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Pulmonary Infectious Disease

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Title: Pulmonary Infectious Disease


1
Pulmonary Infectious Disease
  • Tory Davis, PA-C

2
Pneumonia
  • What is it?
  • Acute infection of the lung parenchyma, including
    alveolar spaces and interstitial tissue
  • Alveoli fill with exudate (pus), fibrin, cells
  • Usually bacterial or viral infection
  • May be fungi, rickettsial, yeasts, parasites

3
Classification of Pneumonia
  • Typical vs. Atypical
  • By site of acquisition (ie where the pt picked up
    the bug)
  • By location in lung
  • Other pt factors (such as imunocompromised,
    HIV-associated, aspiration)

4
General Info
  • Community acquired pneumonia (CAP)- 2-3 million
    cases per year
  • Most deadly infectious disease in US
  • 6th leading cause of death in US
  • 60,000 deaths annually
  • Worldwide leading cause of death in children

5
Community Acquired Pneumonia (CAP)
  • Definition
  • Onset outside hospital or diagnosed within 48
    hours of admission in a patient who has NOT been
    in long-term care facility for ? 14d prior to
    symptom onset AND who does not meet the criteria
    for health-care associated pneumonia (HCAP)

6
HAP VAP
  • Hospital Acquired pneumonia
  • New infection occurring 48 hours or longer after
    hospital admission
  • Ventilator Associated Pneumonia
  • 48-72 hours after endotracheal intubation

7
HealthCare Associated Pneumonia (HCAP)
  • Infection occurring within 90 days of a 2-day or
    longer hospitalization
  • In nursing home or long-term care residence
  • Within 30 days of IV abx therapy, chemotherapy,
    wound care or hemodialysis in a hospital or
    hemodialysis clinic
  • Pneumonia in any pt in contact with a
    multi-drug-resistant pathogen

8
HCAP
  • Includes many pts who used to be considered CAP
  • Newer evidence suggest that pts with HCAP are
    more like pts with HAP (than CAP) and may need
    HAP-like treatments

9
Other things to consider
  • Aspiration pneumonia- who would get this?
  • Opportunistic organisms- such as
  • Pneumocystis jerovecii pneumonia (seen only in
    immunocompromised patients.)

10
Classify by Location
  • Primarily from x-ray observation
  • Lobar pneumonia- Entire lobe
  • Segmental or lobular pneumonia (segment of lobe)
  • Bronchopneumonia- (alveoli contiguous with
    bronchi)
  • Interstitial pneumonia- (Involvement of tissue
    between the alveoli)

11
Common Signs and Symptoms
  • Fever
  • Cough ? sputum
  • Dyspnea
  • Chills/Rigors
  • Diaphoresis
  • Chest pain
  • Abd pain
  • Pleurisy
  • Hemoptysis
  • Fatigue
  • Myalgias
  • Arthralgias
  • Anorexia
  • Headache

12
Typical Presentation
  • Sudden onset fevers, cough with purulent sputum,
    dyspnea, occasional pleuritic chest pain
  • Signs of consolidation, x-ray abnormalities
  • Usually caused by more common bacteria
  • Pneumoccocus, H. influenza, etc.

13
Remember Clinical Assessment?
  • Consolidation
  • ? tactile fremitus (Ninety-nine)
  • Bronchophony (Auscultate Ninety nine) sounds
    like listening without stethoscope
  • Egophony (E?A changes)
  • Rales (crackles)
  • Associated pleural effusion
  • ? tactile fremitus
  • Distant breath sounds
  • Pleural friction rub (creaking leather)

14
Atypical Presentation
  • Gradual onset, dry cough, myalgias, fatigue, sore
    throat, N/V, diarrhea, dyspnea
  • Less remarkable pulmonary exam despite abnormal
    x-ray findings
  • Organisms Mycoplasma pneumoniae, Legionella
    pneumophila, Chlamydia pneumoniae, Chlamydia
    psittaci, Francisella tularensis, viruses

15
Pathogenesis
  • Some combination of
  • Defect in normal host defenses, which include
  • Cough reflex
  • Mucociliary clearance system
  • Immune response
  • Very large infectious inoculation
  • Highly virulent pathogen

16
Mechanism of spread
  • Most common
  • Inhalation of droplets small enough to get to
    alveoli
  • Aspiration of secretions from upper airways
  • Other
  • Hematogenous or lymphatic dissemination
  • Direct spread from nearby infection

17
Predisposing factors
  • URI
  • Smoking
  • Alcoholism dec immune fxn and inc aspiration
  • Institutionalization
  • Heart failure
  • COPD
  • Age extremes
  • Debility or ? consciousness
  • Immunocompromise (including CRF, DM)
  • Dysphagia

