Respiratory Medicine II
FRACP teaching – Wed 24 Oct 2007
Respiratory Medicine
Middlemore Hospital
Programme – 1300-1700hrs
• Asthma and COPD
– Jeff Garrett
• Sleep disorders
– Andy Veale
• Pulmonary physiology and lung function tests
– Conor O’Dochartaigh
• Break (1510-1530)
• Respiratory multi-choice questions
– Anna Tai
• Pulmonary infections
– Conroy Wong
Evaluation Form
• Please complete and hand-in at end of day!
Pulmonary infections
• Pneumonia
• TB
• Empyema
• Airway infections
– Bronchiectasis
– Mycobacterium avium complex (MAC)
– Aspergillus infection
Pneumonia
Which statement from the IDSA/ATS* (2007)
guidelines about community-acquired pneumonia
does not have Level I evidence?
1.
2.
3.
4.
5.
Locally adapted guidelines should be implemented
Inpatients should be treated with a ß-lactam plus macrolide
Patients should be treated with antibiotics for a minimum of 5 days
The first antibiotic dose should be administered while still in ED
Healthcare workers should receive annual influenza vaccination
*Infectious Diseases Society of America / American Thoracic Society
This patient has a community-acquired pneumonia.
Which statement is true?
1.
2.
3.
4.
5.
The CXR shows consolidation associated with a mass in the R middle
lobe
The lobar distribution indicates that Streptococcus pneumoniae is likely to
be the pathogen
This patient should routinely have paired serological tests
A CURB-65 score of < 2 has a 30-day mortality of < 2%
PCR for legionella is indicated for severe pneumonia
Legionella pneumonia – lobar
Serology:
acute = negative
convalescent = 1024
Severity assessment - CURB-65
• British Thoracic Society
– Severity assessment of all patients with pneumonia
•
•
•
•
•
•
•
Confusion (Mental status score 8 or less)
Urea > 7 mmol/L
Respiratory rate ≥ 30
Blood pressure – systolic <90 and/or diastolic ≤ 60
Age over 65
Score ≥ 3 (‘Severe’) – high risk of death (>20%)
Also: Hypoxaemia (SaO2<92%), multilobar involvement
PSI – Pneumonia Severity Index
N Engl J Med 1997;336:243
Procalcitonin in pneumonia
Which statement about procalcitonin in communityacquired pneumonia is false?
1.
2.
3.
4.
5.
Procalcitonin levels are increased in bacterial infections
Persistently elevated levels of procalcitonin are associated with
adverse outcome
Procalcitonin guidance of antibiotic therapy reduces the duration of
antibiotic use
CRP is a better marker of sepsis
Procalcitonin levels rise within 6 to 12 hours
A 75 year-old man presents with a 4 month history of cough and mild
dyspnoea He did not respond to augmentin but has a good response to
prednisone. His chest xray and CT scan are shown below.
What is the most likely diagnosis?
1. Chlamydia pneumonia
2. Legionella pneumonia
3. Organising pneumonia
4. SLE pneumonitis
5. Pneumocystis pneumonia
Organising pneumonia
• Consider if non-resolving pneumonia
• Causes
– Cryptogenic (COP), Infection, Drugs (amiodarone)
• Cough, fever, malaise
– Dyspnoea usually mild
• Radiology – patchy peripheral and bilateral distribution
• Differential dx: chronic eosinophilic pneumonia, alveolar
cell carcinoma, pulmonary lymphoma
Mycobacterium tuberculosis
Positive acid-fast stain
Positive culture
TB pleural effusions
Which statement about tuberculous pleural effusions is
false?
1.
2.
3.
4.
5.
The diagnostic value of pleural investigations is dependent on the
pretest probability
Pleural aspirates show lymphocytic predominance
Microscopy and culture for TB are often negative
Adenosine deaminase has high sensitivity and specificity in TB
effusions with lymphocyte predominance
PCR is the gold standard for diagnosis
Isoniazid prophylaxis
A medical registrar has a repeat Mantoux test after 2 years
and there is a ≥ 10mm increase. Isoniazid is considered.
Which statement is false?
1.
2.
3.
4.
5.
The risk of hepatitis increases with age
The risk of hepatitis is about 2% at age 60
Isoniazid is recommended only if aged <35y
The lifetime risk of tuberculosis is 5-10%
Interferon  release assays are more specific than Mantoux tests
Blood tests for TB – TIGRA
For T cell interferon  release assays, which of
the following statements is false?
1. Interferon  is produced by T cells in response to
antigens specific to M tuberculosis
2. They are more rapid than tuberculin tests
3. They are more specific than tuberculin tests
4. There is no boosting effect
5. They cross react with BCG more often than
tuberculin tests
Interferon  release assays
(Sensitised)
TB
QuantiFERON-TB Gold Assay
TB AG
TB AG
Mitogen
T-Spot.TB assay
A
B
C
Peripheral blood mononuclear cells
D
A:Null
B:Antigen A
C:Antigen B
D:Positive
A 32 year-old man presents with a 2 week history of cough, fevers
and pleuritic chest pain. The ALT was 192 and ALP 391. His CT scan
is shown below.
What is the most likely diagnosis?
1. Lung abscess
2. Haemopneumothorax
3. Empyema with
pneumothorax
4. Mesothelioma
5. Cavitating carcinoma with
liver metastases
A chest drain was inserted. This obtained pus and
Streptococcus milleri was cultured.
The best evidence for the role of intrapleural
streptokinase for empyema indicates that:
1.
2.
3.
4.
5.
