Lecture 10. Consolidation Syndromes PDF

Lecture X Consolidation Syndromes Dr. Popa Stefan Dr. Valentin Militaru CONTENTS 1. Pneumonia 2. Bronchopneumonia 3. Pulmonary infarction 4. Fibrosis – interstitial lung diseases 5. Lung tumors 6. Lung abscess PULMONARY CONSOLIDATION It can be produced by any pathological process tha...

Lecture X Consolidation Syndromes Dr. Popa Stefan Dr. Valentin Militaru CONTENTS 1. Pneumonia 2. Bronchopneumonia 3. Pulmonary infarction 4. Fibrosis – interstitial lung diseases 5. Lung tumors 6. Lung abscess PULMONARY CONSOLIDATION It can be produced by any pathological process that increases the density of the lung parenchyma, by replacing the alveolar air with an exudate or other products (neoplastic cells) This can be caused by: ▪ Pneumonia ▪ Bronchopneumonia ▪ Pulmonary infarction ▪ Fibrosis – interstitial lung diseases ▪ Lung tumors ▪ Lung abscess CRITERIA TO BE ACCESSIBLE TO PHYSICAL EXAMINATION I. size of the lesion should exceed 4 cm, II. location must be close to the thoracic surface, III. there must be sufficient thickness of the consolidation IV. the bronchus corresponding to the consolidation must be permeable PULMONARY CONSOLIDATION = SYNDROME History Taking + Physical Examination ↓ Clinical Diagnosis = Syndrome + Complementary Examinations (Blood Tests, ECG, X ray, Ultrasound, Magnetic Resonance, Computer Tomography, Endoscopy) Final Diagnosis = Positive Diagnosis  History Taking: Cough + Expectoration + Fever + Chest Pain Physical Examination: Dullness, Crackles Pulmonary Consolidation Syndrome Pneumonia Pulmonary Infarction Aspiration Pneumonitis Lung Cancer Young patient Fever X-Ray, Sputum test Crackles Final Diagnosis = Positive Diagnosis PNEUMONIA DEFINITION ▪ inflammation of the alveolar space and/or the interstitium, that leads to pulmonary consolidation. ▪ it is important to be aware that it is not a single disease but rather a spectrum or group of diseases, considering the multitude of causative agents. CLASSIFICATION I. Community-acquired (typical or atypical) = CAP II. Hospital-acquired pneumonia = (HAP), also known as nosocomial pneumonia III. Ventilator-associated pneumonia = (VAP) CLASSIFICATION Regarding the site of the inflammation: I. LOBAR (one lobe, but there is also multilobe pneumonia)/SEGMENTAL II. BRONCHOPNEUMONIA (multiple foci of consolidation in both lungs) III. INTERSTITIAL (inflammation in the interstitial spaces of lungs) ETIOLOGY ▪ BACTERIA: Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, Klebsiella pneumoniae ▪ VIRUSES (Respiratory syncytial virus [RSV], Adenovirus, Influenza A, B and C viruses, Parainfluenza viruses type 1, 2, 3, and 4, Coronavirus) ▪ ATYPICAL AGENTS = BACTERIA: Legionella, Mycoplasma pneumoniae, Chlamydia pneumoniae, Chlamydia psittaci ▪ FUNGI: Aspergillus, Cryptococcus, Pneumocystis, Candida SYMPTOMS ▪ fever ▪ cough (productive with purulent or a blood-tinged sputum/ nonproductive) ▪ pleuritic chest pain - severe ▪ chills or rigors ▪ dyspnea ▪ herpes ▪ headache ▪ nausea ▪ vomiting ▪ diarrhea ▪ myalgia ▪ arthralgia ▪ fatigue PHYSICAL EXAMINATION A. GENERAL PHYSICAL EXAMINATION - fever that typically drops down “in crisis” - tachycardia - red face - facial flushing (slap sign) - labial herpes - sleepiness - confusion B. PULMONARY PHYSICAL EXAMINATION INSPECTION: normal/ tachypnea PALPATION: reduced chest expansion; increased tactile and vocal fremitus PERCUSSION: dullness over the affected area AUSCULTATION: ▪ whispered pectoriloquy ▪ egophony, bronchial breath sounds/harsh vesicular breath ▪ crackles only in congestion and resolution phases  Pectoriloquy = increased resonance of the voice through the lung structures, so that it is clearly comprehensible using a stethoscope on the chest. It usually indicates consolidation of the underlying lung parenchyma. 