18
Whats Buggin Ya?
  • Community Acquired (CAP)- bacterial
  • Streptococcus pneumoniae (pneumococcus) 20-60 of
    CAP
  • Haemophilus influenzae (H. flu)
  • Mycoplasma pneumoniae
  • And a bunch of others

19
Whats Buggin Ya 2
  • Viral
  • Infants and children major pulmonary pathogens
    are VIRAL RSV, parainfluenza, influenza A and B
  • Adults influenza A (B less often), rare
    varicella-zoster
  • Fungal Histoplasma capsulatum, coccidiodies
    immitis, blastomyces dermatitidis, cryptococcus
    neoformans, aspergillus fumigatus, pneumocystis
    carinii/jerovecii
  • Rickettsial primarily Coxiella burnetii

20
Whats Buggin You Worse?
  • HAP/HCAP
  • Enteric aerobic gram-negative bacilli
  • Pseudomonas aeruginosa
  • S. aureus (includng MRSA)
  • Oral anaerobes
  • HIV Infection-Associated
  • Pneumocystis jerovecii
  • M. tuberculosis
  • S. pneumoniae
  • H. influenzae

21
Demographics Aids Diagnosis
  • Influenza assoc with community outbreaks
  • Typical pneumonia outbreak after flu outbreak
  • Legionella exposure to aerosolized water vapor
    (cooling systems) ? outbreak
  • Mycoplasma in younger pts in conjugate settings
    (college, military), with slow transmission
  • Chlamydia psittaci in bird handlers, Tularemia
    from cute bunnies, Anthrax from pigs

22
Pneumococcal pneumonia
  • Caused by Streptococcus pneumoniae (gt80
    serotypes)
  • Most common cause of bac-t pnu
  • Most frequent in winter
  • Most common in age extremes
  • Inhaled/aspirated pneumococci lodge in alveoli.
    Inflammatory process in alveolar spaces, causes
    accumulation of protein-rich fluid which is great
    growth medium for bac-t, helps them spread to
    nearby alveoli

23
Pneumococcal S S
  • Often preceded by URI
  • Sudden onset with SINGLE shaking chill, followed
    by fever up to 40.5º, pleurisy, cough, dyspnea
  • Tachypnea with RR rising to 20-45
  • Tachycardia P 100-140
  • Can have n/v, malaise, myalgias
  • Cough initially dry, progresses to producing
    purulent, rusty or blood streaked sputum
  • Exam may show signs of lobar consolidation or
    pleural effusion (know exam signs)

24
Complications
  • Progressive pneumonia
  • Respiratory distress
  • Septic shock
  • Contiguous infections
  • Bacteremia ? extrapulmonary infections

25
Prognosis- Pneumococcus
  • Pneumococcus accounts for 85 of lethal CAP cases
  • Overall, 10 mortality
  • Poor prognostic markers
  • age lt1 or gt60
  • positive blood cx
  • involvement of gt1 lobe
  • low WBC count
  • extrapulm complication
  • immunosupression
  • CHF
  • Cirrhosis
  • asplenia

26
Staphylococcal Pneumonia
  • 2 of CAP, 10-15 of HAP/HCAP are caused by Staph
    aureus
  • Risks age extremes, hospitalized pts,
    intubated, tracheostomy, immuno-suppressed,
    recent surgery, pts with cystic fibrosis, IVDU
    (who are prone to tricuspid valve endocarditis
    with resultant embolic pneumonia)
  • CXR- multiple bilateral nodular infiltrates with
    central cavitation

27
Staph Aureus S S
  • Similar to pneumococcus, except
  • Recurrent rigors (vs single chill)
  • Tissue necrosis and abscess formation
  • Empyema common- suspect S. aureus in post
    thoracotomy empyema or an empyema complicating
    chest tube drainage s/p chest wall trauma
  • Fulminant course with prostration

28
Staph Aureus prognosis
  • Mortality 30-40, often (but not always) due to
    serious associated conditions
  • Can be lethal in previously healthy adult who
    develops Staph superinfection after influenza
  • Slow response to abx, prolonged convalescence

29
Gram Negative Bacilli
  • Account for lt2 CAP, but the majority of HAP/HCAP
    pneumonias
  • Klebsiella, Pseudomonas aeruginosa, Escherichia
    coli, Enterobacter sp, Proteus sp, Acinetobacter
    sp
  • Rare in healthy adults
  • Seen in infants, elderly, alcoholics,
    debilitated/immunocompromised hosts, esp those
    with neutropenia
  • Bronchopneumonia similar to other infections,
    except very high mortality 25-50 despite abx

