate

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Chlomydophilia pneumoniae

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- Second most common cause of atypical pneumonia
- Seroepidemiologic association wilh coronary artery disease
- Treatment: doxycycline

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Chlamydia trachomatis

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- Newborn pneumonia (passage through birth canal)
- Afebrile, staccato cough (choppy cough), conjunctivitis, wheezing
- Treatment: erythromycin

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M. pneumoniae

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- Most common cause of atypical pneumonia
- Common in adolescents and mililary recruits (closed spaces)
- Insidious onset with low-grade fever
- Complications: bullous myringitis, cold autoimmune hemolytic anemia due to anti-1-IgM antibodies.
- Treatment: erythromycin; azithromycin; clarithromycin
- Cold agglutinins in blood

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Coxiella burnetii

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- Usually transmitted without a vector
- Contracted by dairy farmers, veterinarians
- Associated with the birthing process of infected sheep, cattle, and goats, and handling of milk or excrement
- Atypical pneumonia, myocarditis, granulomatous hepatitis
- Treatment; doxycycline

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Streptococcus pneumoniae

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- Gram-positive lancet-shaped diplococcus
- Most common cause of typical community-acquired pneumonia
- Rapid onset, productive cough, signs of consolidation
- Urine antigen test excellent screen
- Treatment: penicillin C; amoxicillin

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Staphylococcus aureus

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- Gram-positive cocci in clumps
- Yellow sputum
- Commonly superimposed on influenza pneumonia and measles pneumonia
- Major lung pathogen in cystic fibrosis and IV drug abusers
- Hemorrhagic pulmonary edema, abscess formation, and tension pneumatocysts (intrapleural blebs), which may rupture and produce a tension pneumothorax.
- Treatment: TMP-SMX

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Corynebacterium diphtheriae

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- Gram-positive rod
- Toxin inhibits protein synthesis by ADP-ribosylation of elongation factor 2 involved in protein synthesis
- Toxin also impairs B-oxidation of fatty acids in the heart
- Toxin-induced pseudomembranous inflammation produces shaggy gray membranes in the oropharynx and trachea; toxic myocarditis (death)
- Treatment; erythromycin

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Bacillus anthracis

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- Gram-positive rod
- Habitat: soil
- Capsule inhibits phagocytosis
- Exotoxins: edema factor (activates adenylate cyclase); lethal factor (inhibits a signal transduction protein involved in cell division); protective antigen (assists entry of above toxins into cells)
- Transmission: direct contact with animal skins or products {most commonly sheep and cattle) and entry of the organisms through abrasions or cuts; inhalation (use in germ warfare)
- Cutaneous anthrax (90-95% of cases): occurs through direct contact with infected or contaminated animal products; resembles insect bite but eventually swells to form a black scab, or eschar, with a central area of necrosis ("malignant pustule"); if untreated, death occurs in 20% of patients
- Pulmonary anthrax; "first sign of the disease is death"; inhalation of spores present in contaminated hides or germ warfare; necrotizing pneumonia, meningitis, pronounced splenomegaly, and dissemination throughout the rest of lhe body
- Prevention: vaccine available for high-risk patients; e.g., veterinarians, soldiers entering developing countries
- Treatment: ciprofloxacin

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Actinomyces israeli

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- Gram-positive filamentous bacteria; strict anaerobe; normal flora in tonsils and adenoids
- Produces draining sinuses in the jaw, chest cavily. and abdomen: pus contains sulfur granules (yellow specks) that contain the bacteria
- Treatment: ampicillin or penicillin C

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Nocardia asteroides

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- Gram-positive filamentous bacteria; strict aerobe; partially acid-fast
- Produces granulomatous microabscesses in the lungs
- Frequently disseminates to the CNS and kidneys
- Treatment; TMP-SMX

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Bordetella pertussis

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- Gram-negative rod
- Pili attach to cilia in upper respiratory tract; toxin stimulates adenylate cyclase, which catalyzes the addition of ADP-ribose to the inhibitory subunit of the G protein complex; toxin also produces absolute lymphocytosis (normal-appearing lymphocytes) often in leukemoid reaction range
- Produces whooping cough, transmitted by droplet infection
- Catarrhal phase: lasts 1-2 weeks; mild coughing, rhinorrhea, conjunctivitis
- Paroxysmal coughing phase: lasts 2-5 weeks; characteristic 4-5 coughs in succession on expiration followed by an inspiratory whoop; absolute lymphocytosis (20,000-50,000 cells/mm>)
- Convalescence phase: lasts 1-2 weeks; slow decline in coughing and lymphocytosis
- Complications: hemorrhage into skin, conjunctiva, bronchus, brain from coughing; otitis media; meningoencephalitis (10%); rectal prolapse from coughing; pneumonia (most common cause of death in children < 3 years old; children < 1 year old have no protection from mother's immunoglobulins)
- Diagnosis: nasopharyngeal swabs using special cough plate; direct immunofluorescence of swab material
- Treatment: erythromycin

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Haemophilus influenzae

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- Gram-negative rod
- Common cause of sinusitis, otitis media, conjunctivitis ("pinkeye")
- Inspiratory stridor may be due to acute epiglottitis
- Swelling of epiglottis produces "thumbprint sign" on lateral x-ray of the neck
- Most common bacterial cause of acute exacerbation of COPD
- Trealment: cefotaxime; ceftriaxone

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Moraxella catarrhalis

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- Gram-negative diplococcus
- Common cause of typical pneumonia, especially in the elderly
- Second most common pathogen causing acute exacerbation of COPD
- Common cause of chronic bronchitis, sinusitis, otitis media
- Treatment; amoxicillin-clavulanate

