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EVERYTHING YOU NEED TO KNOW ABOUT CHEST INFECTIONS Khadeejah Hullemuth and Johanne Li Reviewed by Dr Kajal Aubeeluck Here’s what we do: ■ Weekly tutorials open to all! ■ Focussed on core presentations and teaching diagnostic technique If you’re new here… ■ Bstudentsl students, for medical ■ Reviewed by doctors to ensure W elcome to accuracy T eaching ■ We’ll keep you updated about our Things! upcoming events via email and groupchats!Learning objectives 1. Identify the key causes of pneumonia and atypical pneumonias 2. List the investigations indicated in pneumonia and outline management 3. Review chest radiographs for key respiratory presentations 4. Identify, investigate and manage para-pneumonic pleural effusions 5. Recall how active and latent TB may present, including risk factors 6. Understand the investigations and management indicated in TBTuberculosis & Lung Abscesses Johanne LiSBA 1 A 64yo woman presents to the outpatients respiratory clinic with a 2w history of low grade fevers, weight loss and a productive cough, that is occasionally tinged with blood. A CXR reveals patchy consolidation in the upper lobe of the rightlung. What is most likely to be seen in the sputum on Ziehl-Neelsen (ZN) staining? A) Blue, rod shaped organisms against a red background B) Red, rod-shaped organisms against a blue background C) Green, coccoid organisms against a purple background D) Red , rod-shaped organisms against a yellow background E) Blue, coccoid shaped organisms against a red backgroundSBA 1 A 64yo woman presents to the outpatients respiratory clinic with a 2w history of low grade fevers, weight loss and a productive cough, that is occasionally tinged with blood. A CXR reveals patchy consolidation in the upper lobe of the rightlung. What is most likely to be seen in the sputum on Ziehl-Neelsen (ZN) staining? A) Blue, rod shaped organisms against a red background B) Red, rod-shaped organisms against a blue background Causative organism of TB: Mycobacterium Tuberculosis ● Waxy coating ● Aerobic, slow dividingPresentation may be - latent - active - multisystemic Transmission is via respiratory droplets in the air Risk factors ● Immunosuppression esp HIV ● High risk country: South Asia, Eastern Europe ● Exposure to infected close contacts ● Homelessness ● Elderly Patients Presentation may be latent, active, and systemic. Transmission is via respiratory droplets in the air Droplets deposit in the alveoli → macrophages release cytokines Immediate clearance Inadequate immune response Formation of caseating granuloma and containment Active/primary disease Latent infection Haematogenous dissemination Reactivation disease ‼Immunosuppression Miliary TbPathology Initial exposure Asymptomatic, or flu-like symptoms 3/52 later, type IV T cells recognise antigens -> immune response, localised lung lesion of inflammation: caseating hypersensitivity granuloma aka Ghon focus Lymphatic spread of Ghon focus + hilar lymph nodes = Ghon complex bacteria Fibrosis, Fibrosis = collagen deposits in granuloma + lymph calcification, healing Calcification = calcium deposits, visible as nodules on CXR Scar tissue of healed lesion = Ranke complex Droplets deposit in the alveoli → macrophages release cytokines Inadequate immune response ● Gradual onset, low grade fever ● Dyspnoea, Chest pain Active/primary disease ● Cough ○ Initially dry, later productive, +/- haemoptysis Haematogenous ● Night sweats, weight loss, anorexia, malaise dissemination Extrapulmonary symptoms: ● Lymphadenopathy Miliary Tb ● Skeletal pain ● Abdominal pain, swelling ● Urinary symptomsSBA 2 67yo man presents to the ED with a 5w history of cough, weight loss and malaise. His daughter has recently travelled back from India and is also unwell. A Tb diagnosis is clinically suspected; which of