30
Klebsiella pneumoniae
  • CAP in alcoholics, common HAP
  • Frequent abscess formation
  • causes Friedlanders pneumonia- affects upper
    lobes, produces current jelly sputum, tissue
    necrosis, early abscess, and fulminant course
  • CXR- bulging fissure sign. Upper lobar
    consolidation with bowing fissure, also abscess
    and lung necrosis

31
Pseudomonas aeruginosa
  • Common VAP pathogen
  • Seen in neutropenic, intubated, ICU or burn unit
    pts, CF, AIDS
  • High mortality
  • CXR- microabscesses coalescing into large
    abscesses

32
Haemophilus influenza
  • 2nd most common cause of CAP (when bug is IDd)
  • Strains containing type B polysaccharide capsule
    most virulent cause meningitis, epiglottitis,
    bacteremic pneumonia. Nearly gone in US due to
    HiB vaccine.
  • Non-type B strains colonize lower resp tract of
    pts with chronic bronchitis, implicated in
    exacerbations (thus abx in bronchitis in pts w/
    COPD)

33
H. influenza
  • Hib pneumonia usually in kids- median age 1 year
    esp if not immunized
  • Usually proceeded by coryza
  • Early pleural effusion in 50
  • In adults, presentation similar to other bac-t
    pneumonias
  • Bacteremia and empyema uncommon

34
Legionnaires Disease
  • Pneumonia caused by Legionella pneumophilia.
    Discovered in members of American Legion during
    1976 convention in Philadelphia.
  • 1-8 of CAP and 4 of lethal nosocomial cases.
  • Occurs in late summer, early fall.
  • Caused by aerosolization of contaminated water
    source, spread by AC systems or shower heads.
  • Risk factors smoking, etoh abuse,
    immunosuppression

35
Legionella
  • Incubation 2-10 days
  • Prodrome resembles influenza malaise, fever,
    myalgia, headache, cough- initially
    non-productive, then productive of mucoid sputum
  • Characteristic high fever, relative bradycardia,
    commonly diarrhea
  • Less common altered mental status

36
Legionella
  • CXR shows patchy segmental or lobar infiltrate,
    unilateral progressing to bilateral, often with
    pleural effusion. Abnormalities persist
  • Labs leukocytosis, hyponatremia,
    hypophosphatemia, abnl LFTs
  • Mortality gt15 in CAP, higher in hospitalized or
    immunosuppressed pts
  • Slow convalescence

37
Mycoplasma pneumoniae
  • Most common pathogen in ages 5-35
  • Walking pneumonia
  • Slow spreading epidemics due to incubation time
    of 10-14 days. Spread common thru close
    contacts, closed populations such as military,
    families, PA students
  • Attaches to and destroys ciliated epithelial
    cells of respiratory tract mucosa

38
M. pneumoniae
  • Initial sx are flu-like malaise, sore throat,
    dry cough with progressive severity
  • Gradual progression (vs fast onset of typicals)
  • Coughing may be paroxysmal, produces mucoid,
    mucopurulent, or blood-streaked sputum
  • Acute sx 1-2 weeks, then slow recovery. Often
    mild sx, spontaneous recovery usually- pts will
    recover with or without treatment

39
M. pnemoniae
  • Prolonged cough due to inhibition of ciliary
    action
  • Exam unimpressive, esp compared to pt complaint
    and xray findings
  • Prognosis good. Abx tx will ? fever and pulm
    infiltrates and ? recovery speed- BUT pts will
    continue to carry mycoplasma for weeks-
  • NB! Mycoplasma doesnt have cell wall, and
    therefore wont respond to abx that interfere
    with cell wall-go with macrolides

40
Chlamydia pneumoniae
  • 5-10 of CAP and nosocomial pnu in adults.
  • May be provocative for asthma
  • Resembles Mycoplasma pneumoniae symptoms
  • Cough, sputum, fever- most not seriously ill,
    but can require admit
  • Older kids, young adults usually

41
Chlamydia psittaci
  • Bird handlers pneumonia
  • Clinically and antigenically distinct from C.
    pneumo
  • Atypical pneumonia transmitted to humans by
    psitticine birds via inhalation of dust from
    feathers, excreta or by bite
  • Clinically similar to other atypicals, plus
    epistaxis, splenomegaly
  • CXR- Pneumonitis radiating from hilum

42
Pneumocystis jerovecii
  • Fungal agent (previously thought to be parasite)
    and previously called P. carinii causes pnu only
    in immunocompromised pts
  • SS fever, dyspnea, nonproductive cough.
    Evolves over days to weeks
  • CXR- diffuse bilateral perihilar infiltrates,
    but 20-30 of CXR are normal

