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    • Histoplasmos -- dimorphic fungi of the Ohio & Mississippi river valleys
    • necrotizing granulomatous inflammation (like TB)
    • infection may follow outdoor dust exposure
    • Also present in bats and batcaves
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    • Coccidiodomycosis immitus
    • In desert SW (So. Utah)
    • Cough, fever
    • Granulomatous infection
    • Can present as solitary lung nodule
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    • Aspergillus (on R Aspergillus GMS stain)
    • 3 forms: invasive in an immunocompromised host; growth in cavity (fungus ball in pre-existing cavity); Allergic form (bronchopulmonary aspergillosis)
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    • Pneumocystis jiroveci pneumonia (PCP)
    • Most common in immunocompromised Pt's (AIDS)
    • HIV Pt's now given prophylaxis to avoid PCP
    • Presents w/ slowly progressive nonproductive cough
    • Usually not in sputum, need BAL to diagnose
  5. Influenza, parainfluenza, cytomegalovirus, hantavirus cause what?
    • Viral Pneumonias (clayton)
    • cough w/ little or no sputum
    • Often no inclusions or specific histologic cultures. Culture is difficult.
    • Serologic titers, PCR, antigen tests & DFA for influenza
    • (late bacterial superinfection is a problem)
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    Influenza pneumonia -- most common viral pneumonia in adults, Resp. & alveolar epithelium are both infected and injured.
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    RSV-- infants and young children (reinfection is common)
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    Herpes simlex pneumonia -- areas of necrosis are common, usually in compromised hosts.
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    CMV (cytomegalovirus)

    Huge cells, big nuclear inclusions, compromised hosts, a type of herpes virus.
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    Smudge cells => adenovirus
  11. How can you make a correct diagnosis?
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    Name the dz
    Poorly staining gram negative rods, fastidious and intracellular oraganisms.
    Invades parenchymal lung cells, and phagocytes and destroys them.
    Produces toxin that blocks phagocytic killing
    Fatal in 15-50%; presents w/ fever, headache, cough, pleuritic chest pain, N/V, mental status changes, hepatic dysfunction.
  13. Name the illness
    Caused by legionella
    dry cough (50%)
    No pregression full recovery, usually in young/healthy adults
    Pontiac fever (much less severe illness than legionnaires dz caused by legionella)

    Legionella can also cause isolated infections, meningitis, endocarditis, soft tissue infections.
  14. What is it?Image Upload 15
    • Legionella (top 2 gram stain, LL = charcoal ager, LR - DFA)
    • Consider it in any severe pneumonia
    • CXR (often see cavities)
    • Gram stain of sputum (PMNs, no organisms)
    • Urinary antigen => direct detection
    • Serology takes up to 6 weeks (not helpful)
    • PCR => $$
  15. What could be a possible cuase of a pneumonia that follows aspiration, is an insidious dz with an altered mental state, only infiltrates the lower lobe, and progresses slowly?
    Anaerobic bacteria (cannot multiply in the presence of oxygen)
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    This organism is gram + but stains poorly (UR is Acid Fast); grows slowly; causes TB; primarily pulmonary dz, but can infect other locations, granulomatous responses, is a major health problem world wide, person-person transmission (resp. droplet).
  17. Mycobacterium tuberculosis
    attaches to alveolar cells, ingested by macrophages, disseminates via lymphatics and circulation, may be controlled and cured. (can be quiescent and then relapse)
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    Name the illness:
    Ordinary resp. flu-like Sx; lower lobe pneumonia, spread from hilum to lymph, controlled in 6-8 weeks, organism lives in lymph tissue for years.
    Primary tuberculosis
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    Miliary spread
  20. Reactivation TB
    • most likely within 2 years of initial infection (although can occur at any time)
    • Predispositions: diabetes, alcoholism, malnutrition, immunodeficiency
    • Progresses slowly, and usually involves lung apices,
    • 80-90% pulmonary
  21. Fever, cough, hemoptysis, night sweats, weight loss, fatigue are classic symptoms of what dz?
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    Apical disease
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  24. How should you diagnise a Pt w/ TB?
    • clinical suspicion
    • exposure
    • prior positive PPD (may or may not help)
    • acid fast stain and culture
    • amplification tests
  25. How can one prevent TB?
    • Recognize clinical cases and isolate them, then treat them appropriately tracing and testing contacts.
    • Skin testing to identify at risk population and health care workers
    • Treatment of Pt's with + PPDs.