the following investigations is the gold standard investigation? A) Mantoux Test (TST) B) CXR C) Sputum culture D) Sputum acid fast bacilli smear E) CT ChestSBA 2: Investigations 67yo man presents to the ED with a 5w history of cough, weight loss and malaise. His daughter has recently travelled back from India and is also unwell. A Tb diagnosis is clinically suspected; which of the following investigations is the gold standard investigation? Bilat hilar A) Mantoux Test (TST) lymphadenopathy B) CXR C) Sputum culture Upper zone D) Sputum acid fast bacilli smear cavitation E) CT Chest Screening Bedside Bloods Imaging Mantoux (TST) Sputum: Smear and culturFBC, CRP, U&Es, LFTs CXR Interferon Gamma Release Urine MCS HIV testing Joint/Spinal Xrays Assays ECG CT head Lymphadenopathy US Echo Management Active infection: RIPE for 2/12, RI for 4/12 RIPE Latent: RIP for 3/12, IP for 6/12 Rifampicin Isoniazid + Pyridoxine (why?) Pyrazinamide Ethambutol Sputum smears and cultures should be obtained monthly until 2 consecutive cultures are -veSBA 3 55yo woman presents to her GP complaining of some changes to her vision.She has noticed that the colours red and green appear “washed out”. She was recently started on a course of antibiotics after presenting to A&E with night sweats, cough and a low grade fever. What drug is responsible for her symptoms? A) Isoniazid B) Rifampicin C) Ethambutol D) Pyridoxine E) PyrazinamideSBA 3 55yo woman presents to her GP complaining of somechanges to her vision. She has noticed that the colours red and green appear “washed out”. She was recently started on a course of antibiotics after presenting to A&E with night sweats, cough and a low grade fever. What drug is responsible for her symptoms? A) Isoniazid B) Rifampicin C) Ethambutol D) Pyridoxine E) Pyrazinamide Management: side effects Red/orange discolouration of fluids CYP450 enzyme inducer RIPE Hepatotoxic Rifampicin Peripheral neuropathy Isoniazid + Pyridoxine CYP450 inhibitor Hepatotoxic Pyrazinamide Ethambutol my peripheries! Eye-thambutol Hyperuricaemia → Gout Arthralgia Optic neuritisPublic Health England: Close contacts of Tb Identifying, testing and treating those at higher risk of latent infection due to infected contacts Contact tracing Contact identified Contact screened : Bloods, Mantoux +/or CXR BCG vaccineSBA 4 78yo M is admitted due to recurrent episodes of fever, chest pain and a productive cough with foul smelling sputum. His past medical history is significant for a recent pneumonia infection. CXR shows a round lesion in the right lung. What is the most likely diagnosis? A) Pleural effusion B) Tuberculosis C) Pleural empyema D) Lung abscess E) Lung cancerSBA 4 78yo Mr X is admitted due to recurrent episodes of fever, chest pain and a productive cough with foul smelling sputum. His past medical history is significant for a recent pneumonia infection. CXR shows a round lesion in the right lung. What is the most likely diagnosis? A) Pleural effusion B) Tuberculosis C) Pleural empyema D) Lung abscess E) Lung cancerLung abscess Collection of pus in the parenchyma, causing a fluid-filled cavity. Usually due to necrosis Risk factors: ● Aspiration ○ Poor oral hygiene ● Immunosuppression ● Necrotising pneumonia ● Tb ● IE ● Thoracic trauma or recent surgeryPresentation P/w: ■ Productive cough with foul smelling sputum – +/- haemoptysis ■ SOB ■ Lethargy ■ Night sweats, weight loss O/e: ■ Finger clubbing ■ Dullness on percussion ■ Reduced air entry over the abscessWhat investigations should we order for Mr X?What investigations should we order for Mr X? Which lobe is most commonly affected? Bedside Bloods Imaging ■ FBC (↑WBC) ■ CXR: well demarcated round ■ Sputum sample ■ CRP lesion with an air-fluid level (MC&S and ■ LFTs, U&Es ■ CT Chest culture) ■ Cultures ■ Bronchoscopy ■ ClottingSBA 5 Mr X is stabilised