43
PCP/PJP and HIV/AIDS
  • 30 of HIV pts get PCP/PJP as initial AIDS
    defining illness
  • Become vulnerable when CD4 count lt200
  • 80 of AIDS pts will get PCP if not prophylaxed,
    usually with TMP/SMX (Bactrim) 80/400 mg daily
    starting when CD4 count hits 200

44
Post-Op/ Post-traumatic
  • Hypoventilation
  • Poor diaphragmatic excursion
  • Impaired cough reflex
  • Bronchospasm
  • Dehydration
  • Combine to cause retention of bronchial
    secretions, segmental atelectasis, and ultimately
    pnu

45
Aspiration
  • 3 syndromes from aspiration
  • Chemical pneumonitis (when aspirated material is
    directly toxic, i.e. gastric acid)
  • Mechanical obstruction (So you inhale a
    meatball)
  • Bacterial pneumonia caused by anaerobic bacteria
    colonizing oropharynx.
  • CXR will show infiltrate in whatever lung segment
    was dependant at time of aspiration.

46
Workup
  • Hx and PE good psx hx
  • CXR- PA and Lateral
  • CBC with diff
  • BMP (glucose and lytes)
  • Liver function tests (LFTs)
  • Remember CMPBMPLFTs
  • Renal function
  • Pulse ox /or ABG

47
What else?
  • Consider EKG, HIV test
  • If immunocompromised pt, consider other causes
    fungal, viral, TB, PCP
  • Flu season rapid flu test with back-up culture

48
PORT severity index
  • Prediction model for prognosis of CAP
  • Scoring system based on 19 variables
  • Demographics
  • Comorbid disease
  • PE Findings
  • Lab findings

49
PSI
  • Risk stratification for death from all causes in
    next 30 days
  • Class I (by algorithm) LOW (outpt tx)
  • Class II ? 70 points LOW (outpt tx)
  • Class III 71-90 points LOW (consider admit)
  • Class IV 91-130 MODERATE (admit, maybe
    intermediate care)
  • Class V gt130 HIGH (likely ICU)

50
Other Admission Considerations
  • Virulence of organism if known (S. aureus)
  • Support at home and functional status
  • Ability to comply with medications
  • Ability to afford treatment
  • Immune status
  • Multilobar involvement
  • Follow-up
  • Clinical judgment paramount

51
Drugs
  • Tx with abx usually initiated before ID of
    causative agent, then modified
  • Outpatient tx usually empiric ( guided by
    practical experience)
  • Often institutions have rotating schedule of 1st
    choice abx
  • Treat pneumococcus PLUS other likely bugs

52
Antibiotics for Pneumonia
  • Choose least-toxic, most cost-effective,
    narrowest spectrum possible
  • Penicillin was mainstay anti-pneumococcal
  • BUT 40 resistance in many locales
  • If you know resistance rates in your community,
    can consider its use
  • IDSA Guidelines for outpts
  • Macrolide (e.g. azithromycin, clarithromycin)
  • Doxycycline
  • Fluoroquinolone (levofloxacin, moxifloxacin,
    gatifloxacin)

53
IDSA Antibiotics for Pneumonia
  • Hospitalized pts
  • Fluoroquinolone, or
  • Ceftriaxone (or cefotaxime) plus macrolide
  • ICU pts
  • Fluoroquinolone or macrolide plus ceftriaxone or
    cefotaxime or ampicillin-sulbactam or
    piperacillin-tazobactam

54
Antibiotics
  • Switch to oral Abx when clinically stable
  • Afebrile 8 hrs, nl resp rate, reduced oxygen
    requirement, wbc ?
  • Fluoroquinolones same bioavailability (IV and
    oral)
  • Treat for 7 to 14 days total

55
Other Therapies
  • IV fluids
  • Oxygen
  • Incentive spirometry
  • Anti-pyretics like acetaminophen
  • Cough suppressants and mucolytics
  • Chest physical therapy
  • PT/OT and consider rehab hospital

56
Preventing Pneumonia
  • Infection control handwashing, cleaning, gloves,
    isolate if indicated, treat promptly
  • Chemoprophylaxis antivirals during flu
    outbreaks, TMP-SMZ for PCP prevention
  • Vaccinations
  • Aspiration precautions
  • Incentive spirometry post-op

57
Follow up
  • Consider repeat CXR in 4-6 weeks to demonstrate
    resolution of imaging findings.
  • Opportunity to address risk factors, possibly
    modify them
  • Great time for intervention with smokers

58
Acute Bronchitis
59
What is it?
  • Inflammation of tracheobronchial tree
  • Usually infectious, but can also be irritant
  • Often occurs in relation to other respiratory
    illness (ie common cold)
  • 5 of US population dx with bronchitis yearly
  • Tends to be self-limited

