Infectious pulmonary diseases
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INFECTIOUS PULMONARY DISEASES. Module H Pneumonia -Chapter 15 (pp. 224-241) Lung Abscess - Chapter 16 (pp. 242-249) Tuberculosis – Chapter 17 (pp. 250-259) Avian Flu SARS Fungal Diseases - Chapter 18 (pp. 260-271). Pneumonia. Inflammatory Process Gas Exchange areas of the lung.

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Infectious pulmonary diseases

INFECTIOUS PULMONARY DISEASES

Module H

Pneumonia -Chapter 15 (pp. 224-241)

Lung Abscess - Chapter 16 (pp. 242-249)

Tuberculosis – Chapter 17 (pp. 250-259)

Avian Flu

SARS

Fungal Diseases - Chapter 18 (pp. 260-271)


Pneumonia

Pneumonia

  • Inflammatory Process

    • Gas Exchange areas of the lung.

  • Alveolar Consolidation

    • Alveoli become filled with fluid, RBC, WBC and macrophages.

  • 2 million cases/year with 40,000 to 70,000 deaths.

    • 6th leading cause of death

    • “Old Man’s Friend”


Etiology

Etiology

  • Bacteria

  • Viruses

  • Fungi

  • Rickettsia

  • Protozoa

  • Anaerobic organisms


Pneumonia vs pneumonitis

Pneumonia vs. Pneumonitis

  • Pneumonia is an infection with an inflammatory response and consolidation of the lung parenchyma.

  • Pneumonitis is an inflammatory response due to a non-infectious agent.


Aspiration pneumonitis

Aspiration Pneumonitis

  • Etiology

    • Strokes

    • Neuromuscular disease

    • Decreased level of consciousness

      • Alcoholics

      • Drug Abuse

      • Head Injury

  • Chemical (Mendelson’s Syndrome)

    • Inhalation of gastric acid


Types of pneumonia

Types of Pneumonia

  • Lobar Pneumonia

    • Involves the entire lobe

  • Segmental (Lobular)

  • Bronchopneumonia

    • Alveoli contiguous to an bronchi

  • Interstitial Tissues

  • Double Pneumonia: Both lungs

  • Walking Pneumonia: Mild form of pneumonia

    • Mycoplasma Pneumoniae

  • Necrotizing Pneumonia


At risk patients

At Risk Patients

  • Elderly

  • Chronic Disease

    • Diabetes, Renal Disease, Alcoholics

  • Immunosuppressed Patients

    • Cancer patients

    • AIDS

    • Transplant patients

    • Malnutrition

    • Patients on steroids

  • Burn victims

  • Leukemia

  • Drug abuse


Classification of pneumonia

Classification of Pneumonia

  • Nosocomial

    • Diagnosed 48 hours after hospital admission.

    • Ventilator Associated Pneumonia (VAP) is a subset of nosocomial infections.

  • Community –Acquired Pneumonia

    • Outside a health care setting.


Pneumonia during mechanical ventilation

Pneumonia during Mechanical Ventilation

  • Use of a modified Clinical Pulmonary Infection Score (CPIS)

    • If score is above 6, pneumonia is likely.


Bacterial etiology gram

Bacterial Etiology – Gram +

  • Streptococcal (Pneumococcal) Pneumonia

    • Most common (80%)

    • 80 different types

    • Pneumococcal Vaccine

  • Staphylococcal Pneumonia

    • Staphylococcal aureus

      • Primary causative agent

      • Methicillin-resistant (MRSA)

    • Staphylococcal epidermidis

      • Normal flora


Bacterial etiology gram1

Bacterial Etiology – Gram -

  • Rare in “healthy” hosts

    • Klebsiella pneumoniae (Friedlander’s Bacillus)

      • Lobar Pneumonia

      • Older men and alcoholics

    • Pseudomonas aeruginosa

      • Chronically ill, tracheotomized patients

    • Haemophilus influenzae

      • Second most common community acquired pneumonia (CAP) to Streptococcus pneumoniae

      • Secondary to viral infection

      • Type B is pathogenic

        • HIB vaccine has reduced incidence


Bacterial etiology gram2

Bacterial Etiology – Gram -

  • Legionella pneumonphila

    • American Legion in 1976

    • 30+ species

  • Escherichia coli

    • GI tract normal flora

  • Enterobacter sp.