2 types: - egophony - bronchophony Egophony = increased resonance of voice sounds – enhanced transmission of high-frequency sound across fluid, lower frequencies filtered out → high-pitched nasal or bleating quality of the voice Bronchophony = atypical increase in the intensity and clarity of the individual's spoken voice heard when auscultating the lungs with a stethoscope PARTICULAR CLINICAL FORMS OF PNEUMONIA ▪ depending on symptoms: abortive (pulmonary congestion) vs. prolonged, hypertoxic ▪ depending on localization: central (no typical thoracic pain and scarce physical examination) vs. massive (the exudate is present even in the lobar bronchi) ▪ related to special groups (categories): children, elderly, alcoholics COMPLICATIONS - parapneumonic pleural effusion - recurrent pneumonia - bronchiectasis - abscess, empyema - mediastinitis - endocarditis, meningitis - sepsis  What is the difference between pleural effusion and parapneumonic effusion? - parapneumonic effusion = pleural effusion that forms in the pleural space adjacent to a pneumonia (through inflammation) - complicated parapneumonic effusion (empyema) = microorganisms infect the pleural space - empyema can also develop in the absence of an adjacent pneumonia INVESTIGATIONS CHEST X-RAY - posteroanterior (PA) ± lateral - the first imaging technique - opacity of a segment/ lobe (corresponding with the localization of the pathological findings during physical examination) - possible complications CT scan: - needed in some patients – more valuable information - more precise localization and characterization - guide the diagnosis/rule out differential diagnoses INVESTIGATIONS LABORATORY TESTS - complete blood cell count – leucocytosis, neutrophilia, „left shift” of the Arneth’s count - high level of C-reactive protein (CRP) - arterial blood gas (ABG) measurements (pH, PaO2, PaCO2) - diagnostic - respiratory failure - prognostic information - sputum microscopy and culture - difficult to obtain, inadequate quantity - blood cultures – children, severe cases - in some cases: - culture of lower respiratory secretions (e.g., bronchoalveolar lavage) - other fluids (e.g., urine - Legionella urinary antigen test) - PCR testing are needed.  PATIENT WITH COVID- 19 PNEUMONIA 6 CHEST COMPUTER SCANS DEATH AFTER 3 MONTHS OF EVOLUTION BRONCHOPNEUMONIA DEFINITION ▪ multiple focal areas of consolidation, in one or multiple lobes ▪ bilateral pulmonary involvement. ▪ elderly, infants and in patients with debilitating diseases like: cancer heart failure cerebrovascular disease SYMPTOMS - chills or rigors, fever 40°C, with altered mental status - atypical thoracic pain - dyspnea - cyanosis - cough (nonproductive or productive), expectoration - headache - nausea - vomiting - diarrhea - myalgia - arthralgia - fatigue  PHYSICAL EXAMINATION - similar with pneumonia - higher intensity of the symptoms compared to physical examination findings - discordance between the altered general status and physical examination INSPECTION: superficial breaths, tachypnoea, wheezing PALPATION: reduced chest expansion; augmented tactile and vocal fremitus (for confluent consolidations > 10-12 cm) PERCUSSION: dullness AUSCULTATION: lack of normal breath sounds, the presence of crackling sounds (rales), or increased loudness of whispered speech (whispered pectoriloquy), wheezing + associated signs if pleural effusion is associated INVESTIGATIONS The investigations needed are similar with those for pneumonia, and in some cases extensive work-up needs to be performed e.g.: bronchoalveolar lavage, PCR testing BRONCHOPNEUMONIA ATYPICAL (INTERSTITIAL) PNEUMONIA DEFINITION Inflammation that involves lung parenchyma – the alveoli, alveolar wall, capillary endothelium, and spaces between these structures, perivascular and lymphatic tissues. It is caused by atypical organisms that are not detectable on Gram stain and cannot be cultured using standard methods: Mycoplasma, Chlamydia species, Legionella species, Coxiella burnetii (Q fever). SYMPTOMS - insidious with an acute upper respiratory tract infection - predominance of the general symptoms: fever, chills, asthenia, headache, myalgias, arthralgias, fatigue, loss of appetite, weight loss, joint stiffness, - sweating and clammy skin, diarrhea, ear pain, eye pain or soreness, rash, sore throat - respiratory symptoms: persistent nonproductive cough, mild dyspnea, haemoptysis, wheezing, chest pain or substernal discomfort - in idiopathic cases, dyspnea is the chief complaint PHYSICAL EXAMINATION Might be normal, but we may also encounter: INSPECTION: tachypnea PERCUSSION: dullness AUSCULTATION: ▪ diminished vesicular breath sounds, ▪ end-inspiratory dry crackles; ▪ if there is also bronchiolitis: scattered late inspiratory high-pitched ronchi “inspiratory