after admission. Given his diagnosis of lung abscess, what is would be the most appropriate next step in management? A) Order a bronchoscopy B) Start a course of oral antibiotics C) Refer for chest physiotherapy D) Insert a chest drain E) Start a course of IV antibioticsSBA 5 Mr X is stablised after admission. Given his diagnosis of lung abscess, what is would be the most appropriate next step in management? A) Order a bronchoscopy not routine unless sputum and cultures fail to reach a diagnosis B) Start a course of oral antibiotics should be given parentally to allow better penetration C) Refer for chest physio helpful after for mucus clearance, but must be managed medically first D) Insert a chest drain next step if poor response to antibiotics E) Start a course of IV antibioticsManagement 1. Broad spectrum IV Abx e.g co-amoxiclav for 2-3w 2. Switch to PO Abx for 4-8w following local guidelines Conservative: Oxygen, analgesia, antipyretics, IV fluids, physiotherapy Indications for surgical management (percutaneous/bronchoscopy drainage or lung resection) ■ Underlying lung malignancy ■ Significant haemoptysisPneumonia, Bronchitis and Pleural Effusions Khadeejah HullemuthLike everyone and their nan this winter season, Nu Moneeya is a 78yo woman presenting to A&E with a productive cough. Take a history (in the chat!)78yo woman presenting with a cough ● 4/7 productive cough - green sputum ● Fever ● Headachetigue / weak ● Tried paracetamol and lemon and honey tea, no improvement ● No CP ● No blood in sputum ● No LOC at any point ● No recent hospitalisation ● Drinks 2 units a week and has never smokedSBA 1 78yo Nu Moneeya presenting with a fever and 4/7 hx of a productive cough with green sputum. She drinks 2 units of alcohol a week. What is the most likely infectious organism that has caused her symptoms? A. Staphylococcus Aureus B. Listeria monocytogenes C. Klebsiella pneumoniae D. Streptococcus pneumoniae E. Haemophilus Influenza BSBA 1 78yo Nu Moneeya presenting with a fever and 4/7 hx of a productive cough with green sputum. She drinks 2 units of alcohol a week. What is the most likely infectious organism that has caused her symptoms? A. Staphylococcus Aureus B. Listeria monocytogenes C. Klebsiella pneumoniae D. Streptococcus pneumoniae E. Haemophilus Influenza BWhat organism is most likely to have caused pneumonia in the following very common SBA stems?? 1. People with ETOH excess? 2. People who have returned from a holiday in the sunshine with dodgy air conditioning? 3. People after a 5 day stay in hospital 4. People after an influenza infection 5. Patients with COPD** 6. Immunocompromised patients / those with cystic fibrosis **a little less common in SBA landWhat organism is most likely to have caused pneumonia in the following very common SBA stems?? 1. People with ETOH excess? Klebsiella pneumoniae 2. People who have returned from a holiday in the sunshine with dodgy air conditioning? Legionella pneumophila 3. People after a 5 day stay in hospital? MRSA 4. People after a influenza? Staphylococcus Aureus 5. Patients with COPD?** Haemophilus influenzae 6. Immunocompromised patients / those with cystic fibrosisPseudomondas aeruginosa / Pneumocystis jirovecii **a little less common in SBA land Causes of pneumonia Infectious agent Name SBA stem Features Streptococcus pneumoniae 80% of bacterial pneumonia Klebsiella pneumoniae EtOH excess “Currant red sputum” Aspiration pneumonia = Bacterial Staphylococcus Aureus Post viral ill essly from stroke/pts with swallowing difficulties. Must Haemophilus influenzae COPD ptsclude MDT meeting/SaLT involvement in management of Legionella pneumophila Dodgy aircona little OSCE tip forHyponatemia Bacterial Mx = eyrthromycin / clarithromycin Chalmydia psittaci Parrot owners Mycoplasma pneumoniae Younger person, neurological Mx = eyrthromycin / features, erythema nodosum clarithromycin Coxiella Burnetti (Q fever) Exposure to bodily fluids in animals (farmer w a flu) Influenza Most common viral aetiology Viral Respiratory Syncytial Virus Infants / elderly (RSV) Fungal Pneumocystis jirovecii ImmunocompromisedAtypical pneumonia Definition: Those that do not gram stain / not covered by normal antibiotics “Legions of pistachio MCQs”A quick note on HAPs vs CAPs CAPs = pneumonia developing before or within 48 hours of admission HAPs = anything from then CAP = Community Acquired Pneumonia HAP = Hospital Acquired PneumoniaSBA 2 78yo Nu Moneeya presenting with a fever and 4/7 hx of a productive cough with green sputum. She drinks 2 units of alcohol a week. What is the single best criteria that can be used to assess the management of this patient? A. HASBLED B. AMTS C. CURB-65 D. MUST E. Waterlow Test yourself by answering what the otherfortions areSBA 2 78yo Nu Moneeya presenting with a fever and 4/7 hx of a productive cough with green sputum. She drinks 2 units of alcohol a week. What is the single best criteria that can be used to assess the management of this patient? A. HASBLED - risk of patients bleeding on anticoag B. AMTS - confusion C. CURB-65 D. MUST - malnutrition E. Waterlow - risk of skin ulcersSBA 3 78yo Nu Moneeya presenting with a fever and 4/7 hx of a productive cough with green sputum. She drinks 2 units of alcohol a week. What investigations would be needed to risk stratify this patient? A. FBCs and U&Es B. Urine dip and AMTS C. CXR and FBC D. CXR, FBC and LFTs E. U&Es and AMTSSBA 3 78yo Nu Moneeya presenting with a fever and 4/7 hx of a productive cough with green sputum. She drinks 2 units of alcohol a week. What investigations would be needed to risk stratify this patient? A. FBCs and U&Es B. Urine dip and AMTS C. CXR and FBC D. CXR, FBC and LFTs E. U&Es and AMTS Remember urine dip is not very helpful in patients > 60 Investigations Bedside → ECG + Observations + Sputum Culture + AMTS Bloods → ABG + Blood culture/Staining + FBC + U&E + CRP + Urinary antigen Imaging → CXR + CT Chest (if suspecting complications)Y our consultant is a little mean and asks you to justify why you’re doing the following investigations: 1. FBC 3. ABGnary antigen 4. Blood cultureYour consultant is a little mean and asks you to justify why you’re doing the following investigations: 1. FBC - infection markers (amongst others!) 3. ABG - if oxygenation levels are lowegionella suspicion 4. Blood culture - for more appropriate abx once results returnSBA 4 78yo Nu Moneeya’s investigations lead the following results: HR 110 RR 33 O2 94% BP 118/80 Urea - 10.1 (2.5 - 7.8) AMTS 9/10 What is her CURB 65 score? A. 0 B. 1 C. 2 E. 4SBA 4 78yo Nu Moneeya’s investigations lead the following results: HR 110 RR 33 O2 94% BP 118/80 Urea - 10.1 (2.5 - 7.8) AMTS 9/10 A quick note: CKD patients may haurea due to impaired renaled What is her CURB 65 score? function… but this wouldn’t add a point to the CURB score unless it A. 0 was a significant deviation from B. 1 their norm C. 2 D. 3 E. 4An X ray… What framework would you use to interpret it?An X ray Details Exposure)ation, Inspiration, Penetration, Airways Breathing Circulation Diaphragm Everything else SBA 5 How would you describe this consolidation? A. Right upper lobe consolidation B. Left upper lobe consolidation C. Right upper zone consolidation D. Right upper and middle lobe consolidation E. Left upper zone consolidation SBA 5 How would you describe this consolidation? A. Right upper lobe consolidation B. Left upper lobe you consolidation C. Right upper zone consolidation D. Left upper and middle lobe consolidation E. Left upper zone consolidation CXR Cheat sheet 1 (Shoutout to Imran Malik from 2023/4 Teaching Things team!) Right upper zone Bilateral lower/middle patchy opacification zones reticular