60
Bronchitis is not pneumonia
  • Infection of bronchial tree by similar organisms
    but no parenchymal infection
  • Cough, sputum, upper respiratory symptoms
  • No lung findings except wheeze, nl xray
  • Usually viral infection, rarely bacterial ( see
    Pertussis)

61
Pathogenesis
  • Infectious
  • Viral adenovirus, influenza, parainfluenza,
    rhinovirus
  • Bacterial chlamydia, pertussis
  • Noninfectious
  • GERD
  • Irritant
  • Asthmatic

62
Risk Factors for Infectious Bronchitis
  • Recent URI
  • Recent LRI
  • Smoker
  • Lung compromise, ie COPD

63
Symptoms
  • Cough (/- purulent)
  • Fever
  • Malaise
  • Nasal congestion
  • /- rhinorrhea
  • Sore throat
  • Looks a lot like a cold so far

64
More sx
  • Wheeze
  • Dyspnea
  • Chest pain-costochondritis inflammation from
    coughing so much (press on it by sternum to
    elicit pain)
  • Myalgia/arthralgia

65
Physical exam
  • No uniform description
  • Can be normal exam
  • /- wheeze/rhonchi
  • No signs of consolidation
  • Because if there IS consolidation, its NOT
    bronchitis

66
DDX
  • Asthma
  • COPD
  • Bronchiolitis
  • Croup
  • Pneumonia
  • Bronchiectasis
  • Influenza
  • TB
  • Cancer
  • Foreign body
  • URI
  • Sinusitis

67
Work up
  • Thorough history
  • PE
  • CXR? can r/o pneumonia if you cant do it with
    hx and PE

68
Treatment
  • Generally aimed at symptoms
  • Analgesics
  • Antipyretic
  • Anti-inflammatory
  • Antitussives
  • Expectorants
  • Bronchodilators

69
but my doc always gives me.
  • In immunocompetent individuals, no abx needed.
    BUT 80 get them.

70
Who should get abx?
  • Moderate-severe COPD
  • Asthmamaybe
  • Immunocompromised pts
  • Suspected pertussis
  • NB! lt5 of bronchitis pts will develop
    pneumonia.
  • Prophylactic antibiotics will NOT decrease
    incidence of pneumonia

71
ABX
  • Macrolides effective against mycoplasma
    chlamydial organisms and B. pertussis
  • Erythromycin, Clarithromycin, Azithromycin
  • Also tetracyclines, tmp/smx (Bactrim), and
    cefditoren (Spectracef)

72
Prevention
  • Stop smoking
  • Influenza vaccines
  • Stop smoking
  • Tdap vaccine
  • Stop smoking
  • Cover that cough
  • Stop smoking
  • Pneumococcal vaccine
  • And WASH YOUR HANDS

73
Pertussis
74
Pertussis
  • aka whooping cough
  • Classic at least 21 days of cough illness with
    paroxysms, associated whoops or post-tussis
    vomiting
  • Bordatella Pertussis highly contagious gram neg
    bac-t in respiratory tract, spread by direct
    contact with secretions
  • Incubation 7-10 days

75
Pertussis Phases
  • Catarrhal (1-2 weeks) Looks like URI, rhinorrhea,
    sneezing, fever, occasional cough
  • Paroxysmal-severe spasms of quick, short, coughs
    like a machine gun without breathing in between
    coughs. Gagging and gasping. After cough spasm,
    pts strain to inhale, making high-pitched
    whooping sound. May be followed by vomiting and
    exhaustion
  • Convalescent- Gradual recovery

76
Pertussis
  • Nearly eradicated in 70s (1,000 cases in 1976),
    now increased incidence (11,000 in 2007)
  • Waning immunity, under-vaccination
  • Infants at greatest risk for complications
    apnea, pneumonia, seizures, brain damage,
    cerebral hemorrhage
  • Milder disease in older children can contribute
    to spread

77
Diagnosis
  • Hx
  • PE
  • Culture respiratory secretions
  • Elevated white count with lymphocytosis

78
Treatment
  • Macrolides for 5 days erythromycin,
    clarithromycin, azithromycin. (2nd line TMP/SMX)
    Treat EARLY, treat often, treat contacts to
    reduce spread
  • If no abx (ie pt refuses), then no contact with
    other humans for 21 days. No work, school,
    daycare, etc.
  • Fluids (IV prn)
  • O2
  • Sedatives

79
Prevention
  • Vaccination with DTaP (kiddos) and Tdap
    (adolescents and adults)
  • Handwashing
  • Prophylactic abx to close contacts to prevent
    spread

80
Tuberculosis
  • Infection with Mycobacterium tuberculosis
  • Most commonly attacks the lungs (as pulmonary TB)
    but can also affect the CNS, the lymphatics, the
    circulatory system, the genitourinary system,
    bones, joints and skin.