squeaks” may be encountered INVESTIGATIONS in some cases, extensive work-up need to be performed such as specific testing: - urinary Legionella antigen - sputum culture for Legionella - molecular diagnosis for Mycoplasma pneumoniae or Chlamydophila pneumoniae: multiplex real-time polymerase chain reaction (PCR) - serology for atypical pathogens (Chlamydophila antibodies) There are several peculiarities concerning imaging: ▪ Chest X-ray: range from normal to pulmonary consolidation and increased reticular markings (honeycombing, reticular shadows, or ground-grass opacity) bilateral; also,it can detect complications such pneumothorax, or lung abscess. ▪ High-resolution CT (HRCT) allows better detection of subtle parenchymal or airflow disease. LUNG ABSCESS DEFINITION: necrosis of the pulmonary tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection Classification of lung abscess is related to I. DURATION OF THE DISEASE Acute: 6 weeks II. ETIOLOGY ▪ Primary: caused by aspiration (of oropharyngeal secretions, necrotizing pneumonia) ▪ Secondary: (hematogenic dissemination, direct spread from infections – e.g., mediastinitis, bronchogenic obstruction, complication of flu, measles, especially in immunosuppressed patients) III. SPREADING BRONCHOGENIC (aspiration of oropharyngeal secretions, bronchial obstruction by tumor, foreign body, enlarged lymph nodes that compress the bronchi, congenital malformations of the bronchi) HEMATOGENIC (from a sepsis source, e.g., infective endocarditis septic thromboembolisms) ETIOLOGY ▪ Staphylococcus Aureus ▪ Anaerobic agents, Aspergillus, B. Fragilis ▪ Fungi LUNG ABSCESS TYPICALLY EVOLVES IN THREE PHASES PHASE I ▪ may mimic an acute pneumonia ▪ possibly consolidation PHASE II ▪ after 8-10 days, the patient will present a high quantity of sputum which can be evacuated either in small portions or in one big portion (fr. vomique). PHASE III ▪ suppurative ▪ characterized by periods in which symptoms aside or aggravate. Only after the formation of a cavity, physical examination will show findings related to cavitary lung disease. SYMPTOMS - malaise - weight loss - low grade fever usually in anaerobic infections and >38.5° C in other infections - chills - foul-smelling sputum (typical, almost pathognomonic sign) - anorexia - clubbing of the fingers - possible gingivitis and/or periodontal disease PHYSICAL EXAMINATION - pulmonary consolidation 1. dullness on percussion 2. reduced breath sounds 3. bronchial breath sounds 4. coarse inspiratory crackles - the amphoric or cavernous breath sounds are rarely elicited in practice, and they can be encountered only after a cavity was formed - lung abscesses may be accompanied by an empyema if the bacteria reach the pleural space or if there is a direct communication between the abscess and pleura.  EMPYEMA Defined as a collection of pus in the pleural cavity or culture from the pleural fluid. Empyema is usually associated with pneumonia but may also develop after thoracic surgery or thoracic trauma. INVESTIGATIONS - similar to pneumonia: laboratory examinations, chest X-ray, CT scan, and depending on the localization, other examinations may be necessary such as: - bronchoscopy - cultures of the specimen brushings/ bronchoalveolar lavage samples obtained via bronchoscopy PULMONARY INFARCTION (PI) DEFINITION ▪ PI is defined as an acute obliteration of a branch of the pulmonary artery that leads to pulmonary consolidation. ▪ Not all pulmonary embolisms lead to infarction. ▪ a complication of a disease (pulmonary embolisms, malignancy, vasculitis, sickle cell disease). ▪ Only when ischemia of lung tissue is not reversible, leading to histopathological modifications, the pulmonary infarction will present with clinical consolidation findings. ETIOLOGY ▪ caused by a thrombus that migrates and lodges in the pulmonary arterial circulatory system. ▪ thrombi or thrombo-emboli originate in the venous system, more frequently the deep venous system, ▪ in situ in the pulmonary artery. ▪ OTHER CAUSES: septic or tumoral emboli, infections (aspergillosis), vasculitis, malignancies, sickle cell disease, amyloidosis. SYMPTOMS ▪ Since PE (Pulmonary embolism) is the leading cause of a PI, presenting symptoms for PI frequently overlap with those of PE. ▪ Patients with PE may present no