  26. M kansasii
    M avium
    M fortuitum and chelonei
    M leprae
    M scrofulaceum
    M marinum
    These are other mycobacteria; no person-person spread.
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    Overwhelming MAC disease
  28. Differentiate between AFB smears, AFB cultures and amplification.
    • AFB smears: rapid test for TB that correlates w/ contagiousness (60% sensitive)
    • AFB culture: gold standard for dx, but takes 10-28 days for + (90-95% sensitive)
    • Amplification: improving rapid method, excellent to confirm an AFB, but not as good for detection. (60-90% sensitive)
  29. When would a TB test not remain positive in a Pt who previously had a + result?
    active dz, immunosuppression, other serious dz, malnutrition, aging
  30. TB skin tests
    • become + in 2-4 wks, use 5 TU strength (3 strengths), interpretations vary by pop., most helpful for screening but can be used to dx.
    • Sensitivity = 70%
    • other mycobacteria can lead to false +'s, but always assume a + is real until proven otherwise.
  31. Name the organism based on the following pathogenesis
    organism inhaled, causes pneumonitis, T-cell response and granuloma formation, enters R-E system, May disseminate like TB, May reactivate like TB
    Clinical Manifestations: most likely asymptomatic, or flu-like symptoms, primary pulmonary dz, reactivates upon immunosuppression (fever, dz of CNS, skin, mucous membranes, adrenals, or lung)Image Upload 23
    Histoplasma (miliary dz caused by histoplasma looks similar but has many small nodules)
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    • How can you confirm suspected Histoplasma?
    • Direct detection in tissue biopsy, culture, antigen test of urine, antibody tests, skin tests.
  33. the following organism is similar to histoplasma (only it is more likely to involve skin and gu tract)
    it is prevelant in the eastern US along the Appalachain Mtns.Image Upload 25
    Blastomyces dermatitidis
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    The organism is similar to Histo and Blasto, but usually found in the SW (including So. Utah)
    Easily acquired -- but usually confined to lung
    Dissemination to: skin, bone, meninges, adrenals, nodes, liver
    Spherules, culture is dangerous, IgMand IgG both detectable via serology
    Coccidioides immitis
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    Used to be considered a parasite, but no recognized as a fungus,
    Life cycle: troph, precyst, cyst
    Cell wall different than other fungi (no glucan or N-acetulclucosamine)
    Most common opportunistic infection associated w/ HIV
    Clinical Manifestations: progressive diffuse pneumonia, tachyapnea, dyspnea w/ cyanosis and hypoxia; slow onset w/ low grade fever; diffuse infiltrate on CXR; disseminates to lymph nodes, bone marrow, spleen, liver, thyroid, GI tract, kidneys
    Diagnosed by induced sputum or bronchoscopy; look for organism: methamine silver, DFA, other stains.
  36. How would you treat a Pt w/ pneumocystis?
    • Sulfamethoxazole trimethoprim,
    • All HIV Pt's w/ CD4<200 are treated w/ bactrim or dapsone to prevent infection.
  37. Image Upload 28Air space opacity
    Think bacterialImage Upload 29
  38. Interstitial opacities (look more like a dirty than cloud-like)Image Upload 30
    Think virus or virus-like (large arrows point to fibrous exudate, small arrows point to interstitial thickening due to fibroblastic proliferation)Image Upload 31
  39. Apical airspace opacity (especially if cavitating)Image Upload 32
    Think reactivation TB
  40. Multifocal opacities (especially lower lung zones and right > left)Image Upload 33
    Think aspiration (pneumonia)
  41. Numerous small nodulesImage Upload 34
    Think miliary TB (blood bourne)
  42. Ill-defined nodules and cavities in a neutropenic patientImage Upload 35
    Think fungus/aspergillus
  43. Multiple ill-defined nodules and cavities peripherally in a Pt with infective endocarditis who is very illImage Upload 36
    Think septic emboli (often staph. aureus)
  44. Patchy, hazy, ground glass opacities in an AIDS patientImage Upload 37
    Think PcP
  45. Older Pt with pneumonia -- get follow up in about 6 weeks
    Look for complete clearing to exclude underlying process, especially malignancy
  46. Diaphragm, external intercostals, scalene, sternocleidomastoid, internal intercostals
    muscles of respiration
  47. Candida albicans, neisseria spp, viridans streptococci, moraxella, peptostreptococcus
    normal flora of the oropharynx
Card Set
.5W,H,F_Micro, .5Path