81
Background
  • Among communicable diseases, 2nd leading cause of
    death worldwide.
  • Prevalence 2 billion
  • Incidence 8 million
  • Mortality 2 million people yearly
  • 20-40 of world population is infected
  • 15 million people infected in US

82
Mycobacterium tuberculosis
  • Non-motile pleomorphic rod
  • Highly resistant to desiccation
  • Very slow growing- generation time 12-18 hours
    (vs 20 min for E. coli)

83
Pathophysiology
  • Aerosol transmission cough, sneeze, speak or
    sing
  • One cough? 3000 infective droplets
  • 10 bacilli can initiate pulmonary infection
  • In alveoli, taken up by alveolar macrophage, then
    on to the nodes, and to organs- 80 of disease is
    in lung, but can affect ANY organ

84
Risk
  • Minority 2/3 of cases
  • Indigent 300x risk of national average
  • HIV 200-400 increase risk
  • Other high risk groups hospital employee, inner
    city resident, nursing home resident, alcoholic,
    incarcerated, illicit drug users, travel to
    endemic area

85
LTBI vs Active Disease
  • Two forms- distinct
  • Latent TB Infection- pt is infected with M.
    tuberculosis, but is NOT sick, NOT infectious
  • Active Disease- Pt is infected, sick, and
    contagious

86
  • 2-8 weeks after inoculation, PPD caused by
    cell-mediated immunity and hypersensitivity
    reaction
  • 90-95 primary infections are unrecognized
  • 10-30 of healthy pts will proceed directly to
    active disease (up to 50 if MDR- TB)
  • The rest will have latent infection. No
    symptoms, non-infectious. Can convert to active
    ANY time.

87
Stages
  • Primary or initial infection- often leaves
    nodular scars called Simon foci in one/both
    lungs.
  • Simon foci provide seeds for reactivation
  • Latent or dormant infection
  • Can convert to active later
  • Can be treated to decrease risk/likelihood of
    conversion

88
Active TB
  • Either direct from initial infection, or
    reactivated latent infection
  • Symptomatic
  • Infectious
  • Must be treated to decrease mortality and spread
  • Increasingly RESISTANT to treatment
  • MDR-TB
  • XDR-TB

89
Classic Symptoms of Active TB
  • Productive cough
  • Hemoptysis
  • Fever
  • Weakness
  • Anorexia
  • Weight loss
  • Night sweats
  • Malaise

90
Physical Findings
  • Fever
  • Cachexia
  • Hypoxia
  • Tachycardia
  • Lymphadenopathy
  • Abnormal lung sounds- post-tussive rales

91
Extrapulmonary Symptoms
  • Skin
  • Kidney
  • Bone
  • Brain
  • More common with decreased immune function

92
Lab
  • Presence of acid-fast bacteria in sputum is a
    rapid presumptive positive
  • Definitive dx from sputum cx or DNA/RNA
    amplification demonstrating M tuberculosis
  • Culture takes weeks

93
PPD/Mantoux Test
  • 0.1ml intradermal purified protein derivative
  • Area of INDURATION (NOT erythema) seen 48-72h
    after placement
  • I said INDURATION, not erythema
  • Measure transverse to long axis of arm
  • Expressed in mm- and a lack of induration is
    written as 0 mm, not neg

94
False Neg PPD
  • 20 of active cases
  • Cancer/recent chemo
  • Anergy
  • Drugs (steroids)
  • AIDS
  • Recent live attenuated virus vaccines (so place
    PPD same day or 6 weeks after vax)
  • Concurrent infection
  • Metabolic derangement (CRF)
  • Lymphoid disease
  • Stress (surgery, burn, graft-vs-host)
  • Distant primary infection- role for 2-step
    testing, booster reaction

95
Population Based PPD Criteria
  • gt5 mm HIV , abnl CXR, recent TB contact
  • gt10 mm IVDU, nursing home, jail, minority
    groups, age lt 4, DM, CRF
  • gt15 mm no risk factors
  • Positives are reportable to state
  • False positives may occur in persons with
    previous BCG vaccine
  • This will be on boards!