symptoms, mild symptoms, or severe symptoms, reaching to obstructive shock. - dyspnea - sharp chest pain (pleuritic chest pain), - cough, hemoptysis or blood-stained sputum, - palpitations, syncope PHYSICAL EXAMINATION - anxiety (extreme anxiety) - dyspnea - fever - tachycardia (increase in pulse rate and no elevation of temperature – Mahler’s sign ) - syncope - hypotension - possible signs of DVT (unilateral pitting edema, Homans’s sign, Lisker’s sign) - haemoptysis or blood-stained sputum  PHYSICAL RESPIRATORY EXAMINATION ▪ Typical pulmonary consolidation findings with permeable bronchi. ▪ Depending on the location – peripheral, lesion size (< 4 or > 4 cm), presence of complications (pleurisy) during physical respiratory examination typical pulmonary consolidation findings, cavitary lung disease (abscess and cavity formation) or pleural disease (pleural friction rub) may be found. ▪ Since PE is a challenging diagnosis, several clinical scores have been proposed in order to assess the probability of PE using clinical ± paraclinical data. ▪ The most frequently used score in clinical practice is the Wells score  Investigations Laboratory: elevated levels of D-dimers (> 500 ng/mL), can be suggestive for pulmonary embolism and DVT (deep vein thrombosis) Chest X-ray pulmonary infarction is described as a wedge-shaped opacity with its base pointing towards the pleural cavity, with bulging borders, and the apex pointing towards the hilum, corresponding to the “Hampton hump”, a sign- wedge-shaped pleural-based opacity pointing towards the hilum INVESTIGATIONS PLANAR VENTILATION/PERFUSION (V/Q (LUNG) SCINTIGRAPHY shows underperfused zones (rarely used today) COMPUTED TOMOGRAPHY PULMONARY ANGIOGRAPHY (CTPA) is the preferred imaging technique. The contrast agent fills the pulmonary vessels and any filling defects are interpreted as pulmonary emboli. INVESTIGATIONS ECHOCARDIOGRAPHY – gives valuable information in stratifying risk, guiding management, monitoring response to therapy, appreciating prognosis in certain patients (high-risk or unstable patients). ELECTROCARDIOGRAM: right axis deviation of the QRS axis, sinus tachycardia, typical pattern of “S1Q3T3”, right atrial enlargement, complete or incomplete right bundle branch block, ST segment elevation in V1 and aVR. LUNG TUMORS ▪ Benign and malignant tumors located in the lungs may be the cause of a pulmonary consolidation. ▪ Malignant tumors are either primary or secondary – metastasis from other cancers such as breast, digestive, etc. SYMPTOMS ▪ 15% of patients asymptomatic, diagnosed on certain occasions, such as periodical examinations or those related to employment. ▪ In other patients, the symptoms are discreet - paucisymptomatic patients. ▪ Lung cancer patients may present a multitude of symptoms and signs, generated by the local tumor, invasion or obstruction of nearby structures, metastasis or secondary to tumor products (paraneoplastic syndromes). ▪ It is not unusual that the first complaint is one caused by a complication or a metastasis. SYMPTOMS ▪ Cough is frequently encountered and is resistant to treatment. It may be accompanied by rust-colored sputum or hemoptoic expectoration, with blood or, rarely, with tumoral fragments. ▪ Chest pain is present in patients where the tumor is in direct contact with the pleura or when there is metastasis. ▪ Dyspnea or aggravation of preexistent dyspnea, wheeze or stridor may be the main symptoms. SYMPTOMS Regarding the symptoms that are induced by the primary tumor, 2 situations can be encountered: 1. those generated by central tumors: cough, dyspnea, hemoptysis 2. those generated by peripheral tumors: cough, dyspnea, chest pain due to pleural involvement (pleural effusion, infiltration of parietal pleura) and chest wall infiltration THE PANCOAST TOBIAS SYNDROME ▪ In pulmonary tumors located apically, due to local invasion. ▪ This syndrome gathers a constellation of symptoms, including ipsilateral shoulder and arm pain, paresthesia, paresis and atrophy of the thenar muscles of the hand, and Claude Bernard Horner's syndrome due to cervical sympathetic nerve involvement 1. MIOSIS 2. ENOPHTHALMOS 3. PTOSIS 4. IPSILATERAL LOSS OF SWEATING [ANHIDROSIS] BRONCHOPULMONARY TUMORS ARE ASSOCIATED WITH PARANEOPLASTIC SYNDROMES - endocrinological