PANCE Blueprint Pulmonary (10%)

Infectious Pulmonary Disorders (PEARLS)

The NCCPA™ PANCE Pulmonary Content Blueprint covers nine topics under the label infectious disorders, including four types of pneumonia.

Condition Summary Key Differentiators
Acute Bronchiolitis Inflammation of small airways in the lungs, typically affects children under 2, caused by RSV, may present with wheezing. Children, RSV, wheezing, treatment is oxygen.
Acute Bronchitis Inflammation of larger airways in the lungs, can affect people of all ages, caused by viruses or bacteria, may present with cough but not wheezing. All ages, viruses or bacteria, cough, normal vital signs, no rales, no egophony.
Acute Epiglottitis Life-threatening inflammation of epiglottis, caused by H. influenzae type B, presents with stridor. Life-threatening, H. influenzae type B, tripod positioning ⇒ 3 Ds of epiglottitis: dysphagia, drooling, and (respiratory) distress, thumbprint sign on x-ray lateral neck film.
Croup Upper airway infection that leads to swelling around vocal cords, typically affects children between 6 months and 3 years old, caused by parainfluenza virus, presents with "barking" cough and stridor. Children, parainfluenza virus, "barking" cough, and stridor, steeple sign on PA CXR (narrowing trachea in the subglottic region)
Influenza Contagious viral infection that affects the nose, throat, and lungs, can cause severe disease in certain populations, seasonal, rapid onset. Seasonal, rapid onset, severe disease, vaccinate all persons aged ≥6 months, antivirals ⇒ ideally< 48 hours
Pertussis (Whooping Cough) A highly contagious bacterial infection that causes severe coughing spells, caused by B. pertussis, can affect people of all ages, characterized by "whooping" cough. Gram-negative bacteria Bordetella pertussis, "whooping" cough, all ages, treat with macrolide (erythromycin/azithromycin)
Pneumonia Infection of the lungs that can cause inflammation, fluid buildup, and damage to lung tissue. Can affect people of all ages, most common in infants, young children, and older adults. Symptoms include fever, cough, shortness of breath, and chest pain. All ages, most common in infants, young children, and older adults, fever, cough, shortness of breath, chest pain.
RSV (Respiratory Syncytial Virus) Common virus that causes infections of the lungs and respiratory tract, most common cause of bronchiolitis in children, affects infants, young children, and older adults. Most common cause of bronchiolitis in children, infants, young children, older adults. Diagnosed with nasal washing.
Tuberculosis Potentially serious infectious disease caused by Mycobacterium tuberculosis, can affect other parts of the body, can be latent or active. Potentially serious, other parts of the body, latent or active, PPD rules.
Acute bronchiolitis (ReelDx)
ReelDx Rotation Room (bronchiolitis)
Patient will present as → a 9-month-old infant presents with a three-day history of a mild respiratory tract infection with serous nasal dischargefever of 38.5 C (101.4 F), and decreased appetite. Physical exam reveals a tachypneic infant with audible wheezing and a respiratory rate of 65. Flaring of the alae nasi, use of accessory muscles, and subcostal and intercostal retractions are noted. Expiratory wheezes are present.

Most often caused by RSV - commonly in the fall and winter months

  • Infants and young children
  • Tachypnea, respiratory distress, wheezing

DX: Nasal washing for RSV culture and antigen assay; CXR = normal

Treatment:

  • The only treatment demonstrated to improve bronchiolitis is oxygen
  • Hospitalization if O2 saturation < 95-96%, age <3 months, RR > 70, nasal flaring, retractions, or atelectasis on CXR
  • Treatment is supportive; bronchodilators sometimes relieve symptoms but probably do not shorten hospitalization, and systemic corticosteroids are not indicated in previously well infants with bronchiolitis
  • Ribavirin for severe lung or heart disease and in immunocompromised patients
  • There is no vaccine. Monoclonal antibodies to RSV (palivizumab) prophylaxis (once per month for five months beginning in November) for special populations (immunocompromised, premature infants, neuromuscular disorders
Acute bronchitis (ReelDx)
Patient will present as → a 23-year-old female with a one-week history of cough productive of whitish sputum. This was preceded one week prior by a URI. She denies chills, night sweats, shortness of breath, or wheezing. Temperature is 99.9°F (37.7°C).