96
QuantiFERON-TB Gold Test
  • Whole blood test to detect both latent and active
    TB
  • One visit/one sample testing
  • Results in 24 hrs
  • No reader bias
  • Not affected by BCG vaccine

97
Imaging
  • Pos CXR trumps neg PPD, but neg CXR doesnt r/o
    active TB
  • Classic xray of active TB shows lesions in
  • Post RUL
  • Apicoposterior LUL
  • Apical segments of LLL

98
Differential
  • Asthma
  • Pneumonia
  • Influenza
  • CA
  • HIV/AIDS
  • ARDS
  • Pneumothorax
  • Pleural effusion
  • MAC (mycobacterium avian complex)

99
Treatment
  • Therapeutic principles
  • Must use multiple drugs to which M. tuberculosis
    is susceptible
  • Must be taken regularly
  • Must have sufficient duration to resolve the
    illness

100
Treatment Active TB
  • Isolation
  • Negative pressure rooms
  • Mask- N95
  • Abx - First dose decreases bacillary load 10
    fold
  • 2 weeks decreases load 100-fold
  • 4 wk tx plus 3 neg sputum smears means pt is no
    longer infectious

101
Tx Daily Regimen
  • Initial 4 drug regimen
  • INH (isoniazid) 300 mg po q day
  • Hepatitis, rash, GI upset, neuropathy
  • Co-administer pyridoxine (vitamin B6)
  • RIF (rifampin) 600 mg po q day
  • GI upset, rash, orange body fluids, hepatitis
  • PZA (pyrazinamide) 2 g po q day
  • Hepatotoxicity, rash, GI upset
  • ETB (ethambutol) 2 g po q day
  • Optic neuritis

102
Daily Regimen
  • Drop ETB if cx favorable
  • Drop ETB and PZA after 2 mo if decreased symptoms
    and nl smear
  • 6 month total
  • Compliance 60.

103
Denver Protocol DOT
  • 91 compliance
  • First 2 weeks DAILY INH 300mg, RIF 600 mg, PZA
    2g, streptomycin 1g
  • Next 6 weeks, Same doses, 2 x/week
  • Next 18 weeks INH RIF 2x/wk
  • Relapse comparable to daily protocol (1.6)

104
Exceptions
  • HIV tx to 9 months min
  • Pregnant- tx 9 months, daily INH, RIF, ETB. OK
    to breastfeed
  • Meningitis- add dexamethasone
  • MDR TB- 7 (yup, seven) drug daily protocol, DOT
    essential. There are organisms resistant to
    SEVEN drugs. What then? XDR-TB

105
Latent infection
  • PPD or QFT-G
  • Neg CXR
  • No signs/symptoms of active disease
  • In healthy adult, 1 per year conversion to
    active
  • HIV person has 10 per year conversion

106
Latent Infection Tx
  • INH 300 qd x 12 m has 75 risk reduction for
    converting to active disease
  • INH 300 qd x 6 m (65 RR)
  • INH 900 2x/wk for 12 m

107
Seasonal Influenza
  • Respiratory illness usually occurring in epidemic
    form in Oct- April, epidemics in US q 2-3 years
  • Caused by strains of influenza virus (an
    orthomyxovirus)
  • Annually in US
  • Affects 5-20 of population
  • Results in 200k hospitalizations for
    complications
  • Causes 36,000 deaths

108
Tell me you already know this...
  • Influenza has 2 surface glycoproteins to allow
    virus to attach to and infect hosts
  • HA- hemagglutinin-to fuse to host membrane
  • NA- neuraminidase- enzyme to allow dispersion of
    new budding viruses
  • Mutations of HA or NA ? drift
  • Exchange of entire gene segments (usually between
    human flu and animal flu)? shift

109
Influenza Acute SS
  • Chills, fever to 39.5?C
  • Sudden onset myalgias- worse in back and legs
  • Prominent HA with photophobia and retrobulbar
    aching
  • Sore throat, retrosternal burning
  • /- coryza
  • Nonproductive cough

110
Later on
  • Lower respiratory symptoms become dominant with
    persistent productive cough
  • Acute symptoms and fever resolve in about 3 days
  • Weakness, diaphoresis and fatigue can persist for
    weeks
  • Secondary bacterial pneumonia suggested by
    recurrence of symptoms in 2nd week

111
Transmission
  • Droplet nuclei (not large particle aerosol like
    the common cold.) Rare fomite transmission.
  • Cough or sneeze
  • Incubation average 48 hours (range 1-4 days)
  • Infectious for
  • 1 d before sx onset to 5 d after (Adults)
  • 1 d before to 10d after (Kiddos)
  • Several days before sx 10d after (Wee kiddos)
  • Immunocompromised folks can shed virus for weeks
    to months

112
Complications
  • Bacterial pneumonia
  • Purulent bronchitis
  • Otitis media
  • Sinusitis
  • Dehydration
  • Worsening of chronic medical illnesses, ie CHF,
    DM, asthma

113
Rarer complications
  • Encephalopathy
  • Myocarditis
  • Pericarditis
  • Rhabdomyolysis
  • Reyes Syndrome- (fatty liver with
    encephalopathy) no ASA for children under 18

114
Diagnosis
  • Good history, incl knowledge of current local
    trends.
  • As of October 3, 2009, 99 of circulating
    influenza viruses in the United States were 2009
    H1N1 influenza
  • PE febrile, tachycardic, flushed face,
    pharyngeal, tonsillar and soft and hard palates
    injected without exudate. Conjunctival
    injection. Usually normal lung exam. No signs
    of consolidation.
  • Clinical alone ? low sensitivity and specificity
  • Check some labs?

