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.

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


  • 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 if 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


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


  • Cough, fever (unusual), constitutional symptoms
  • Typically, less severe than pneumonia, normal vital signs, no rales, no egophony
  • Obtain CXR if the diagnosis is uncertain, or symptoms persist despite conservative treatment

Treatment is symptomatic and supportive - hydration, expectorant, analgesic, B2 agonist, cough suppressant

  • Corticosteroids if a history of underlying reactive airway disease
  • Ribavirin if severe lung or heart disease and in immunocompromised patients
  • 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
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 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

The classic finding is thumbprint sign on x-ray lateral neck film, secure airway then culture for H.flu

Treatment involves intubating if necessary, supportive care, ceftriaxone, may treat as an outpatient if stable

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 PA CXR (narrowing trachea in the subglottic region)


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


  • 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)
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 a 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



  • 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 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, 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
  • 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 and humidified oxygen, and steroids (controversial) => resolves in 5-7 days
  • Vaccine for children with lung issues or born premature/immunocompromised at birth, should get Synagis prophylaxis (palivizumab) = once per month for five months beginning in November

See Bronchiolitis

Tuberculosis (ReelDx)
ReelDx Virtual Rounds (Tuberculosis)
Patient will present as → 34 yo F nurse presents with 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

  • NAAT helps to diagnose better and sooner
  • CXR: cavitary lesions, infiltrates, Ghon complexes in the apex of lungs
  • Biopsy ⇒ caseating granulomas
  • Miliary tuberculosis = spread outside lungs ⇒ vertebral column: Pott disease; scrofula (TB to cervical lymph nodes)



  • 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

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