Streptokinase is no better than saline flushes
Urokinase is superior to streptokinase
Streptokinase reduces mortality
Streptokinase reduces the need for surgical drainage
Streptokinase reduces the length of stay in hospital
1 Sept 2005
28 Oct 2005
Largest clinical trial in pleural infection
UK: Multicenter Intra-Pleural Sepsis Trial
(MIST)
52 centers
Pleural fluid >1 of criteria:
• purulent
• Gram stain +ve
• Culture +ve
• pH<7.2 & clinical evidence
of pneumonia
430 patients (age >18):
Most have severe disease
80% frankly purulent fluid
Pleural fluid pH 6.8 (mean)
MIST trial - results
• Streptokinase has no benefit over placebo for the
following endpoints
– Primary
• Mortality or surgery at 3 months
– Secondary
•
•
•
•
Mortality
Surgery
Radiograph outcome
Length of hospital stay
• SK group had increased serious adverse events (p=0.08)
Conclusion
• No benefit of streptokinase over saline flushes
– For any outcome measure
• Not to be used routinely
• Also metaanalysis (Tokuda. Chest 2006;129)
–
5 trials with 575 patients
• MIST II – DNAse v TPA v DNAs + TPA v Placebo
Bronchiectasis
Treatment of bronchiectasis
Which one of these statements is (most) correct?
1.
2.
3.
4.
5.
Oral steroids are beneficial for acute exacerbations?
Inhaled steroids are beneficial for stable bronchiectasis?
Prolonged antibiotics are superior to standard courses of
antibiotics for patients with bronchiectasis?
Physiotherapy is recommended but has not been shown to be
effective
Short-acting beta-agonists are effective in bronchiectasis
Steroids for bronchiectasis
• Oral steroids for bronchiectasis
– Cochrane review
• No randomised trials
– Benefit unknown
• Inhaled steroids for bronchiectasis
– Cochrane review
• Three trials
• Limited, if any, effect on any outcomes
• May improve lung function (trend) and sputum volume
– Benefit unclear
Antibiotics and bronchiectasis
• Cochrane review
• 6 trials, 302 patients
– One study contributed 40%
• Antibiotics for between 4 weeks and 1 year
• Prolonged antibiotics
– Improved response rates (OR 3.4)
– No effect on exacerbations
• Conclusions
– Limited data. Small benefit from prolonged antibiotics
Mycobacterium avium complex (MAC)
Which one of these statements is correct?
1.
2.
3.
4.
5.
MAC is found in various sources including water, house dust,
soil and animals?
‘Hot tub lung’ is MAC infection that responds to antibiotic
therapy
MAC lung disease rarely occurs in patients with pre-existing
lung disease or immunosuppression?
In patients without pre-existing lung disease, MAC usually
affects young men?
The presence of bronchiectasis and multiple small nodules are
not predictive of MAC lung disease?
2007 ATS/IDSA criteria for diagnosis
• Clinical features
• Radiographic
– Fibrocavitary disease
• CXR - cavitary opacities
– Noncavitary disease
• CXR – nodular opacities
• HRCT Multifocal bronchiectasis with multiple small nodules
• Bacteriologic
– Sputa – two positive in one year
– Bronch wash – one positive culture
– Tissue – positive culture or granuloma & +ve sputum/wash
Multifocal
bronchiectasis
MAC
infection
Peripheral
nodules
Which statement is correct about macrolide
antibiotics?
1.
2.
3.
4.
5.
They act by disrupting cell membranes of microorganisms
They have no activity against Pseudomonas aeruginosa
They have minimal anti-inflammatory effects on neutrophils and
macrophages
They substantially reduce mortality in panbronchiolitis?
Low dose azithromycin taken for 6 months improves lung
function in patients with cystic fibrosis but causes irreversible
hearing loss
Macrolide antibiotics
• Anti-infective, anti-inflammatory,
immunomodulatory properties
• Low dose azithromycin is effective in cystic
fibrosis
• Highly effective in panbronchiolitis
20 yr Indian man with panbronchiolitis
Allergic bronchopulmonary aspergillosis
Which statement is false?
1.
2.
3.
4.
5.
ABPA occurs more commonly in patients with cystic
fibrosis than in chronic asthmatics?
ABPA is unlikely if the total IgE level is less than 400
IU/mL
Skin prick testing is a useful screening test to identify
patients with ABPA
Almost 100% of patients with an established aspergilloma
have aspergillus precipitins
Proximal bronchiectasis is a prerequisite for diagnosis
ABPA
• Key diagnostic features
–
–
–
–
–
–
–
–
Asthma*
Positive skin prick test to Aspergillus fumigatus*
Total IgE > 400 IU/mL (1000 ng/mL)*
Elevated specific IgE (and IgG) to Aspergillus*
Aspergillus precipitins (IgG)
Pulmonary infiltrates
Proximal bronchiectasis
Also eosinophilia, sputum culture
ABPA
•
•
•
•
•
•
•
June 04
Poorly controlled asthma
Eosinophilia – 1.1
Total IgE - 3959 IU/ml
Precipitins – negative
Specific IgE – 3+
Asp. skin prick – 7mm
HRCT – ‘central bronchi
have irregular walls’ (2004)
Itraconazole
Which one of the following adverse effects does not
occur with itraconazole treatment
1.
2.
3.
4.
5.
Rise in ALT
Nausea
Peripheral neuropathy
Cholestatic jaundice
SIADH
Itraconazole and ABPA
• Cochrane review
• 2 studies only
• Reduction in sputum eosinophils by 35% compared to
19% with placebo (p < 0.01)
• More likely to have decline in serum IgE over 25% or
more (OR 3.3)
• number of exacerbations requiring oral corticosteroids
was 0.4 per patient with itraconazole compared with 1.3
per patient with placebo (p < 0.03).
Aspergilloma
Almost all pts have +ve aspergillus precipitins