PANCE Blueprint Pulmonary (10%)

Pneumonias (PEARLS)

The NCCPA™ PANCE and PANRE Pulmonary Content Blueprint requires you to understand and differentiate between 4 types of infectious pneumonia

Bacterial pneumonia (ReelDx)
Patient will present as → a 40-year-old alcoholic male with sudden onset of severe chills, fever, dyspnea, and cough productive of red mucoid sticky sputum. He appears ill-looking with cyanosis. Examination reveals vital signs: Temp – 102 degrees F; Pulse – 120 /minute and regular; 89 RR – 28/min; BP 90/62 mm Hg. Lungs reveal minimal rales and dullness in the right upper lobe with decreased breath sounds. Chest x-ray reveals right upper lobe consolidation with a bulging fissure. Gram stain reveals many white blood cells and many gram-negative rods. (klebsiella pneumoniae)

S. Pneumoniae - Rust-colored sputum - common in patients with splenectomy

S. Aureus - Salmon colored sputum - MRSA treat with vancomycin

Pseudomonas - Ventilators, patients become sick fast - treat with 2 antibiotics

Legionella - low NA+ (hyponatremia), GI symptoms (diarrhea), and high fever

Mycoplasma - Young people living in dorms, (+) cold agglutinins, bullous myringitis

Klebsiella - currant jelly sputum, drinkers, aspiration

Viral pneumonia
Patient will present as → a 45-year-old male with a one-week history of hacking, non-productive cough, low-grade fever, malaise, and myalgias. The chest x-ray reveals bilateral interstitial infiltrates and a cold agglutinin titer that is negative. Examination reveals scattered rhonchi and rales upon auscultation of the chest.

Adults → The influenza viruses are the most common viral cause of pneumonia

  • Primary influenza pneumonia manifests with a persistent cough, sore throat, headache, myalgia, and malaise for more than three to five days. The symptoms may worsen with time, and new respiratory signs and symptoms, such as dyspnea and cyanosis, appear.

Kids → RSV, 1st episode of wheezing

  • Respiratory syncytial virus (RSV) is the most frequent cause of lower respiratory tract infection in infants and children and the second most common viral cause of pneumonia in adults
  • Patients with RSV pneumonia typically present with fever, nonproductive cough, otalgia, anorexia, and dyspnea. Wheezes, rales, and rhonchi are common physical findings.

Parainfluenza virus pneumonia

  • Parainfluenza virus (PIV) is second in importance only to RSV as a cause of lower respiratory tract disease in children and pneumonia and bronchiolitis in infants younger than 6 months.
  • The signs and symptoms include fever, cough, coryza, dyspnea with rales, and wheezing.

DX:

Chest radiography usually demonstrates bilateral lung involvement, but none of the viral etiologies of pneumonia result in pathognomonic findings with CXR

  • Rapid antigen testing for influenza
  • RSV nasal swab
  • Cold agglutinin titer that is negative

TX:

Influenza can be treated with oseltamivir (Tamiflu)

    • Zanamivir and Oseltamivir (Tamiflu) both treat influenza A and B must be given within 48 hours
    • Amantadine and Rimantadine treat only influenza A
    • Their efficacy in patients with influenza viral pneumonia or severe influenza is unknown.

RSV pneumonia

  • Ribavirin is the only effective antiviral agent available to treat RSV pneumonia, but there are conflicting data regarding its efficacy.

PIV pneumonia

  • Treatment is mainly supportive, but aerosolized and oral ribavirin have been associated with a reduction in PIV shedding and clinical improvement in immunocompromised patients
Fungal pneumonia
Patient will present with → a 21-year-old male presents with a cough and mild shortness of breath for three days. The cough is productive of yellowish mucus. He reports a low-grade fever with this episode but says that he has otherwise been healthy. He has spent the last month working in bat caves. He denies tobacco or alcohol use. (Histoplasmosis)

Coccidioides (valley fever): Look for this in a patient with non-remitting cough/bronchitis non-responsive to conventional treatments.

  • Caused by fungal inhalation in western states.
  • Serologic tests using enzyme-linked immunoassays (EIA) for IgM and IgG should be ordered first, if possible. If the EIA is positive, a confirmatory immunodiffusion test should be performed.
  • Treatment: fluconazole or itraconazole.

Histoplasma capsulatum is an opportunistic fungus that is known to cause systemic disease in HIV patients that involves low-grade fevers, cough, hepatosplenomegaly, and tongue ulceration

  • AIDS-defining illness - Highest risk is with a CD4+ cell count of < 150 cells/mm3
  • Histoplasma is commonly transmitted by bird or bat (animal) droppings, and should always be borne in mind in spelunkers presenting with tuberculosis-like symptoms
  • Mississippi and Ohio River Valleys
  • DX: Culture is the gold standard for diagnosis but requires a lengthy incubation period
  • Treat with itraconazole orally for weeks to months or Amphotericin B  if severe or failed Itraconazole
    • In general antifungal prophylaxis with itraconazole is not administered to prevent primary infection without special indications

Cryptococcus: Caused by the fungus Cryptococcus neoformans, common in AIDS and immunocompromised states, is considered an AIDS-defining illness

  • Budding yeast found in soil contaminated with pigeon/bird droppings
  • Diagnose with CSF and serum serology
    • India ink may be positive
  • Treat with Amphotericin B + Flucytosine for 2 weeks followed by Fluconazole for 10 weeks
    • Prophylaxis if CD4 < 100 with Fluconazole

Pulmonary aspergillosis: The majority of cases occur in people with underlying illnesses such as tuberculosis or chronic obstructive pulmonary disease (COPD), but with otherwise healthy immune systems

  • Treatment: fluconazole or itraconazole

Pneumocystis Jiroveci (formerly PCP Pneumonia now called PJP)

  • Pneumocystis jirovecii is a yeast-like fungus of the genus Pneumocystis
  • Common in HIV-infected patients with a low CD4 count of less than 200
  • The radiograph shows diffuse interstitial or bilateral perihilar infiltrates
  • Diagnose with bronchoalveolar lavage (PCR), labs, and an HIV test.
  • Treat with Trimethoprim-sulfamethoxazole (BACTRIM) and steroids
  • Prophylaxis for high-risk patients with a CD4 count of less than 200 or with a history of PJP infection. Daily Bactrim is the prophylaxis antibiotic of choice.
HIV-related pneumonia
Patient will present as → a 32-year-old male with dyspnea and a nonproductive cough. He is tachycardic, tachypneic and febrile. Auscultation of his chest reveals scattered rhonchi. His chest x-ray demonstrates a diffuse interstitial infiltrate. His ABG demonstrates moderate hypoxemia and his LDH is elevated

Formerly PCP Pneumonia now called (PJP) Pneumocystis jiroveci (there are other HIV-related types of pneumonia, but this is the one you will need to know for the test)

  • Common in HIV-infected patients with a low CD4 count of less than 200

DX: CXR is the cornerstone of diagnosis.  The radiograph shows diffuse interstitial or bilateral perihilar infiltrates

  • Bronchoalveolar lavage (PCR), labs, and an HIV test
  • Will often have very low O2 saturation despite supplemental O2

TX: Trimethoprim-sulfamethoxazole (Bactrim) and steroids

  • If allergic treat with Pentamidine

Prophylaxis for high-risk patients with a CD4 count of less than 200 or with a history of PJP infection

  • Daily Bactrim is the prophylaxis antibiotic of choice
Pertussis (Whooping Cough) (Prev Lesson)
(Next Lesson) Brian Wallace PA-C Podcast: Pneumonia
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