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Questions and Answers
What is the most common site for lung abscesses associated with necrotizing pneumonia?
What is the most common site for lung abscesses associated with necrotizing pneumonia?
- Right upper lobe (correct)
- Left lower lobe
- Right lower lobe
- Left upper lobe
Clubbing is a sign associated with acute abscesses in necrotizing pneumonia.
Clubbing is a sign associated with acute abscesses in necrotizing pneumonia.
False (B)
Which of the following is NOT a thick-walled cavity cause for lung cavities?
Which of the following is NOT a thick-walled cavity cause for lung cavities?
- Blastomycosis
- Asthma (correct)
- Abscess
- Necrotising SCC
What organisms are most commonly responsible for lung abscesses in necrotizing pneumonia?
What organisms are most commonly responsible for lung abscesses in necrotizing pneumonia?
Squamous Cell Carcinoma is the most common cause for lung cavities.
Squamous Cell Carcinoma is the most common cause for lung cavities.
The pathogenesis of necrotizing pneumonia includes consolidation and suppuration leading to _______.
The pathogenesis of necrotizing pneumonia includes consolidation and suppuration leading to _______.
Name two types of infections that can cause lung cavities.
Name two types of infections that can cause lung cavities.
The mnemonic for causes of lung cavities is _____
The mnemonic for causes of lung cavities is _____
Match the following clinical features with their descriptions:
Match the following clinical features with their descriptions:
Match the following causes of lung cavities with their respective categories:
Match the following causes of lung cavities with their respective categories:
Which of the following is NOT a clinical feature of atypical infection?
Which of the following is NOT a clinical feature of atypical infection?
Pontiac fever is classified as a mild form of infection.
Pontiac fever is classified as a mild form of infection.
What is the drug of choice (DOC) for treating the infection discussed?
What is the drug of choice (DOC) for treating the infection discussed?
Respiratory secretions will typically show ____ cells and neutrophils during Gram staining.
Respiratory secretions will typically show ____ cells and neutrophils during Gram staining.
Match the following tests to their respective characteristics:
Match the following tests to their respective characteristics:
Which of the following is characteristic of Mycoplasma pneumonia?
Which of the following is characteristic of Mycoplasma pneumonia?
Mycoplasma can cause pneumonia in immunocompromised patients.
Mycoplasma can cause pneumonia in immunocompromised patients.
What is the first-line treatment (DOC) for Mycoplasma pneumonia?
What is the first-line treatment (DOC) for Mycoplasma pneumonia?
Mycoplasma pneumonia is primarily transmitted through __________ infection.
Mycoplasma pneumonia is primarily transmitted through __________ infection.
Match the extrapulmonary manifestations of Mycoplasma pneumonia with their descriptions:
Match the extrapulmonary manifestations of Mycoplasma pneumonia with their descriptions:
Which of the following is NOT a characteristic feature of empyema?
Which of the following is NOT a characteristic feature of empyema?
Lung abscess treatment includes Vancomycin and Meropenem.
Lung abscess treatment includes Vancomycin and Meropenem.
What is the typical radiological finding in a lung cavity?
What is the typical radiological finding in a lung cavity?
Empyema is associated with ________ protein levels in pleural fluid.
Empyema is associated with ________ protein levels in pleural fluid.
Match the following characteristics with empyema and lung abscess:
Match the following characteristics with empyema and lung abscess:
Which of the following statements about Chlamydia is false?
Which of the following statements about Chlamydia is false?
Legionella is known for its ability to thrive in biofilms in aquatic bodies.
Legionella is known for its ability to thrive in biofilms in aquatic bodies.
What is the gold standard for serological investigation to diagnose Chlamydia infections?
What is the gold standard for serological investigation to diagnose Chlamydia infections?
Which imaging finding is characterized by a hazy, translucent area in the lungs?
Which imaging finding is characterized by a hazy, translucent area in the lungs?
The primary treatment for Legionella infections often includes __________.
The primary treatment for Legionella infections often includes __________.
Match the bacterial characteristics with the correct organism:
Match the bacterial characteristics with the correct organism:
AA amyloidosis is frequently seen in patients with tuberculosis, bronchiectasis, and lung abscess.
AA amyloidosis is frequently seen in patients with tuberculosis, bronchiectasis, and lung abscess.
What is the recommended duration of antibiotic therapy for the treatment discussed?
What is the recommended duration of antibiotic therapy for the treatment discussed?
Accumulation of fluid in the pleural space surrounding the lungs is referred to as _______.
Accumulation of fluid in the pleural space surrounding the lungs is referred to as _______.
Match the following complications with their descriptions:
Match the following complications with their descriptions:
Which of the following is a potential extrapulmonary manifestation of community-acquired pneumonia?
Which of the following is a potential extrapulmonary manifestation of community-acquired pneumonia?