  • Enterococcus sp.

    • Normal flora in GI tract

    • Vancomycin Resistant Enterococcus (VRE)

  • Proteus sp.

  • Serratia marcesens


Antibiotic resistant respiratory bacterial pathogens

Antibiotic Resistant Respiratory Bacterial Pathogens

  • Methacillian Resistant Staphylococcus Aureus (MRSA)

    • Treated with Vanomycin

  • Vancomycin Resistant Enterococcus(VRE)

    • Normally found in GI tract

    • Nearly impossible to treat

    • Treated with teicoplanin & Synercid


Viral pneumonia

Viral Pneumonia

  • 90% of acute upper respiratory tract infections are caused by viruses.

  • 50% of lower respiratory tract infections are due to viruses.


Types of viral pneumonias

Types of Viral Pneumonias

  • Influenza Virus

    • Types A and B are the most common

    • Winter months

  • Respiratory Syncytial Virus (RSV)

    • Bronchiolitis in infants & pneumonias in elderly

  • Parainfluenza Viruses

    • 5 types

      • Type 1, 2, 3, 4A and 4B

    • Type 1 is associated with croup infections

  • Adenovirus


Types of viral pneumonias1

Types of Viral Pneumonias

  • Varicella

    • Chickenpox & pneumonia

  • Rubella

    • German Measles & pneumonia

  • Rubeola

    • Measles

  • Cytomegalovirus (CMV)

    • Member of the herpes virus

    • Usually seen in AIDS patients


Other causes of pneumonia

Other Causes of Pneumonia

  • Mycoplasma Pneumoniae (Primary Atypical Pneumonia)

    • Walking Pneumonia

    • Young (5 to 35 years of age)

  • Rickettsiae

    • Rocky Mountain Fever, Typhus, Q fever

    • Transmitted by fleas, ticks, mites

  • Chlamydia Psittaci (Psittacosis)

    • Found in respiratory tract and feces of a variety of birds

      • Parrots, parakeets, cockatoos, chickens, pigeons

    • Transmitted to humans via aerosol or direct contact

    • Chlamydia Pneumoniae


Other causes of pneumonia1

Other Causes of Pneumonia

  • Pneumocystis carinii

    • Opportunistic, often fatal, form of pneumonia seen in immunocompromised patients.

    • Has been thought to be a protozoa but more recently, information suggests a fungus.

    • Major cause of pneumonia in AIDS patients.


Fungal infections

Fungal Infections

  • AIDS patients and patients on steroids

    • Histoplasma capsulatum

    • Coccidioides immitis

    • Blastomyces dermatitidis

    • Candida albicans

      • Oral thrush

    • Aspergillus

  • Treatment

    • Amphotericin B (IV)

    • Nystatin

    • Fluconazole


Infectious pulmonary diseases

  • Aspergilloma


Tuberculosis

Tuberculosis

  • One of the oldest diseases – 4,000 B.C.

  • 1.5 Billion cases worldwide

    • 15 million of these are active

  • TB is still prevalent in US

    • 15,000 cases/year – 50% occur in patients born outside the US

    • Highest incidence in SE US, inner cities, homeless & jails

  • HIV infection is the greatest single medical risk factor (no defense mechanism)

  • Age has traditionally been considered an independent risk factor (greater chance of exposure)


Tuberculosis1

Tuberculosis

  • Chronic disease requiring months of treatment.

    • Suboptimal treatment can result in drug-resistant TB.

  • TB can affect many organs in the body but most common location is the lungs.

    • BrainKidneys

    • BonesGenital tract

  • TB is caused by mycobacterium tuberculosis.

    • Produces a tubercle (lesion) that undergoes caseation.

    • Highly aerobic & like to grow in areas with high oxygen tension

    • Brain, lung apex

  • TB has airborne mode of transmission

    • Transmitted within aerosol droplets from cough/sneeze & can remain suspended in the air for several hours


Tuberculosis2

Tuberculosis

  • Initial infection results in no sickness, no symptoms, and the individual is not contagious (Latent TB).