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Pseudomonas aeruginosa

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- Green sputum (pyocyanin)
- Water-loving bacteria most often transmitted by respirators
- Most common cause of nosocomial pneumonia and death due to pneumonia in cystic fibrosis
- Pneumonia often associated with infarction due to vessel invasion
- Treatment: antipseudomonal beta-lactam 4- aminoglycoside + antipseudomonal quinolone or macrolide

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Klebsiella pneumoniae

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- Gram-negative fat rod surrounded by a mucoid capsule
- Most common gram-negative organism causing lobar pneumonia and typical pneumonia in elderly patients in nursing homes
- Common cause of pneumonia in alcoholics; however, S. pneumoniae is still the most common pneumonia
- Atypical pneumonia associated with blood-tinged, thick, mucoid sputum
- Lobar consolidation and abscess formation are common
- Treatment: ceftriaxone

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Legionella pneumophila

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- Gram-negative rod (requires IF stain or Dieterle silver stain to identify in tissue)
- Antigens can also be detected in urine
- Water-loving bacterium (water coolers; mists in produce section of grocery stores; outdoor restaurants in summer; rain forests in zoos)
- Risk factors: alcoholic, smoker, immunosuppression
- Pneumonia associated with high fever, dry cough, flu-like symptoms
- May produce tubulointerstitial disease with destruction of the JC apparatus leading to hyporeninemic hypoaldosteronism (type IV renal tubular acidosis—hyponatremia, hyperkalemia, metabolic acidosis)
- Urine antigen test excellent screen
- Treatment: fluoroquinolone; azithromycin

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Yersinia pestis

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- Gram-negative rod
- Cause of plague
- Transmitted by bite of rat flea; primary reservoir for bacteria are ground squirrels in the Southwest
- Also transmitted person-to-person by droplet infection
- Macrophages cannot kill bacteria due to protection by V and W antigens
- Three types of disease; bubonic (most common), pneumonic (transmitted by aerosol), septicemic
- Bubonic type: bite by rat flea that has recently bitten an infected ground squirrel; infected lymph nodes enlarge (usually in the groin), mat together, and drain to the surface (buboes)
- Treatment:
Pneumonic type: gentamicin + doxycycline
Bubonic type; gentamicin or streptomycin

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Cryptococcus neoformans

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- Budding yeast with narrow-based buds; surrounded by a thick capsule. Found in pigeon excreta (around buildings, outside office windows, under bridges)
- Primary lung disease (40%): granulomatous inflammation with caseation
- Treatment: Fluconazole

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Aspergillus fumigatus

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- Fruiting body and narrow-angled (<45 degrees), branching septate hyphae
- Aspergilloma; fungus ball (visible on x-ray) that develops in a preexisting cavity in the lung (e.g., old TB site); cause of massive hemoplysis
- Allergic bronchopulmonary aspergillosis: type I and type III hypersensitivity reactions; IgE levels increased; eosinophilia intense inflammation of airways and mucus plugs in terminal bronchioles. Repeated attacks may lead lo bronchiectasis and interstitial lung disease; treatment with corticosteroids
- Vessel invader with hemorrhagic infarctions and a necrotizing bronchopneumonia
- Treatment: voriconazole

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Mucor species

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- Wide-angled hyphae (>45 degrees) without septa
- Clinical settings: diabetes, immunosuppressed patients
- Vessel invader and produces hemorrhagic infarcts in the lung
- Invades the frontal lobes in patients with diabetic ketoacidosis (rhinocerebral mucormycosis)
- Treatment: amphotericin B

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Coccidioides immitis

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- Spherules with endospores in tissues
- Contracted by inhaling arthrospores in dust while living or passing through arid desert areas in the Southwest (valley fever); increased after earthquakes (increased dust)
- Flu-like symptoms and erythema nodosum (painful nodules on lower legs; inflammation of subcutaneous fat)
- Granulomatous inflammation with caseous necrosis
- Treatment; usually self-limited; if severe: itraconazole or fluconazole

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Histoplasma capsulatum

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- Most common systemic fungal infection
- Endemic in Ohio and central Mississippi river valleys
- Inhalation of microconidia in dust contaminated with excreta from bats (increased incidence in cave explorers, spelunkers), starlings, or chickens (common in chicken farmers)
- Granulomatous inflammation with caseous necrosis
- Yeast forms are present in macrophages
- Simulates TB lung disease; produces coin lesions, consolidations, miliary spread, and cavitation
- Marked dystrophic calcification of granulomas; most common cause of multiple calcifications in the spleen
- Treatment: usually self-limited; if severe, itraconazole or amphotericin B

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Blastomyces dermatitidis

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- Yeasts have broad-based buds and nuclei
- Occurs in Great Lakes region, central, and southeastern United States
- Male dominant disease
- Produces skin and lung disease; skin lesions simulate squamous cell carcinoma
- Granulomatous inflammation with caseous necrosis
- Treatment; itraconazole or amphotericin B

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Pneumocystis jirovec

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- Cysts and trophozoites present; cysts attach to type 1 pneumocytes
- Primarily an opportunistic infection; occurs when CD4 count < 200 cells/mm3,
- Most common initial AIDS-defining infection
- Patients develop fever, dyspnea, and severe hypoxemia
- Diffuse intra-alveolar foamy exudates with cup-shaped cysts best visualized with silver or Giemsa stains
- Chest x-ray shows diffuse alveolar and Interstitial infiltrates
- Treatment: TMP-SMX given prophylactlcally when CD4 counts < 200 cells/mm3