Air bronchograms are a specific finding only observed in pneumonia.
Air bronchograms are a specific finding only observed in pneumonia.
What is indicated by the consolidation observed in the left lower lobe?
What is indicated by the consolidation observed in the left lower lobe?
The presence of ___ filling is described as a non-specific radiological finding.
The presence of ___ filling is described as a non-specific radiological finding.
Match the following findings with their descriptions:
Match the following findings with their descriptions:
What finding suggests a possible Klebsiella infection?
What finding suggests a possible Klebsiella infection?
A loss of the ascending aorta silhouette is a normal finding in community-acquired pneumonia.
A loss of the ascending aorta silhouette is a normal finding in community-acquired pneumonia.
Name one possible diagnosis based on the radiological findings associated with community-acquired pneumonia.
Name one possible diagnosis based on the radiological findings associated with community-acquired pneumonia.
What is a classic sign found in a focal suppurative lung abscess?
What is a classic sign found in a focal suppurative lung abscess?
Pneumatoceles are commonly observed in IV drug users.
Pneumatoceles are commonly observed in IV drug users.
What type of pneumonia is associated with bilateral dense consolidation on chest X-ray?
What type of pneumonia is associated with bilateral dense consolidation on chest X-ray?
Necrotizing pneumonia may be associated with _________, a bacterium that can lead to severe lung infection.
Necrotizing pneumonia may be associated with _________, a bacterium that can lead to severe lung infection.
Match the following pneumonia types with their key characteristics:
Match the following pneumonia types with their key characteristics:
What does the 'C' in the CURB-65 scoring system stand for?
What does the 'C' in the CURB-65 scoring system stand for?
A urea level greater than 7 mmol/L contributes to the CURB-65 scoring system.
A urea level greater than 7 mmol/L contributes to the CURB-65 scoring system.
What is one of the criteria used in the CURB-65 scoring system to indicate respiratory distress?
What is one of the criteria used in the CURB-65 scoring system to indicate respiratory distress?
The CURB-65 scoring system is primarily used to assess the ______________ of pneumonia.
The CURB-65 scoring system is primarily used to assess the ______________ of pneumonia.
Match the CURB-65 criteria to their corresponding indicators:
Match the CURB-65 criteria to their corresponding indicators:
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Study Notes
Lung Abscess
- Common causes: Aspiration pneumonia, necrotizing SCC, Wegener's granulomatosis, blastomycosis
- Aspiration Pneumonia: Chronic symptoms, often anaerobes, usually in posterior segment of right upper lobe
- Pathogenesis: Lung consolidation, suppuration, necrosis, rupture of abscess, purulent expectoration, abscess with air-fluid level
Causes of Lung Cavities
- Mnemonic: CAVITY
- Cancer (Squamous cell carcinoma, most common), Aspergillosis, Autoimmune (Wegener's granulomatosis), Abscess
- Aspergillosis, Autoimmune (Wegener's granulomatosis), Abscess
- Vascular (Emboli)
- Infection (Staphylococcus aureus, Klebsiella)
- Tuberculosis (TB)
- Young patients (congenital abnormality)
- Fungus (Cryptococcus, Aspergillus, Coccidioidomycosis)
Necrotizing Pneumonia
- Mode of transmission: Microaspiration, aerosolization
- Culture: Buffered charcoal yeast extract (BCYE) medium
- Gram staining: Pus cells, neutrophils present, no organisms seen
- Clinical features: Rapidly progressive, high fever, dense bronchial consolidation, leucocytosis
- Atypical features: Non-productive cough, GI symptoms, hyponatremia, elevated LFTs, thrombocytopenia, hematuria
- Diagnosis:
- "Mild" - Pontiac fever
- "Severe" - Legionnaires' disease
- Direct fluorescence antibody test (DFAT) - high specificity, urinary antigen testing - high specificity, sputum/aspiration testing - not usually done
- Risk factors: Poor cellular immunity (CMI), cigarette smoking, immunosuppression, hairy cell leukemia
- Treatment: Azithromycin (DOC) + Rifampicin, quinolones
Complications of Necrotizing Pneumonia
- Empyema: Macroscopic pus in pleural cavity, thickened parietal & visceral pleura, increased protein & LDH, decreased glucose, treated with intercostal drainage
- Lung abscess: Destruction of lung parenchyma, cavity formation, treated with vancomycin + meropenem + clindamycin for 6-8 weeks
- ARDS with MDR:
- Metastatic Infection (rare)
- Lung cavity: Gas-filled space, often caused by expulsion of necrotic debris via bronchial tree, air fluid level, thickening of wall after sealing of cavity