Right sided homogenous with air bronchograms shadowing opacification with a meniscus PNEUMONIAE ILD PLEURAL EFFUSION CXR Cheat sheet 2 (Shoutout to Imran Malik from 2023/4 Teaching Things team!) Loss of right lung markings Air under right PNEUMOTHORAX Right sided white out with hemidiaphragm tracheal deviation towards PNEUMOPERITONEUM lesion LUNG COLLAPSE SBA 6 What can you see an example of on this CXR? A. Normal B. Pleural effusion C. Bronchitis D. Idiopathic pulmonary fibrosis E. No clue Practice going through your DR even if you know the answer SBA 6 What can you see an example of on this CXR? A. Normal B. Pleural effusion C. Bronchitis D. Idiopathic pulmonary fibrosis E. No clue SBA 7 How would you manage this pleural effusion? A. Treat the pneumonia and let it settle B. Chest drains within 24 hours C. Ultrasound D. Pleural aspirate E. Unsure SBA 7 How would you manage this pleural effusion? A. Treat the pneumonia and let it settle B. Chest drains within 24 hours C. Ultrasound D. Pleural aspirate E. Unsure WHY? Ex = ‘Ex life’ cells die, inflammation, cancer etc Light’s criteria EXUDATIVE IF…. ● Pleural protein / serum protein > 0.5 ● Pleural LDH / Serum LDH > 0.6 ● Pleural LDH is ⅔ the upper limit of the normal range Careful not to confuse with SAAG (serum ascites for ascitesdient)Bronchitis - a quick note A lot less high yield but worth knowing about Cause ● Viral (RSV, rhinovirus, adenovirus and coronavirus), Hx ● Productive cough, sore throat, rhinorrhea. ● May have low grade fever / wheeze Mx 1. Supportive management (fluids, analgesia) 2. Doxycycline if CRP>100 or systemically unwell 3. Could consider delayed script if CRP < 100SBA 8 A 41-year-old man has felt unwell for 5 days. He has a cough productive of green sputum with an occasional reddish tinge. He has been feeling hot and cold, particularly at night, and has pain in the right side of his chest. He has smoked ten cigarettes a day for 25 years. T 37.8°C, HR 100bpm, BP 115/80mmHg, RR 22/min, SaO 2 93% on air. There are basal crepitations on the right side of the chest. Which is the single most likely diagnosis? A Bronchial carcinoma B Community-acquired pneumonia C Sarcoidosis D Tuberculosis E Wegener’s granulomatosisSBA 8 A 41-year-old man has felt unwell for 5 days. He has a cough productive of green sputum with an occasional reddish tinge. He has been feeling hot and cold, particularly at night, and has pain in the right side of his chest. He has smoked ten cigarettes a day for 25 years. T 37.8°C, HR 100bpm, BP 115/80mmHg, RR 22/min, SaO 2 93% on air. There are basal crepitations on the right side of the chest. Which is the single most likely diagnosis? A Bronchial carcinoma B Community-acquired pneumonia C Sarcoidosis D Tuberculosis E Wegener’s granulomatosis SBA 9 A 31-year-old woman has been increasingly short of breath for the past 3 weeks. She sweats at night, has a non-productive cough, and has lost 5kg. T 37.6°C, HR 95bpm, BP 100/60mmHg, SaO 2 92% on air (decreased to 86% on exertion). She is cachectic and has thick white patches on her tongue. Her chest X-ray is as follows Which is the single most likely diagnosis? A Bronchial carcinoma B Lymphoma C Pulmonary tuberculosis D Pneumocystis jiroveci pneumonia E Sarcoidosis SBA 9 A 31-year-old woman has been increasingly short of breath for the past 3 weeks. She sweats at night, has a non-productive cough, and has lost 5kg. T 37.6°C, HR 95bpm, BP 100/60mmHg, SaO 2 92% on air (decreased to 86% on exertion). She is cachectic and has thick white patches on her tongue. Her chest X-ray is as follows Which is the single most likely diagnosis? A Bronchial carcinoma B Lymphoma C Pulmonary tuberculosis D Pneumocystis jiroveci pneumonia E Sarcoidosis THANKS FOR WATCHING! Tutor 2: Khadeejah Hullemuth Please fill out the feedback form on Medall and see you next week!