Acute bronchitis is defined by a cough >5 days; can last 1-3 weeks

Organisms:

  • Most common - viral (95%)
  • Common bacterial = M. catarrhalis
  • Chronic lung patients: H. influenzae, S. pneumoniae, M. catarrhalis

Presentation:

  • Cough, fever (unusual), constitutional symptoms
  • Typically, less severe than pneumonia, normal vital signs, no rales, no egophony

DX: Obtain CXR if the diagnosis is uncertain or symptoms persist despite conservative treatment

TX: symptomatic and supportive - hydration, expectorant, analgesic, B2 agonist, cough suppressant

  • Corticosteroids if a history of underlying reactive airway disease
  • If O2 < 96% on room air, the patient should be hospitalized
  • Antibiotics are indicated in the elderly, underlying cardiopulmonary disease, cough >7-10 days, or immunocompromised
    • A macrolide such as azithromycin 500 mg orally once, then 250 mg orally once a day for 4 days, or clarithromycin 500 mg orally twice a day for 7 days is the preferred choice
Acute epiglottitis
Patient will present as → a 3-year-old boy who is brought to the ER with a sudden onset of fever (104.0 F), respiratory distress, and stridor. On examination, the boy appears acutely ill. He is sitting, leaning forward with his mouth open. He has a muffled voice and is drooling. When asked, the parents report, “We don’t believe in vaccinations.”

Supraglottic inflammation and obstruction of the airway due to infection with Haemophilus influenzae type B (Hib)

  • This is a medical emergency!
  • Caused by Hib - usually unvaccinated children (Hib vaccine at 2, 4, 6, 12-15 mo)

Tripod positioning ⇒ 3 Ds of epiglottitis:

  • Dysphagia
  • Drooling
  • Respiratory Distress

DX: lateral neck X-ray, which will classically show a thumbprint sign from swelling of the epiglottis. Secure airway, then culture for H.flu

  • CT scan would also show a narrow airway from tissue swelling, but lying flat for a CT can obstruct the airway
  • Definitive diagnosis is by laryngoscopy (in a controlled clinical setting like the OR)
    • The endoscopic appearance of edematous or "cherry red" epiglottis is indicative of epiglottitis

TX: Treatment involves intubating if necessary, supportive care, and ceftriaxone. May be treated as an outpatient if stable

Epiglottitis

The lateral soft-tissue radiograph reveals the "thumb sign" that indicates a swollen epiglottis, suggestive of epiglottitis.

Croup (ReelDx)
Patient will present as → a 2-year-old boy who is brought to you by his father, who is concerned about a barking cough,” mild fever, and a hoarse voice. He reports that he had a runny nose last week that has since resolved. Physical exam reveals inspiratory stridor. AP neck film is shown here.

Croup refers to an infection of the upper airway, which obstructs breathing and causes a characteristic barking cough

  • Caused by the parainfluenza virus
  • Common in children 6 mo-3 yrs., fall and early winter months (same time of year as bronchiolitis)
  • Barking cough and stridor
  • Steeple sign on AP CXR (narrowing trachea in the subglottic region)

Treatment:

  • Supportive (air humidifier), antipyretics
  • Severe: IV fluids and nebulized racemic epinephrine, steroids

Croup steeple sign

AP x-ray of the neck in a child with croup demonstrating the steeple sign (narrowing of the trachea)

Influenza (ReelDx)
Patient will present as → a 5-year-old with sudden onset of fever, chills, malaise, sore throat, headache, and coryza. The child is also complaining of myalgia, especially in her back and legs. On physical exam, the patient appears lethargic, has a temperature of 102.5 F, and palpable cervical lymph nodes. Breath sounds are distant with faint end-expiratory wheezes.

Influenza is a viral respiratory infection caused by orthomyxovirus resulting in fever, coryza, cough, headache, and malaise

  • Three strains exist: A, B, and C

Vaccination

  • The CDC recommends routine annual influenza vaccination is recommended for all persons aged ≥ 6 months who do not have contraindications

Dx: rapid antigen test in the clinic, rapid serology test more accurate

Treatment is symptomatic (for most) or with antivirals ⇒ ideally< 48 hours – Tamiflu (oseltamivir), inhaled Relenza (zanamivir), IV Rapivab (peramivir), and oral baloxavir (Xofluza)

  • Zanamivir and Oseltamivir both treat influenza A and B ⇒ (think Dr. “OZ” treats the flu)
    • Intravenous Peramivir and Oral Baloxovir also treat influenza A and B
  • Antiviral treatment reduces the duration of illness by about 1 day and should be specifically considered for high-risk patients
    • Indications for antiviral treatment: hospitalized, outpatient with severe/progressive illness, an outpatient at high risk for complications (immunocompromised, pt with chronic medical conditions, >65 yo, pregnant women / 2 weeks postpartum)

CMV-Pneumonie 27W - CR pa - 001

Chest X-ray in a patient with viral pneumonia demonstrating diffuse bilateral infiltrates.

Pertussis (Whooping Cough)
Patient will present as → a 4-year-old boy with a severe cough following one week of cold symptoms, including sneezing, conjunctivitis, and nocturnal cough. He presents with paroxysms of cough followed by deep inspiration and occasional post-tussive emesis.