syndromes: syndrome of inappropriate ADH secretion (SIADH), ectopic Cushing’s syndrome, acromegaly - neurological syndromes: neuropathies (subacute sensitive neuropathy); Lambert-Eaton myasthenic syndrome; cerebellar degeneration - rheumatological syndromes: hypertrophic pulmonary osteoarthropathy ,inflammatory myopathies - glomerular diseases: nephrotic syndrome: glomerulopathies - dermatological syndromes: acanthosis nigricans - hematological: hypercoagulability PARANEOPLASTIC SYNDROMES ▪ Paraneoplastic syndromes are a group of rare and diverse medical conditions that are triggered by an underlying malignancy, such as cancer. ▪ These syndromes are not directly caused by the local effects of the tumor or its metastases, but rather result from the body's immune response to the presence of the cancer. ▪ Paraneoplastic syndromes can affect various organ systems and produce a wide range of symptoms.  PARANEOPLASTIC SYNDROMES ▪ The exact mechanisms behind paraneoplastic syndromes are not fully understood, but they often involve the production of autoantibodies or abnormal immune system responses to tumor-related antigens. ▪ These immune responses can lead to inflammation and dysfunction in different parts of the body, including the nervous system, endocrine system, skin, and connective tissues. ▪ Paraneoplastic syndromes can manifest with neurological symptoms (paraneoplastic neurological syndromes), such as muscle weakness, difficulty with coordination, and sensory disturbances, or with systemic symptoms, such as fever, weight loss, and skin rashes. ▪ Early recognition and diagnosis of these syndromes are essential, as they may precede the detection of the underlying cancer.  ACANTHOSIS NIGRICANS ▪ Acanthosis nigricans is a skin condition characterized by the development of dark, thickened, and velvety patches or streaks of skin, typically in the folds and creases of the body. ▪ These affected areas may appear brown or black and often have a rough texture. Acanthosis nigricans is not a disease itself but rather a cutaneous (skin) manifestation that can be associated with an underlying medical condition, such as obesity, insulin resistance, type 2 diabetes, hormonal disorders, paraneoplastic syndromes or certain cancers. ▪ The darkening and thickening of the skin in acanthosis nigricans result from an overproduction of skin cells and an increase in the skin's pigmentation. ▪ It is often seen in areas like the neck, armpits, groin, and inner thighs. ▪ While acanthosis nigricans can be benign and harmless, it may also serve as a clinical marker for an underlying health issue. GENERAL PHYSICAL EXAMINATION ▪ Pallor ▪ Cyanosis ▪ Malnutrition ▪ Fever ▪ Hypertrophic osteoarthropathy RESPIRATORY PHYSICAL EXAMINATION Depending on the tumor size, location, complications associated diseases (cardiac disease, e.g., heart failure – hydrothorax): pulmonary consolidation (in peripheral tumors in contact with the pleura), physical examination may reveal ▪ atelectasis (obstruction of a bronchia) ▪ pleural disease findings ▪ cavitary lung disease findings (after necrosis, if the liquefication necrosis is evacuated) ▪ mediastinal syndrome ▪ no modification INVESTIGATIONS ▪ HISTOLOGICAL EXAMINATION IS MANDATORY. ▪ In order to obtain the histological diagnosis, sputum cytologic studies, bronchoalveolar lavage or specimens procured via bronchoscopy, CT-guided transthoracic needle biopsy, or ultrasound guided transthoracic needle biopsy can be used depending on the location of the tumor – central/ peripheral. ▪ Chest X-ray is usually the first line examination and can detect a spiculated mass (opacity), complications as necrosis, atelectasis, or mediastinal lymph nodes. ▪ CT-scan allows better characterization of the lesion, especially those located in the mediastinum or in the hilar region. ▪ Bronchoscopy allows direct identification of the tumor (if the tumor has bronchial extension) or indirect signs (compression). During bronchoscopy, samples can be obtained through washing, brushing and biopsy. ▪ Lung ultrasound is used for peripheral tumors in contact with the pleura and permit guided biopsy. Impossible to know if the tumour is benign of malignant without a biopsy and histological examination for this reason histological examination is mandatory. THANK YOU