115
Better living thru nasopharyngeal swabs
  • Rapid testing (30 min)-often performed in office.
    Vary in types of flu detected, ability to
    distinguish types, also in specimen type needed.
    Know your lab!
  • Viral culture, esp to f/u negative rapid test
    when clinical suspicion is high. Results in 3 to
    10 days
  • Also available immunofluorescence, EIA, PCR.
    Use of serology reserved for public
    health/research.

116
Treat em
  • Conservative tx rest, fluids, acetominophen for
    fever, headache, myalgia, cough suppressant prn.
  • NB- NO ASA for children!! (Why?)
  • Monitor for complications
  • Antivirals effective in ? sx duration,
    severity, also to ? contagion. Ideally initiate
    tx within 2 d of sx onset, duration of tx 5 days
  • Currently reserving antivirals for ill, high-risk
    folks with H1N1

117
Antivirals
  • Oseltamavir (Tamiflu)- seasonal and H1N1
  • Zanamavir (Relenza)- seasonal and H1N1
  • Amantidine and rimantidine- Only effective
    against influenza A. Rapidly developing
    resistance to these drugs, so use of these agents
    is currently NOT advised. Awaiting
    reestablishment of susceptibility.

118
PREVENTION
  • Vaccinations
  • Chemoprophylaxis with antivirals (70-90
    effective)
  • Handwashing- soap and water or waterless alcohol
    based
  • Education
  • Fingers out of nose, eyes, mouth
  • Good respiratory hygiene
  • Avoid sick people if youre well, and well people
    if youre sick

119
The Flu Shot
  • Trivalent inactivated vaccine-
  • Killed viruses- 2 A strains, and a B
  • Representative of the influenza strains predicted
    to circulate
  • New vaccine yearly.
  • Usually one strain changes.
  • Available thimerosal-free

120
This years model
  • A/Brisbane/59/2007(H1N1)-like virus
  • A/Brisbane/10/2007 (H3N2)-like virus
  • B/Brisbane/60/2008-like virus
  • Too early to tell if we got it right!
  • Also, attention and data is all about H1N1

121
Vaccine
  • If well matched to circulating strains, vaccine
    can decrease risk of flu 70-90 in healthy adults
    and 66-90 in children
  • Can be 30-70 effective in preventing
    hospitalization for pneumonia in elderly
  • Decrease risk of death from influenza by 80 in
    elderly people in nursing homes
  • Even poorly matched vax can provide
    cross-protection

122
Other option LAIV
  • Live attentuated influenza vaccine
  • Nasal spray
  • LIVE virus, weakened
  • Only for healthy, non-preg people ages 5-49

123
Who gets flu shot?
  • People at ? risk for complications kids 6
    months to 19 years, pregnant women, age over 50,
    residents of LTC facilities or nursing homes,
    those with chronic medical conditions (see next
    slide), healthcare workers
  • Folks who live with/care for the above
  • Anyone who wants to ? risk of flu

124
Chronic Medical Conditions
  • Pulmonary ds (incl asthma and any other disease
    that can compromise respiratory function)
  • Cardiovascular ds (except HTN)
  • Renal ds
  • Hepatic ds
  • Hematologic ds
  • Metabolic ds (including diabetes!)
  • Immunosuppressed folks

125
NO SHOT for you
  • Severe egg allergy
  • Hx of severe reaction to a flu vax
  • Hx Guillain Barre Syndrome
  • Age lt6 months
  • Currently moderately ill with fever
  • Fine to give to pt w/ low-grade fever

126
Influenza vaccine factoids
  • Production starts in January
  • Usually available in October and after
  • Works by provoking immune response and antibody
    development
  • Effective in about 2 weeks. Immunity lasts
    months to a year

127
Pandemics
  • 1918- Spanish influenza. Killed 40-50 million
    people worldwide.
  • 1957- Asian Influenza (2 million dead)
  • 1968- Hong Kong Influenza (1 million)
  • 2009- H1N1 Swine Flu
  • ????- Avian Influenza. WHO conservative estimate
    of about 7.4 million deaths. Pandemic within 3
    months of evolution of virus to easily
    transmissible state. Are we ready?
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