PANCE Blueprint Pulmonary (12%)

Infectious Pulmonary Disorders (PEARLS)

The NCCPA™ PANCE and PANRE Pulmonary Content Blueprint requires that you know nine topics under the label "infectious disorders" including four types of pneumonias.

Acute bronchitis (ReelDx) Cough which persists for more than five days, 95% are viral

  • Organisms:
    • Most common: Viral
    • Chronic lung patients: H. influenzae, S. pneumoniae, M. catarrhalis
  • Presentation:
    • Cough, fever, constitutional symptoms
    • Typically less severe than pneumonia, normal vital signs, no rales, no egophony
  • Chest radiograph: Normal
  • Treatment: If O2 is less than 96% on room air the patient should be hospitalized
    • Treatment is supportive with Humidified 02, antipyretics
    • Beta agonists, nebulized racemic epinephrine, corticosteroids if h/o underlying reactive airway disease - all are commonly used but do not have proof of efficacy
    • Ribavirin if severe lung or heart disease and in immunocompromised patients
Acute bronchiolitis (ReelDx) Most often caused by RSV, diagnosed by nasal washing

Presentation:

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

Treatment:

  • RSV- admit if O2 sat < 95% and/or retractions. give IV ribavirin
  • Not RSV- supportive, suction
Acute epiglottitis Caused by Hib, unvaccinated child, Thumbprint sign on X-Ray
Croup (ReelDx) Etiology: Parainfluenza virus

Presentation:

  • Winter months, patients < 3 years old
  • Barking cough, stridor at night
  • AP radiograph: “Steeple sign”

Treatment:

  • Supportive (air humidifier)
  • Severe: IV fluids and racemic epinephrine
Influenza (ReelDx) Presentation: Fevers, chills, coryza, myalgia

Rapid antigen test can be performed in clinic

Treatment:

  • Supportive therapy
  • Zanamivir and Oseltamivir (Tamiflu) both treat influenza A and B must be given within 48 hours
  • Amantadine and Rimantadine treat only influenza A

Annual vaccine for everyone 6 months and older unless contraindicated

Pertussis (Whooping Cough) Organism: Bordetella pertussis (gram negative capsule)

Presentation:

  • 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)

Diagnostic studies:

  • diagnose by nasopharyngeal swab
  • Lymphocytosis

Treatment: Macrolide

Vaccine: Tdap booster at 11-12 y/o, DTaP

Pneumonias (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 PCP pneumonia

  • Dapsone is second line

Admission criteria: CURB65

  • Confusion, Urea >7, RR >30, BP <90/<60, age >65
Pathogen Demographics Presentation
Streptococcus pneumoniae Most common, postsplenectomy Rust colored sputum, single rigor. Lobar infiltrate
Mycoplasma pneumoniae College student, 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, postsplenectomy
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) See Bronchiolitis, nasal washing for RSV
Tuberculosis (ReelDx) Organism: Mycobacterium tuberculosis

Presentation: Cough, night sweats, weight loss, post-tussive rales, endemic area, immunocompromised.

  • Xray: cavitary lesions, infiltrates, ghon complexes in apex of lungs
  • Acid-fast bacilli stain
  • Biopsy: Caseating granulomas

Mantoux Test: Test is positive if induration

  • >5 mm in immunosuppressed patients
  • >10 in patients age < 4 or has risk factors
  • >15 mm if there are no risk factors

Treatment:

  • Latent treatment: Isoniazid for 9 months
  • Active quad therapy: Isoniazid, Rifampin, Ethambutol, Pyrazinamide for 8 weeks
    • Isoniazid- peripheral neuropathy (give with B6)
    • Rifampin- Red orange urine, hepatitis
    • Ethambutol- Optic neuritis (eye changes), red-green blindness
    • Pyrazinamide- hyperuricemia

Prophylaxis for household members: Isoniazid for 1 year

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