Rr-Symptoms-Cough

Front 1

Differential of Cough

Back 1

• Infection
– Bacterial, fungal, viral
• Respiratory diseases
– Asthma, COPD, chronic sinusitis
• GI
– Acid reflux
• Medication side effect

Front 2

TB X-ray Pattern

Back 2

• Miliary pattern for TB
• Named after “millet seeds”
• “Lymphangitic spread”
• Other illnesses can cause similar appearance

Front 3

Lobar Pneumonia X-Ray Pattern

Back 3

• “Lobar pneumonia”
• Usually “typical bacteria”

Front 4

Atypical Pneumonia X-Ray Pattern

Back 4

• “Atypical pneumonia”
pattern
• “Ground glass”
• Atypical bacteria
• e.g.mycoplasma
• e.g.PJP (PCP)

Front 5

Normal X-Ray Pattern

Back 5

Front 6

MTB Risk Factors

Back 6

• Immunosuppression
– HIV, alcoholism, diabetes, chronic kidney
disease
• Endemic areas
– Mexico, India, Philippines, China, Vietnam
• Poverty
• Malnutrition

Front 7

MTB

Back 7

• Transmitted human-to-human via
aerosol droplets containing bacteria
• Acid-fast aerobic rod (unique
staining)
• Infects and survives within alveolar
macrophages for years-decades
• Host response includes formation of
granulomas to control infection
• 2 billion individuals latently infected, 8
million active infections and 2 million
deaths due to MTB annually

Front 8

MTB causes what types of infections?

Back 8

Active or Latent Infections

Front 9

Active cases of TB

Back 9

Due to "Reactivation" from latent infections

Front 10

Suppression of immune systems does what to TB?

Back 10

Greatly increases incidence of active or reactivation disease

Front 11

Characteristics of Active TB

Back 11

• Active replication of bacteria within granuloma
• Granuloma becomes “liquified” due to exaggerated immune response to control infection
• Cavitation can lead to expulsion of bacteria from lungs into sputum
• Those with active disease infectious to transmit organism

Front 12

What type of individual has the most risk factors for MTB?

Back 12

35 yo migrant worker from Mexico with diabetes, HIV seen in the ED for chronic cough with hemoptysis

Front 13

Diagnosing TB: Sputum Smear

Back 13

• AFB (Acid fast Bacillus)

• Requires ~ 5,000 bacilli per ml sputum for positive
ID

• However, HIV-infected individuals often test
sputum smear negative

Front 14

Diagnostic Tests for TB

Back 14

• Tuberculin skin test
• Interferon gamma release assay
• AFB smear and culture
• Nucleic acid amplification

Front 15

TST (Tuberculin Skin Test)

Back 15

• TST > 5 mm (induration!)- HIV, recent
contacts active MTB,immunosuppressed
(TX pts.), CXR c/w prior TB
• TST> 10 mm- < 5 years from endemic
area, IVDA, residents of jails, LTCF
• TST > 15 mm- all others
• Comment on anergy!

Front 16

TB: Interferon Gamma

Back 16

• < .35 IU/ml- negative
• > .35 IU/ml- positive

Front 17

NAAT

Back 17

DNA Amplification
Equipment reads intensity of fluorescent labeled probes
Can also test for rifampin resistance

Front 18

Which one of these lab test results is
diagnostic of active MTB?

Back 18

Sputum smear negative for acid fast bacillus, but culture positive for growth and nucleic acid amplification (NAA) test positive for MTB

Front 19

Treatment for TB

Back 19

Isoniazid, Rifampin, Pyrazinamide and Ethambutol

Front 20

How long is the initial phase of TB treatment?

Back 20

2 months

Front 21

How long is the continuation phase of treatment?

Back 21

4-7 months

Front 22

How does isoniazid exert its anti-tuberculous effect by inhibiting

Back 22

mycolic acid synthesis

Front 23

Why would you have a multiple drug cocktail and extended drug therapy duration for TB?

Back 23

• Antibiotics targeting different molecules
• MTB grows very slowly, difficult to kill all of
the bacteria
• Antibiotics most effective on “actively”
growing bacteria…not effective on latent or
dormant bacilli
• Minimize chance of developing antibiotic
resistant variants

Front 24

Cough Reflex

Back 24

Front 25

Acute Cough

Back 25

Less than 3 weeks

Front 26

Chronic Cough

Back 26

More than 3 weeks

Front 27

Common causes of acute cough

Back 27

 Common cold 60%
 Acute Bronchitis 20%
 Asthma 10%
 COPD 4%
 Environmental irritants 2%
 Influenza 2%

Front 28

Common cause of Chronic Cough

Back 28

Rhinitis

Front 29

Clues that the cough is due to rhinitis

Back 29

 “ I cough when I have a runny nose.”

 “I can feel something drip in the back of my throat.”

 “I have to constantly clear my throat.”

 “I cough more when I lay down.”

