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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
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.
    • Brain Kidneys
    • Bones Genital 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
slide27

Protective Cell Wall

2-10 weeks

Neutrophils

TB Bacilli & Macrophages

Fibroblasts

Lymphocytes

Tubercle or granuloma

slide28

Caseous Lesion

  • Necrosis
  • Cottage Cheese
  • Caseation
slide29

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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