  • Active TB occurs with immunosuppression.

    • AIDS, Young, Old, Cancer, substance abuse

  • Treatment is multiple first line drug therapy for 6 or 9 months

  • There is an emergence of drug resistant strains of TB (MDR-TB)

    • Cure rate is poor


Categories of tuberculosis

Categories of Tuberculosis

  • Primary TB

  • Post-primary TB

  • Disseminated TB


Primary tb

Primary TB

  • First exposure to the pathogen

  • Bacilli implant in the alveoli & multiply over 3-4 weeks

  • Inflammatory reaction

    • Leukocytes, macrophages move into the area to engulf (but not kill) the bacilli

    • Alveolar Consolidation

  • Positive TB reaction

  • WBC normal


Infectious pulmonary diseases

Protective Cell Wall

2-10 weeks

Neutrophils

TB Bacilli & Macrophages

Fibroblasts

Lymphocytes

Tubercle or granuloma


Infectious pulmonary diseases

Caseous Lesion

  • Necrosis

  • Cottage Cheese

  • Caseation


Infectious pulmonary diseases

Healing

  • Fibrosis

  • Calcification

  • Retraction of lung tissue


Post primary tuberculosis

Post-primary Tuberculosis

  • Reactivation of the tuberculosis months or years after the initial infection

  • Most patients recover completely but the live tubercle bacilli can remain dormant for decades

    • May reactivate in patients with weakened immunity

  • Positive TB test

  • Cavity formation and possible rupture


Disseminated tuberculosis

Disseminated Tuberculosis

  • Bacilli escape from the tubercle and rapidly disseminate to other parts of the lung or other organs

    • Move via the lymphatics or bloodstream

  • Miliary Tuberculosis

    • Small tubercles scattered throughout the body via blood stream.


Symptoms

Symptoms

  • General malaise

  • Cough with sputum production

    • Minimal initially, gradually increasing

  • Night sweats

  • Chills

  • Increasing dyspnea

  • Chest pain

  • Loss of appetite

  • Weight loss

CONSUMPTION


Chest x ray

Chest x-ray

  • Initial Lung Lesion is called a Ghon nodule

  • Ghon nodule + involvement of lymph nodes in the hilar region is the Ghon Complex

  • Multiple Nodules (supra- or retroclavicular)

  • Pleural Effusions

  • Cavity Formation


Diagnostic testing

Diagnostic Testing

  • TB skin test

    • Mantoux Test

    • 5 m of purified protein derivative (PPD) in 0.1 mL of solution is injected.

    • Induration of 10 mm or greater is positive test

  • Sputum Cultures and Acid fast stain

    • Ziehl-Neelsen & Fluorescent Stain

    • Culture will differentiate M. Tuberculosis from other acid fast organisms (6-8 weeks)

    • Sputum may show AFB but negative for TB

  • Chest x-rays


Drug therapy for tuberculosis

Drug Therapy for Tuberculosis

  • First Line

    • R – rifampin (Rimactane) (*)

    • I – isoniazid (INH) (+)

    • P – pyrazinamide (Tebrazid)

    • E – ethambutol (Myambutol)

    • R – rifapentine (Priftin) (*)

    • R – rifabutin (Mycobutin)

      • Use if patient receiving antiretroviral

  • Second Line

    • Streptomycin

  • (*) Reduces efficacy of oral contraceptives.

  • (+) Liver toxicity when alcohol is used.


Treatment

Treatment

  • If a patient does not respond to treatment in 2-3 weeks, suspect:

    • Non-compliance with drug regimen

    • Multiple drug resistant organisms (MDR-TB)

  • Oxygen


Prophylactic treatment

Prophylactic Treatment

  • Isoniazid if often prescribed as a daily dose for one year in individuals exposed to TB

    • Positive TB skin Test


Safety precautions

Safety Precautions

  • Isolation

    • Keep door closed

  • National Institute for Occupational Safety and Health (NIOSH) recommends particulate filter respirators for HCWs

    • Surgical masks are not very effective against TB


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