Front 30

Tonsils with a cobblestone pattern

Back 30

Inflamed pharyngeal mucosa/adenoid glands

Front 31

Allergic Rhinitis

Back 31

 Related to Eczema , Asthma.
 Have an itchy nose.
 Positive skin test and RAST test.
 Clear discharge

Front 32

Immunology of Allergy

Back 32

Front 33

Gustatory Rhinitis

Back 33

Triggered by eating

Front 34

Inflammatory Rhinitis - but no elevated IgE in serum

Back 34

Local tissues may show elevated IgE

Front 35

Treatment of nasal steroids

Back 35

Beclomethasone, Fluticasone
Binds to intracellular receptors, reduce inflammatory mediators

Front 36

Oral antihistamines

Back 36

Benadryl, Loratidine
Down regulates H1 receptors, decrease inflammatory mediators

Front 37

Cromolyn Sodium

Back 37

Mast cell stabilizer

Front 38

Nasal Ipratropium

Back 38

Reduces Substance P

Front 39

Leukotriene Inhibitors

Back 39

Montelukast

Front 40

GERD

Back 40

In 30% of chronic cough
 Esophageal-tracheobronchial cough reflex.
 ( Chemo receptors in the lower
esophagus)
 Direct laryngeal irritation.
 ( Chemo/mechanical receptors
receptors)
 Aspiration of gastric acid.
 ( Chemo/mechanical receptors
receptors)

Front 41

GERD Treatment

Back 41

 Weight loss , elevation of head of bed , Avoiding certain foods.

 Antacids: calcium carbonate

 H1 blockers: Famotidine

 Proton pump inhibitors: Omeprazole

 Surgical : Nissen fundoplication, Vagotomy , Gastric bypass

Front 42

How do ACE-I cause cough?

Back 42

Front 43

An 80-year-old female with past history of
Mycobacteria tuberculosis infection develops a
productive cough that is blood tinged. The
patient has a temperature of 39.4° C. A chest
radiograph was performed and was significant
for bilateral interstitial infiltrates. Sputum is
collected to determine if there has been a
reactivation of her past Mycobacteria
tuberculosis infection. What stain should be
performed because of its increased sensitivity in
this case?

Which stain should you use?

Back 43

Auramine-rhodamine stain

Front 44

A 20-year-old white man presents to the
hospital complaining of a 1-month history of
tingling sensations in his legs. He is on
treatment for pulmonary tuberculosis with
isoniazid. On examination you note a greasy
yellow scale over his scalp and eyebrows.
Laboratory investigations reveal a hemoglobin of
9 g/dl.

What is the most likely diagnosis?

Back 44

Pyridoxine Deficiency

Front 45

A 45-year-old man suffering from viral hepatitis
requires being started on antitubercular therapy
for pulmonary tuberculosis. He has icterus with
hepatomegaly, and his liver function tests are
moderately deranged. What antitubercular drug
combination is safest for this patient?

Back 45

Isoniazid + Streptomycin

Front 46

A 36-year-old man is admitted to isolation for
treatment of pulmonary tuberculosis, detected at
a routine checkup the day before. He works at a
construction site and has not been in contact with
any farm animals. Besides treatment, he needs to
be aware of the most common way to transmit
the disease. What contamination is usually
responsible for spread of the disease?

Back 46

Aerosol droplets

Front 47

An outbreak of respiratory illness occurred in
a day-care center involving children who had
not completed the primary vaccination series.
The illness was characterized by catarrhal
symptoms followed by paroxysmal cough. The
etiological agent of the outbreak was a small
Gram-negative coccobacillus that was isolated
from the nasopharyngeal aspirates of children
in the early phase of the illness. Bordet
Gengou medium was the selective medium
used for isolating the bacterial agent.

What is a characteristic of this bacterial
species that caused the outbreak?

Back 47

Can produce a symptomatic infection in adults

Front 48

These results indicate that the organism
causing the pulmonary infection in this
patient is what?

Back 48

Streptococcus pneumoniae

Front 49

A 45-year-old individual with a 20 pack-year history of
smoking presents because of a chronic cough. The cough has been worsening for the past 3 months. The patient does not have a primary care physician and usually visits the ER for exacerbations of his cough. What type of epithelium would be anticipated lining the larynx in this individual?

Back 49

Stratified squamous

Front 50

Most likely diagnosis?

Back 50

Sarcoidosis

Front 51

A 28-year-old woman presents with an itchy throat,
prolonged sneezing episodes, watery red eyes, and
inflamed nasal membranes. Her temperature is normal and a throat culture is negative. She is most likely suffering from allergic rhinitis. Her physician will most likely prescribe diphenhydramine. To what class of compounds does the drug of choice belong?

Back 51

Antihistamine (H1)

Front 52

A 28-year-old woman visits her doctor's office
complaining of an itchy throat, prolonged sneezing
episodes, watery red eyes, and inflamed nasal
membranes. Her temperature is normal and a throat
culture is negative. She is most likely suffering from
allergic rhinitis. Her physician will most likely prescribe which of the following?

Back 52

Diphenhydramine

Front 53

A 45-year-old individual with a 20 pack-year history
of smoking presents because of a chronic cough. The
cough has been worsening for the past 3 months. The
patient does not have a primary care physician and
usually visits the ER for exacerbations of his cough. What type of epithelium would be anticipated lining the larynx in this individual?

Back 53

Stratified Squamous