Whooping cough (pertussis) is a highly contagious respiratory tract infection marked by a severe hacking cough followed by a high-pitched intake of breath that sounds like a whoop.

  • Gram-negative bacteria Bordetella pertussis – highly contagious
  • Consider in adults with cough >2 weeks, patients < 2 years old
    • Catarrhal stage: cold-like symptoms, poor feeding, and sleeping
    • Paroxysmal stage: high-pitched "inspiratory whoop"
    • Convalescent stage: residual cough (100 days)

Diagnosed by a nasopharyngeal swab of nasopharyngeal secretions – culture

Tx: macrolide (erythromycin/azithromycin); supportive care with steroids / beta2 agonists

  • Vaccination: 5 doses – 2, 4, 6, 15-18 mo, 4-6yrs (DTap)
  • 11-18 yo = 1 dose Tdap
  • Expectant mothers should get Tdap during each pregnancy, usually at 27-36 weeks
Pneumonia (PEARLS)

Presentation: Tachycardia, tachypnea, dyspnea, febrile, age 65+

Physical exam: Egophony, fremitus, rales

Chest radiograph: Infiltrates and or consolidation

Treatment:

Community-Acquired

  • Adult:
    • Healthy patients:
      • First line: Macrolide
      • Second line: Doxycycline
    • Comorbidities:
      • First line: Fluoroquinolone
      • Second line: Beta-lactam + Macrolide
    • Child:
      • First line: Amoxicillin
      • Second line: 2nd or 3rd generation Cephalosporin, Clindamycin or Macrolide

Hospital-Acquired (HAC): Vancomycin + Piperacillin/Tazobactam

AIDs patients receive Bactrim prophylaxis against PJP pneumonia

  • Dapsone is second line

CURB-65 Score for Pneumonia Severity
Estimates mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment.

  • confusion, urea >7, RR >30, Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg, age >65
    • 0-1 = low risk, consider home tx
    • 2 = probable admission vs close outpatient management
    • 3-5 admission, manage as severe

Pathogen Demographics Presentation
Streptococcus pneumoniae Most common, post-splenectomy Rust-colored sputum, single rigor. Lobar infiltrate
Mycoplasma pneumoniae College students, dorms Walking pneumonia: low temp, bullous myringitis
Klebsiella pneumoniae Alcohol abuse, chronic illness Currant jelly sputum
Legionella pneumophila Air conditioning, aerosolized water
Chlamydia pneumoniae College kids Long prodrome, sore throat
Pseudomonas spp. Cystic fibrosis *HAC: Ventilator-associated
Haemophilus influenzae COPD, smokers, post-splenectomy
Pneumocystis jiroveci HIV CD4 <200, immunosuppressed Slow onset, increased LDH, interstitial infiltrates, bilateral
Staphylococcus spp. After influenza/viral infection *HAC (MRSA)  S. Aureus - salmon-colored/lobar
Fungus Leukemia, lymphoma, immunosuppressed, AIDs

  • Histoplasma capsulatum caused by bat droppings -looks like sarcoidosis on CXR
  • Cryptococcus causes meningitis
  • Coccidioides (valley fever) in dry states
Viral
  • Influenza pneumonia: Most common in adults, characterized by a more precipitous onset and fulminant course
  • Adenovirus: Tends to cause symptoms fast, will present with GI symptoms and lasts about 1 week. May differentiate from bacterial mycoplasma pneumonia as mycoplasma is slow and insidious.
  • RSVChildren < 1 year old
  • Parainfluenza: Children 2-5 years old
Respiratory syncytial virus infection (ReelDX)
Patient will present as → a 5-month-old infant with a three-day history of a mild respiratory tract infection with serous nasal discharge, fever of 38.5 C, and decreased appetite. Physical exam reveals a tachypneic infant with audible wheezing and a respiratory rate of 65.  Nasal flaringuse of accessory musclessubcostal and intercostal retractions are noted. Expiratory wheezes and cough are present.