Mycoplasma
- Characteristics: Smallest free-living organism capable of replication, no cell wall, beta-lactams ineffective, sterols present, no flagella
- Diseases: Tracheobronchitis/pharyngitis, Pneumonia (10%)
- Extrapulmonary manifestations: Cold antibody autoimmune hemolytic anemia, Steven Johnson Syndrome (SJS)/erythema multiforme, Guillain Barre Syndrome (GBS), encephalitis, bullous myringitis, myocarditis/pericarditis, arthralgia, adenopathy
- Transmission: Droplet infection
- Investigations: X-ray, CT, reticulonodular/patchy consolidation, interstitial involvement, ground glass appearance, tree in bud appearance, serology, PCR (rapid and most sensitive)
- Culture: PPLO agar (Dienes' method), biphasic with fried-egg appearance
- Treatment: Azithromycin, doxycycline, respiratory quinolones
- Prognosis: Good
- Pathogen: Hydrogen peroxide and superoxide produced by organism leading to epithelial cell injury
Chlamydia Pneumoniae
- Characteristics: Obligate intracellular bacteria, lack of peptidoglycan, human-to-human transmission
- Elementary body: Extracellular, metabolically inactive, infectious form
- Clinical Features: Prolonged asymptomatic upper respiratory tract infection, atypical pneumonia (10%), "walking pneumonia", low-grade fever, minimal sputum, dry cough
- Investigation: Isolation by HEP-2 cells, serology (microimmunofluorescence- gold standard), absence of lobar consolidation
- Treatment: Resistant to sulfonamides, azithromycin, doxycycline
Legionella
- Characteristics: Gram-negative, predominantly intracellular, strict aerobes, motile, partially acid-fast
- Locations: Aquatic bodies (contaminated water), microcolonies within biofilms
- Virulence: Type 1 serovar - most pathogenic, pathogenic factor - Type 4 secretion system
- Extrapulmonary manifestations: Cold antibody autoimmune hemolysis, Steven Johnson's syndrome, Guillain Barre syndrome
Community Acquired Pneumonia (CAP) - Radiologic Findings
- Air Bronchogram: May be observed in pneumonia, can be present in cardiogenic pulmonary edema
- Consolidation: Opacification on x-ray, suggests fluid/inflammation, left lower lobe consolidation, right upper lobe consolidation, lobar consolidation
- Loss of left heart silhouette: Loss of normal heart shape on x-ray/CT
- Intact diaphragm silhouette
- Loss of ascending aorta silhouette
- Collapse of right upper lobe
- Golden S/Reverse S sign & Bulging Fissure Sign: Suggestive of Klebsiella infection
- Shifting of mediastinum to same side
- Non-specific air filling: Air-filled spaces, suggestive of potential illness
CAP - Possible Diagnoses
- Klebsiella infection
Imaging Findings:
- Ground glass opacity: Hazy, translucent areas in the lungs.
- Pleural effusion: Fluid accumulation in the space surrounding the lungs.
- Consolidation: Lung tissue filled with fluid or inflammatory material.
- Thick-walled cavity: Localized collection of pus or material surrounded by a dense wall.
- Air-fluid levels: Air and fluid in the same space within a cavity.
CAP - Complications
- Metastatic infection
- Pyopneumothorax
- Bronchopleural fistula
- AA amyloidosis (secondary amyloidosis)
Differential Diagnosis of AA Amyloidosis:
- Tuberculosis (TB)
- Malignancy
- Nocardia
- Actinomycetes
CAP - Treatment:
- Antibiotics with postural drainage
- Vancomycin + Piptaz + Clindamycin (anaerobes)
- 6-8 weeks of therapy
- Response: Fever resolution in 7-10 days
- Surgery: For MDR organisms if unresponsive to treatment
Pneumonia with Multiple Pneumatocele
- Pathogenesis: Dense white opacity on x-ray representing mass, consolidation, or nodule.
- Focal Supurative Lung Abscess: Necrosis and destruction of lung parenchyma, bursts into bronchus, air entry into abscess, gas within consolidation surrounded by wall (minimum 4mm thick), air-fluid levels present (classic sign), cavity formation (thick walled or thin walled).
- Myoplasma/Chlamydia: Minimal interstitial infiltrates, often misdiagnosed as normal.
- Legionella: Bilateral dense consolidation.
- Bronchopneumonia: Air space opacification, consolidation.
- Fibrosis:
- Fibrocalcific scar post TB: (Description likely refers to a healed Tuberculosis infection)
- Necrotizing Klebsiella: Upper lobe involvement, bulging fissure sign.
- Pneumatocele, cyst, bulla: Often seen in IV drug abusers, post viral infection, may progress to cavity, associated with MRSA, size greater than 4mm.
Scoring of Pneumonia
- CURB-65: Assessment of severity
- Confusion
- Urea greater than 7 mmol/L
- Respiratory rate greater than 30/min
- Blood pressure less than 90 mmHg systolic or 60 mmHg diastolic
- Age 65 years or older
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