MC cause of lower respiratory tract infection in children worldwide – virtually all get it by age 3; the leading cause of pneumonia and bronchiolitis

  • Rhinorrhea, wheezing/coughing that persists for months, low-grade fever, nasal flaring/retractions, nail bed cyanosis
  • Diagnosed with nasal washing, RSV antigen test; CXR can show diffuse infiltrates

Tx: Indications for hospitalization ⇒ tachypnea with feeding difficulties, visible retractions, oxygen desaturation < 95-96%

  • Supportive measures include albuterol via nebulizer, antipyretics, humidified oxygen, and steroids (controversial) => resolves in 5-7 days

Vaccination (view current CDC guidelines)

  • Approved for individuals 60 years and older
  • Under review for use during pregnancy

Infants and young children

  • 1 dose of nirsevimab for all infants younger than 8 months born during or entering their first RSV season
  • 1 dose of nirsevimab for infants and children 8–19 months old who are at increased risk for severe RSV disease and entering their second RSV season

Prophylaxis: Palivizumab (Synagis) prophylaxis, FDA-approved for children at high risk for severe RSV disease

  • Premature infants born at < 29 weeks, < 1 year of age
  • Premature infants born at < 32 weeks, < 1 year of age with chronic lung disease
  • In the 2nd year of life for children who need supplemental oxygen or long-term corticosteroid or diuretic therapy
  • Children < 24 months who have significant congenital heart disease or pulmonary hypertension

See Bronchiolitis

Tuberculosis (ReelDx)
ReelDx Virtual Rounds (Tuberculosis)
Patient will present as → 34-year-old female nurse presents with a worsening cough of six weeks’ duration together with weight loss, fatigue, night sweats, and fever.  A recent HIV test was negative. A CT scan of the chest reveals a 3 cm lesion in the upper lobe of the left lung and calcification around the left lung hilus. A sputum smear was positive for acid-fast organisms. 

Tuberculosis (TB) is a disease caused by bacteria called Mycobacterium tuberculosis (acid-fast bacilli)

  • Presentation: fatigue, productive cough, night sweats, weight loss, post-tussive rales
  • RF: endemic area, immunocompromised (HIV), recent immigrants (<5 y/o), prisoners, healthcare workers
  • Transmission: inhalation of aerosolized droplets

Screening with tuberculin skin test (TST) or interferon-gamma release assays IGRAs

Mantoux Test Rules: The test is positive if induration

  • > 5 mm at high risk, fibrotic changes on CXR, immunocompromised HIV/drugs, steroids/TNF antagonists daily, or close contact with pt with infectious TB
  • > 10 mm in patients age < 4 or some risk factors = hospitals and other healthcare facilities, IVDU, recent immigrants from high prevalence area, renal insufficiency, prison, homeless shelter, diabetes, head/neck cancer, gastrectomy/jejunoileal bypass surgery
  • > 15 mm if there are no risk factors

Diagnosis with sputum for AFB smears and Mycobacterium tuberculosis cultures – have to be 3 AFB negative

TX:

If PPD/IGRA is POSITIVE, order a CXR

  • Start empiric treatment in those who likely have it

PPD positive or IGRA + CXR negative = latent TBCDC recommends short-course, rifamycin-based, 3- or 4-month latent TB infection treatment regimens over 6- or 9-month isoniazid monotherapy

    • Three months of once-weekly isoniazid plus rifapentine (3HP)
    • Four months of daily rifampin (4R)
    • Three months of daily isoniazid plus rifampin (3HR)

PPD positive or IGRA + CXR positive = active TB ⇒ Several treatment regimens are recommended in the United States for active TB disease. TB treatment can take 4, 6, or 9 months depending on the regimen.

    • 4-month Rifapentinemoxifloxacin TB treatment regimen
      • High-dose daily rifapentine (RPT) with
      • Moxifloxacin (MOX): QT-prolonging agent and has been associated with cardiac arrhythmias, which may be fatal
      • Isoniazid (INH) and
      • Pyrazinamide (PZA)
    • 6- or 9-month quad therapy (RIPE) TB treatment regimen:
      • Rifampin (RIF): Orange body fluids, hepatitis - "remember R = red/orange body fluids"
      • Isoniazid (INH): peripheral neuropathy (give with B6 - pyridoxine 25 to 50 mg/day)
      • Pyrazinamide (PZA): Hyperuricemia (Gout)
      • Ethambutol (EMB): Optic neuritis, red-green blindness - "remember E = eyes"

All are hepatotoxic, so you need to get baseline labs

  • Most outpatients will be managed by your local health department to directly observe them taking TB meds for monitoring, etc.
  • Patients with active TB will need two negative AFB smears and cultures in a row for therapy cessation
  • Prophylaxis for household members ⇒ (example) Isoniazid for one year
  • D/C therapy if transaminases > 3-5 × ULN
  • Pts on INH should take supplemental Vitamin B6 (pyridoxine 25-50mg/day) to prevent neuropathy

Monitor serum creatinine; take meds on an empty stomach since food can reduce absorption, watch for hepatotoxicity, be aware of drug interactions, especially with HIV meds

Tuberculosis-x-ray-1

Upper cavitary lesion on CXR associated with Tb

Tubercular adinitis with sinus

A case of long-standing tubercular lymphadenitis with sinus

Emphysema (Prev Lesson)
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